Risk factors for shoulder dystocia include all the following, except:
Correct Answer E:
Antepartum risk factors for shoulder dystocia are listed below in order of importance:
Intrapartum risk factors are as follows:
You are attending the delivery of a 34-year-old gravida 2 para 1 with no prenatal complications who entered spontaneous labor at full term several hours ago. All fetal heart tones have been reassuring. The head delivers in the occiput anterior position over a posterior midline episiotomy without problems. However, the delivery stalls with the infant’s chin pressing against the perineum. When there is a contraction or the mother attempts to push, the head descends slightly and then returns to the same position.
After you call for additional assistance, which one of the following should you do to facilitate delivery?
Correct Answer D:
The scenario described represents a case of shoulder dystocia. Applying fundal pressure without other maneuvers has been shown to cause a 77% complication rate and should be avoided.
Approach to the Management of Shoulder Dystocia:
Other options:
Which one of the following describes the McRoberts maneuver for managing shoulder dystocia?
Correct Answer C:
When the just-delivered fetal head retracts firmly against the perineum, shoulder dystocia is apparent. This is an obstetric emergency that requires appropriate assistance and a calm but timely approach to ensure a safe delivery. While all of the maneuvers described are steps in managing shoulder dystocia, the McRoberts maneuver by itself (maximal flexion and abduction of the maternal hips) relieves the impaction of the anterior shoulder against the maternal symphysis in a large percentage of cases, especially when combined with suprapubic pressure.
A 32-year-old gravida 3 para 2 is in labor at term following an uncomplicated prenatal course. As you deliver the fetal head it retracts against the perineum. Downward traction fails to free the anterior shoulder.
The most appropriate course of action would be to:
While there are several risk factors for shoulder dystocia, most cases occur in fetuses of normal birth weight and are not anticipated. Once it does occur, excessive force should not be applied to the fetal head or neck and fundal pressure should be avoided, as these maneuvers are unlikely to free the fetus and can injure both mother and infant.
Up to 40% of shoulder dystocia cases can be successfully treated with the McRoberts maneuver, in which the maternal hips are flexed and abducted, placing the thighs up on the abdomen. Adding suprapubic pressure can resolve about half of all shoulder dystocias. Additional maneuvers include internal rotation, removal of the posterior arm, and rolling the patient over into the all-fours position. As a last resort, one can deliberately fracture the fetal clavicle, perform a cesarean section with the vertex being pushed back into the birth canal, or have the surgeon rotate the infant transabdominally with vaginal extraction performed by another physician. General anesthesia or nitroglycerin, orally or intravenously, may be used to achieve musculoskeletal or uterine relaxation. Intentional division of the cartilage of the symphysis under local anesthesia has been used in developing countries, but should be used only if all other maneuvers have failed and a cesarean delivery is not feasible.
You are asked to consult on a laboring 29-year-old multipara in active labor. The patient is concerned about the large size of her fetus. She is concerned about the possibility of this fetus having a difficult delivery. She tells you that her last delivery was complicated by a shoulder dystocia.
You tell her that shoulder dystocia has been associated with all of the following,except:
Paternal diabetes has a genetic risk to the child, but does not pose any risk during pregnancy and delivery compared to other normal infants. If a patient is a gestational diabetic with a macrosomic fetus and a prior shoulder dystocia, a cesarean delivery is indicated.
→ This is probably the greatest risk for another shoulder dystocia. If her prior delivery resulted in a dystocia (especially if the child has permanent sequelae), then most obstetricians would proceed with an elective cesarean delivery.
→ Maternal obesity is associated with larger birth weights and an increased risk of complicated delivery.
→ Prolonged second stage can be a warning feature of an impending shoulder dystocia.
→ Fetal macrosomia increases the risk of complicated vaginal delivery, especially when the fetal weight is over 4500 g.
Click to expand