Hi, my name is Julia Boucher and I'm a fourth year medical student from the University of Ottawa. Today we're going to be talking about the diagnosis and management of shoulder dystocia. Shoulder dystocia is a complication that can occur during a vaginal delivery.
It is an obstetrical emergency. Shoulder dystocia occurs when after delivery of the fetal head, additional obstetrical maneuvers are required to deliver the fetal shoulders. It occurs in approximately 1% of births. Shoulder dystocia can be caused by impaction of the anterior or posterior shoulder during vaginal delivery.
Anterior shoulder is more common and is caused by impaction at the maternal pubic symphysis. Posterior shoulder is less common and is caused by impaction at the maternal sacral promontory. Risk factors for shoulder dystocia include maternal diabetes, suspected macrosomia, gestational age more than 42 weeks, previous shoulder dystocia, and operative delivery. However, over 50% of shoulder dystocia cases are not predictable and have no risk factors, so you need to be prepared for the possibility of shoulder dystocia at every delivery.
Shoulder dystocia is a clinical diagnosis that should be made promptly. The diagnosis is made when the routine practice of gentle, downward traction of the fetal head fails to deliver the anterior shoulder. It is very important to diagnose shoulder dystocia as soon as it occurs. That way, the obstetrical team can start to manage it right away. The goal of management is to deliver the infant before asphyxia from umbilical cord compression occurs without causing any fetal or maternal trauma.
So, now that we know how to diagnose shoulder dystocia, let's talk about management. There's a helpful acronym to remember the steps of how to manage shoulder dystocia. It's called ALARMER.
Let's use a case study to go through the acronym and learn the management of shoulder dystocia. Sarah is a 28-year-old G1 at 40 weeks gestation that has been laboring for the past 10 hours. She is healthy and takes no medications. She has had a normal pregnancy so far. Sarah had an epidural to manage her labour pain when she was 4cm dilated.
Now she is fully dilated and has been pushing well for the past 2 hours. You and the resident that you are working with notice that the fetal head delivered, but then retracted back into the perineum, also known as the turtle sign. What do you and the resident do next? To answer this question, we need to go through our ALARMR acronym. This acronym is a step-by-step method to manage shoulder dystocia.
Starting from the top, each step should be followed as necessary. It's possible that the shoulder dystocia resolves after the first step. Moving on to the next step is only required if the shoulder dystocia does not resolve.
If you were to encounter shoulder dystocia on rotation, you may be involved in the first few steps. However, each step is progressively more invasive and requires an increasing amount of skill, so most of the later steps will be done by the resident or staff you are working with. Let's go through the acronym. A stands for Ask for Help.
Depending on where you're working, this may mean pulling the alarm bell or asking a team member to call for additional staff. L stands for Legs. Specifically, two members of the obstetrical team need to stand on either side of the patient and hyperflex their legs.
This is known as McRoberts maneuver. The patient's legs should be flexed all the way back so that her thighs are against her abdomen. This movement rotates the pubis symphysis and flattens the sacrum to relieve obstruction.
This may be sufficient to relieve obstruction in up to 42% of patients. If the shoulder dystocia persists, move on to the next step. A stands for apply suprapubic pressure and anterior shoulder disimpaction.
To do this, one of the team members needs to grab a stool to stand on and then use their palm or fist to apply downward and lateral pressure suprapubically. This maneuver adducts and rotates the fetal shoulders to disimpact the anterior shoulder. Another way to disimpact the anterior shoulder is using the Rubin Maneuver.
This is done by placing one hand in the vagina and on the back surface of the posterior fetal shoulder and rotating it anteriorly to disimpact the anterior shoulder. If you're unable to do so, move on to the next step. R stands for release the posterior shoulder. To do this, one hand is placed in the vagina after finding the fetal arm, flex the elbow across the chest to grasp the forearm or hand and pull it out of the vagina.
If you can't deliver the fetal arm, it may be possible to deliver the shoulder. If not, move on to the next step. M stands for maneuver of woods. This is also called the screw maneuver because you try to rotate the fetus or unscrew it by putting pressure on the clavicle of the posterior shoulder and rotating it until it becomes anterior. If none of these maneuvers work, E stands for episiotomy and can be considered.
An episiotomy is a surgical cut. made the opening of the vagina to allow more room and better access to the posterior arm. The last letter of the acronym R stands for roll onto all fours. The patient is helped onto her hands and knees.
This is in an effort to take advantage of gravity to facilitate delivery. If none of the steps of the acronym work, there are several last resort methods that can be considered. However, these are associated with a significant increase in fetal and maternal morbidity.
These include fracture of the fetal clavicle, Zavinelli maneuver or returning the fetal head and attempting a cesarean delivery, and symphysiotomy, separation of the maternal pubic bones. Now that we know the acronym, let's return to our patient Sarah. Sarah had been pushing well for two hours when the obstetrical team noticed the turtle sign. You and your resident suspect shoulder dystocia and initiate the ALARMER acronym. The resident asks for the staff to be called and the dystocia belt to be pulled to alert the rest of the staff.
The first step, ask for help, is complete. What's next? You and one of the nurses start to hyperflex the patient's leg for the McRoberts maneuver.
L for legs is complete. Unfortunately, the shoulder dystocia persists. What's next? Apply suprapubic pressure and anterior shoulder disimpaction.
A nurse who are working with steps on a stool and shows you how to properly apply suprapubic pressure downwards and laterally towards the baby's head. Luckily, the combination of McRoberts and suprapubic pressure relieves the impaction of the anterior shoulder and the resident is able to deliver the baby. Congrats! You have helped deliver Sarah's baby by promptly diagnosing and managing shoulder dystocia with the help of the ALARMER acronym. Let's review the key points from this video.
1. Shoulder dystocia is an obstetrical emergency that requires prompt diagnosis and management. 2. Diagnosis of shoulder dystocia is made when the routine practice of gentle downward traction of the fetal head fails to deliver the anterior shoulder. 3. ALARMER provides an acronym for the management of shoulder dystocia.
Can you remember what each letter stands for? A stands for ask for help. L is legs hyperflexed or McRoberts.
A, apply suprapubic pressure and anterior shoulder disimpaction. R, release posterior arm. M, maneuver of woods.
E, episiotomy. And R, roll onto all fours.