Introduction
Serious but rare complication of vaginal delivery in which the fetal shoulders fail to deliver spontaneously after the head emerges.
- OBSTETRIC EMERGNECY
Definition:
Mechanical problem occurring during a vaginal delivery characterized by one of the following parameters:
- Failure to deliver the fetal shoulders using solely gentle downward traction
- Requirement of additional delivery maneuvers
- Head-to-body interval > 1 minute
Aetiology
Risk factors:
- Fetal macrosomia (M/significant risk factor)
- Other factors:
- Pregestational/gestational diabetes
- Prior history of shoulder dystocia
- Maternal obesity
Complications
Brachial plexus injury (BPI): M/C
- Upper lesions (M/C): “Waiter’s tip” palsy
- Lower lesions: “Claw hand” palsy
- Total plexus palsies: Flaccid extremity with both motor and sensory deficits
Other complications:
- Asphyxial/traumatic CNS damage
- Long bone fractures:
- Clavicular fracture
- Humerus fracture
- Fetal death
Management
Advanced Life Support in Obstetrics protocol:
HELPERR
- H: call for help
- E: evaluate episiotomy
- L: legs (the McRobertsʼ manoeuvre)
- P: suprapubic pressure
- E: enter manoeuvres (internal rotation)
- R: remove the posterior arm
- R: roll the patient (all-fours position, Gaskin Maneuver)
First-line maneuvers:
Perform episiotomy prior to these maneuvers for more accessibility
- McRoberts maneuver (first & best maneuver) + suprapubic pressure: Patient’s thigh hyper flexed towards the abdomen (straightening maternal sacrum on the lumbar spine)
- Suprapubic pressure: Decrease fetal bisacromial diameter by adducting the anterior fetal shoulder
Second-line maneuvers:
Rotational maneuvers
- Rubin’s maneuver: Placing hand into vagina and applying pressure to posterior aspect of the most accessible fetal shoulder towards the fetal chest (leads to adduction of the fetal shoulder which would then allow the anterior shoulder to rotate and deliver from behind the pubic bone where is it impacted)
- Woods corkscrew maneuver: Placing a hand on anterior aspect of posterior fetal shoulder and rotates the shoulder toward the fetal back and attempt to rotate the fetal shoulder 180° (allows the fetus to descend while rotation is occurring)
- Delivery of the posterior arm: Slide a hand along the fetal posterior shoulder and arm, and the fetal forearm/wrist is grasped and swept across the anterior fetal chest to effect delivery of the posterior arm (with successful delivery of posterior arm, the axillo-acromial diameter becomes the presenting part, and it is typically about 3cm shorter and leads to delivery of the anterior shoulder)
- Gaskin Maneuver: Patient on her hands and knees (all fours position) or in a racing start or sprinter position, gentle downward traction is applied to the posterior shoulder (the shoulder against the maternal sacrum) or upward traction is applied on the anterior shoulder (the shoulder against the maternal symphysis).
Second-line maneuvers:
Posterior axillary traction: Useful in situations where fetal arms are extended
With each method, the assistant should hold the fetal head and flexes it upward toward the anterior shoulder.
- Menticoglou maneuver: Obstetrician, places their middle fingers under the posterior fetal axilla and applies downward and outward traction which leads to delivery of the posterior shoulder; this is then followed by delivery of the posterior arm.
- Posterior axilla sling traction: Suction catheter/firm urinary catheter is used as a sling and traction is applied to the sling to deliver the posterior shoulder followed by the arm. Alternatively, the sling can be used to rotate the shoulders by applying lateral traction towards the baby’s back while the other hand is placed on the anterior shoulder putting pressure towards the fetal chest.
Heroic measures:
Last-resort options, associated with significant fetal & maternal mortility and morbidity
- Cleidotomy: Deliberate clavicle fracture (decrease the bisacromial diameter)
- Zavanelli maneuver: Fetal head rotated to its pre-restitution attitude, flexed and elevated up to the vagina and back into the uterus. A Cesarean section then achieves delivery.
- Symphysiotomy: Recommended only as a last resort when all the other measures have failed or in cases where immediate access to an operating room facility for Zavenelli or abdominal rescue is not available