Shoulder Dystocia- how care providers manage this obstetric emergency

Shoulder dystocia is a childbirth complication that occurs when a baby's shoulders become lodged behind the mother's pelvic bone after the head has already been delivered. This situation can lead to difficulties in delivering the baby’s body and requires immediate medical intervention to avoid complications for both the baby and the mother.

Causes and Risk Factors

While shoulder dystocia can occur unexpectedly in any delivery, certain factors may increase the likelihood of it happening:

1. Fetal Size:

   • Large babies (macrosomia), often weighing over 8 pounds 13 ounces (4,000 grams), are at a higher risk of shoulder dystocia.

2. Maternal Diabetes:

   • Mothers with gestational diabetes or pre-existing diabetes are more likely to give birth to larger babies, increasing the risk.

3. Labor Complications:

   • Prolonged second stage of labor (the pushing phase) can increase the risk.

   • Use of assistive devices, such as forceps or vacuum extraction, may sometimes be associated with shoulder dystocia.

4. Maternal Obesity:

   • Obesity is associated with a higher risk of delivering a large baby, which can increase the chance of shoulder dystocia.

5. History of Shoulder Dystocia:

   • If a mother has experienced shoulder dystocia in a previous birth, the risk may be higher in future pregnancies.

6. Post-term Pregnancy:

   • Babies born after their due date are often larger, which increases the risk.

7. Induction of Labor:

   • Induced labor, especially for larger babies, can increase the risk of shoulder dystocia.

Signs of Shoulder Dystocia

• Turtle Sign: This is a classic sign of shoulder dystocia. After the baby's head is delivered, it retracts slightly back into the birth canal (like a turtle retracting into its shell), indicating that the shoulders are stuck.

• Difficulty in delivering the shoulders: The baby’s head may be out, but the shoulders don’t follow within the normal time frame, signaling the need for immediate intervention.

Complications of Shoulder Dystocia

If not resolved quickly, shoulder dystocia can lead to complications for both the baby and the mother:

For the Baby:

1. Brachial Plexus Injury (Erb's Palsy): This is the most common injury associated with shoulder dystocia. It occurs when the network of nerves controlling the arm and hand is stretched or damaged during delivery. Most cases resolve over time, but severe cases may result in permanent nerve damage.

2. Fractures: The baby may suffer fractures of the clavicle or humerus during attempts to resolve shoulder dystocia.

3. Oxygen Deprivation: Prolonged delivery can cause compression of the umbilical cord, leading to a lack of oxygen (hypoxia). This can result in brain injury or even death if not addressed immediately.

4. Neonatal Death: In rare cases, shoulder dystocia can be fatal if oxygen deprivation occurs and is not quickly resolved.

For the Mother:

1. Postpartum Hemorrhage: The prolonged and difficult delivery may cause severe bleeding after childbirth.

2. Vaginal Tears: There is a higher risk of significant tears in the vaginal or perineal tissue during attempts to deliver the baby.

3. Uterine Rupture or Injury: The intense pressure and interventions needed to free the baby's shoulders may cause trauma to the uterus or surrounding tissues.

Managing Shoulder Dystocia: Maneuvers and Techniques

In the event of shoulder dystocia, healthcare providers use specific techniques to safely deliver the baby:

1. McRoberts Maneuver:

   • This is the most common and effective technique. The mother’s legs are flexed sharply toward her chest, which helps widen the pelvis and may allow the shoulders to be freed.

2. Suprapubic Pressure:

   • Applying pressure just above the pubic bone helps to dislodge the baby’s shoulder by pushing it downward.

3. Rubin and Woods Corkscrew Maneuvers:

   • These maneuvers involve rotating the baby’s shoulders or changing the baby’s position to make it easier to deliver.

4. Delivery of the Posterior Arm:

   • Sometimes, the doctor or midwife may attempt to deliver the baby’s lower arm first, which reduces the size of the baby’s shoulders and allows for easier delivery.

5. Zavanelli Maneuver (Last Resort):

   • If all other methods fail, the baby's head is reinserted into the birth canal, and a cesarean section is performed. This is very rare and considered a last resort.

Prevention and Risk Management

While shoulder dystocia cannot always be predicted or prevented, certain measures can help reduce the risk:

1. Monitoring Fetal Size: If the baby is suspected to be very large, especially in cases of gestational diabetes, a planned cesarean delivery may be recommended.

2. Gestational Diabetes Management: Proper control of blood sugar levels during pregnancy can reduce the risk of macrosomia and shoulder dystocia.

3. Labor Monitoring: Careful monitoring of labor progression, especially during the second stage, can help detect early signs of potential complications.

Summary

Shoulder dystocia is an obstetric emergency that can result in serious complications for both the baby and mother. Prompt recognition and skilled management are crucial for minimizing risks. While the condition cannot always be predicted, managing risk factors like gestational diabetes, monitoring fetal size, and using appropriate delivery techniques can help reduce the likelihood of shoulder dystocia.