Shoulder dystocia


Shoulder dystocia is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone. Signs include retraction of the baby's head back into the vagina, known as "turtle sign". Complications for the baby may include brachial plexus injury, or clavicle fracture. Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.
Risk factors include gestational diabetes, previous history of the condition, operative vaginal delivery, obesity in the mother, an overly large baby, and epidural anesthesia. It is diagnosed when the body fails to deliver within one minute of delivery of the baby's head. It is a type of obstructed labour.
Shoulder dystocia is an obstetric emergency. Initial efforts to release a shoulder typically include: with a woman on her back pushing the legs outward and upward, pushing on the abdomen above the pubic bone, and making a cut in the vagina. If these are not effective, efforts to manually rotate the baby's shoulders or placing the women on all fours may be tried. Shoulder dystocia occurs in approximately 0.4% to 1.4% of vaginal births. Death as a result of shoulder dystocia is very uncommon.

Signs and symptoms

One characteristic of a minority of shoulder dystocia deliveries is the turtle sign, which involves the appearance and retraction of the baby's head, and a red, puffy face. This occurs when the baby's shoulder is obstructed by the maternal pelvis.

Complications

One complication of shoulder dystocia is damage to the upper brachial plexus nerves. These supply the sensory and motor components of the shoulder, arm, and hands. The ventral roots are most prone to injury. The cause of injury to the baby is debated, but a probable mechanism is manual stretching of the nerves, which in itself can cause injury. Excess tension may physically tear the nerve roots out from the neonatal spinal column, resulting in total dysfunction.
Possible complications include:
About 16% of deliveries where shoulder dystocia occurs have conventional risk factors. These include diabetes, fetal macrosomia, and maternal obesity.
Risk factors:
Factors which increase the risk/are warning signs:
For women with a previous shoulder dystocia, the risk of recurrence is at least 10%.

Management

The steps to treating a shoulder dystocia are outlined by the mnemonic ALARMER:
Typically the procedures are performed in the order listed and the sequence ends whenever a technique is successful. Intentional fracturing of the clavicle is another possibility at non-operative vaginal delivery prior to Zavanelli's maneuver or symphysiotomy, both of which are considered extraordinary treatment measures. Pushing on the fundus is not recommended.
Simulation training of health care providers to prevent delays in delivery when a shoulder dystocia prevents is useful.

Procedures

A number of labor positions and maneuvers are sequentially performed in attempt to facilitate delivery. These include:
More drastic maneuvers include:
Shoulder dystocia occurs in about 0.15% to 4% of term vaginal births.