Shoulder dystocia occurs as a result of disproportion between the bisacromial diameter of the fetus and the antero-posterior diameter of the pelvic inlet, the anterior shoulder of the fetus becoming impacted behind the symphysis pubis.
|
|
|
|
|
|
|
|
|
Management principles
|
Emergency manoeuvres for the management of shoulder dystocia are designed to do one of three things:
|
1. Increase the functional size of the bony pelvis- McRoberts manoeuvre
|
2. Decrease the bisacromial diameter of the fetus utilising:
|
|
|
|
3. Change the relationship of the bisacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter
|
|
|
- Reverse Woods screw manoeuvres
|
|
NOTE: Each of the following manoeuvres should be attempted for up to 30 seconds before moving to the next manoeuvre.
|
|
|
|
NOTE: Consider cutting an episiotomy or extending an existing episiotomy
|
|
|
|
McRoberts manoeuvre
|
- Place the woman in a recumbent position.
|
- Remove or lower the bottom of the bed and manipulate her buttocks to the extreme edge.
|
- With the aid of an assistant either side, the thighs are abducted and hyperflexed onto the abdomen.
|
|
| This is the time to cut (or extend) an episiotomy (if you anticipate entering the pelvis), as the perineum is clearly visible. |
 | - The assistant may be required to elevate the baby's head to improve the view of the perineum (thereby reducing potential trauma to the baby's face).
| - This allows the accoucheur to use both hands to cut (or extend) the episiotomy.
|
|
|
- The accoucheur applies gentle downwards traction to the baby's head.
|
|
Suprapubic pressure - Also known as Rubin (1)
|
While the accoucheur applies gentle downwards traction to the baby's head, an assistant compresses suprapubically on the posterior aspect of the anterior shoulder, to disimpact the anterior shoulder.
|
- The initial pressure applied is continuous.
|
- If delivery is unsuccessful, a rocking motion may be applied.
|
- The adoption of a CPR position over the anterior shoulder will assist with maintaining effective pressure.
|
|
Diagrams
|
NOTE: The following manoeuvres may be undertaken in any order according to need.
|
Rubin Manoeuvre (2)
| The accoucheurs hand is inserted into the vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter. Attempt delivery.
|
| | Woods Screw Manoeuvre
| While maintaining pressure as above, the accoucheur introduces their second hand and locates the anterior aspect of the posterior shoulder. Pressure is applied to rotate the posterior shoulder. Attempt delivery once the shoulders move into the oblique diameter. If this movement is unsuccessful continue rotation through 180° and attempt delivery.
|
| | Reverse Woods Screw Manoeuvre
| Apply pressure to the posterior aspect of the posterior shoulder and attempt to rotate it through 180° in the opposite direction to that described in the Wood Screw manoeuvre.
|
| | Delivery of the Posterior Arm
| The accoucheur passes their hand into the vagina over the chest of the fetus to identify the posterior arm and elbow. Apply pressure to the antecubital fossa to flex the elbow in front of the body, and / or grasp the posterior hand to sweep the arm across the chest and deliver the arm. This is followed by rotation of the fetus into the oblique diameter of the pelvis, or through 180°, bringing the anterior shoulder under the symphysis pubis.
|
| |
|
|
Rotation of patient onto all fours
|
Rotation of the patient onto all fours may also facilitate delivery by increasing the pelvic diameters and allowing better access to the posterior shoulder.
|
NOTE: Throughout these manoeuvres the shoulders must be rotated using pressure on the scapula or clavicle. Never rotate the head.
|
Internal manoeuvres are more successful if combined with suprapubic pressure in a direction which facilitates rotation within the vagina.
|
While nomenclature of these manoeuvres may change within various textbooks, the management principles remain the same.
|
Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
|
Please remember to read our disclaimer.
|
