ED Management of Shoulder Dystocia
The Article: Emergency Department Management of Shoulder Dystocia del Portal et al J Emergency Med. 2014
The Idea: To review multiple techniques for managing shoulder dystocia in the ED
Quick Review: Shoulder dystocia is the impaction of the fetal anterior shoulder behind the maternal pubic symphysis. Although rare, it is important to recognize it quickly and know the management maneuvers in order to reduce fetal and maternal morbidity and mortality.
The Recommendations/Techniques: -Have a plan in place for shoulder dystocia -Call for assistance immediately when it is recognized (nurse, additional doctor, OB, etc) -Have ready equipment for complicated delivery and neonatal resuscitation -Tell mom to stop pushing and catheterize bladder -Maneuvers (from least to most invasive):
1. McRoberts- maternal legs in extreme lithotomy position 2. Suprapubic Pressure- use with McRoberts 3. Woods’ Screw/Reverse Woods’ Screw- two fingers in vagina to apply pressure to posterior shoulder in either direction to rotate infant 180 degrees 4. Gaskin- mother on all fours while delivering practitioner applies downward traction to fetal head 5. Delivery of Posterior Arm- hand in vagina, grab fetal arm and flex until hand can be gripped and swept across chest to deliver the posterior arm and shoulder 6. Episiotomy- incise perineum to extend birth canal; controversial as risk of perineal injury without improvement in fetal outcomes 7. Zanavelli- reversing cardinal movements to push fetal head back into vagina until c section can be performed 8. Intentional Fracture of Clavicle- anterior and superior pressure to break the infant’s clavicle to reduce the bisacromial diameter 9. Symphysiotomy- dissection of pubic symphysis; only a last resort
The Takeaway: The emergency physician should be familiar with these techniques to prevent neonatal complications like hypoxic-ischemic encephalopathy and maternal morbidity, and emergency departments should have an action plan for when a shoulder dystocia occurs.