Friday, February 26, 2010

Shoulder Dystocia

Shoulder Dystocia is a type of difficult childbirth in which the baby's shoulders get stuck in the pelvis after the head is delivered and additional action must be taken to get the baby out. It occurs in less than 1% of all births.

A common strategy to deal with shoulder dystocia is the McRoberts Maneuver, in which the mother, already in a lithotomy position (on her back) legs are pushed tightly up against her stomach.  An obstetrician will also frequently cut an episiotomy to help the baby out, although it is not the perineum, but the pelvic bone, that is holding the baby back.

Here is a video of the McRoberts Maneuver:


Suprapubic pressure
Pushing on the top of the pubic bone in an attempt to widen it.

Zavanelli maneuver
Involves pushing back the delivered head into the birth canal and then performing a Cesarean section. A study on 9 cases using this maneuver in 1988 found:
In one of these cases, the fetal head “remained outside the vulva for twenty to twenty-five minutes before it was reinserted” and the baby was delivered by cesarean. There was one stillbirth among these nine cases, one mother suffered from sepsis and subsequent hysterectomy, one baby was born with an Apgar score of 1/4 but was reported normal at age seven, and one baby currently has some degree of mental retardation.
 Another study in 1993 found even more infant problems, and
Maternal complications included two ruptured uteruses, three lacerations of lower uterine segments, six transfusions, and eight morbid postoperative courses. (The All-Fours Maneuver for Reducing Shoulder Dystocia During Labor)

The Gaskin Maneuver, or the All-Fours Maneuver
The woman turns over onto her hands and knees, which flexes and widens the pelvis.
I introduced the all-fours maneuver in the United States in 1976, after learning about it from a Belizean midwife who had, in turn, learned it from Mayan midwives in the highlands of Guatemala.
 Out of 4452 births in the study and 82 babies with shoulder dystocia,
Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.
“The most significant observations of the study were the negative findings. No still births or neonatal deaths were reported. Not a single infant suffered Erb palsy, either transient or permanent, and no newborns experienced seizures, hemorrhage, hypoxic-ischemic encephalopathy, cerebral palsy, or fractured clavicle. No patients required any tocolytic medication during labor. No vaginal, cervical, or uterine lacerations occurred. No women required transfusions. And no cases of postpartum, ileus or pulmonary embolus were reported. Overall, the maternal complication associated with the use of the “Gaskin Maneuver” was 1.2 percent (one case of postpartum hemorrhage, transfusion not required), and the neonatal complication rate was 4.9 percent. . . None of these patients required any additional maneuvers. . . Not only was the Gaskin Maneuver instrumental in relieving shoulder impact in every instance, it is also a non-invasive procedure requiring only a change of maternal position.” The average time needed to assume the position and complete the delivery was 2-3 minutes, with the longest reported interval being 6 minutes. (The All-Fours Maneuver for Reducing Shoulder Dystocia During Labor)
The Gaskin Maneuver may not be useful, however, if the mother has been numbed by an epidural anesthesia.  And it is not easy to do if the mother is hooked up to several monitors and an IV.

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