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Shoulder Difficulty

Shoulder Difficulty. Max Brinsmead PhD FRANZCOG May 2012. Definition. When extra steps are required to deliver the shoulders Or a delay of >60 sec between head and shoulders Most commonly involves the anerior shoulder which impacts over the symphysis pubis. Incidence.

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Shoulder Difficulty

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  1. Shoulder Difficulty Max Brinsmead PhD FRANZCOG May 2012

  2. Definition • When extra steps are required to deliver the shoulders • Or a delay of >60 sec between head and shoulders • Most commonly involves the anerior shoulder which impacts over the symphysis pubis

  3. Incidence • 0.58 to ≈1.0% for normal birthweight infants • 5 - 7% of those with BW >4500g • Although there are many risk factors • It is now agreed that the condition is basically Unpredictable

  4. Sequelae • Maternal trauma • Soft tissue e.g. 3rd and 4th degree tears • Symptoms from symphyseal separation • Femoral neuropathy • Postpartum haemorrhage • Fetal Brachial Plexus Injury (BPI, about 1:6) • Fracture of clavicle or humerus • Fetal hypoxia

  5. Risk Factors • Large baby - Symphysis fundal height >42cm • Past history of shoulder difficulty • Obese mother (BMI>30) • Diabetic mother +/- fetal macrosomia • Slow progress in 2nd stage of labour with turtle sign of head between contractions • After assisted delivery of the fetal head

  6. Prevention • Elective CS not recommended for suspected fetal macrosomia UNLESS • Associated with maternal diabetes • Requires 443 CS to prevent one case of permanent neonatal injury • IOL at term for gestational diabetes • Recurrence risk after previous shoulder dystocia reaches 25% • But any decision about mode of delivery requires patient involvement in the decision

  7. Prevention of Brachial Plexus Injury • Use AXIAL traction only (avoid lateral and downward traction) • Avoid sudden traction • Prophylactic McRobert’s for suspected shoulder dystocia is of no help

  8. Management – Systematic H E L P E R R • Send for Help • Legs up (McRobert’s manoeuvre) • Pressure suprapubically plus axial traction • Consider episiotomy • Rotate the shoulders internally • Bring down the posterior arm • Try moving to all fours position • (requires a slim, mobile woman)

  9. Manoeuvres of Last Resort • Replace the fetal head (Zavanelli) • Symphysiotomy • Cleidotomy

  10. Medicolegal Consequences • Neonatal brachial plexus injury (BPI) is the most common litigious consequence of shoulder dystocia • And the 3rd most common obstetric-related subject of claim • Fortunately, only 10% of BPI is permanent • And be aware that it can occur after elective CS!

  11. To Keep You Out of Court • Be Prepared… • Mental rehearsal • Practice drills (RCT’s have been done) • Early recognition • Work with the mother and the uterus • Don’t pull too hard on the fetal head • The hollow of the sacrum is your HELPERR • Document carefully • Debrief parents

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