If your emergency department is in an area like mine (or even more remote), you do not have an in-house obstetrician. At night, the on-call obstetrician is at least 20 minutes away, if not longer. To make matters worse, it still takes at least 5-10 minutes to come from clinic during the day. This means our emergency physicians deliver more babies each year than those at larger centers. Sometimes those babies just won’t wait.
This month we talk about a case I had earlier this year: a precipitous delivery in the Emergency Department. This case was complicated by a shoulder dystocia. We talk about what I did in the case, my thought process at the time, what I would do differently, and then discuss the current recommendations for shoulder dystocia.
Shoulder dystocia is fairly common and occurs in 1-2% of the delivers. If this is not recognized quickly and if the shoulder is not delivered, this can lead to brachial plexus injuries, hypoxia, and even death. There is a mnemonic that can help you remember the steps to take to allow you to successfully deliver the baby. This mnemonic is HELPERR:
H: Call for Help
E: Evaluate for Episiotomy
L: Legs (McRoberts maneuver)
P: Pressure in the suprapubic region
E: Enter the vagina (rotational maneuvers)
R: Remove the posterior arm
R: Roll the patient to hands and knees.
The first step is to call for help. This is important as you will need additional staff to help you with these maneuvers and to help in ressusitative maneuvers if required.
Once you have called for help, you can evaluate the need for episiotomy. The main reason for the episiotomy is to allow to you more easily place fingers into the vaginal vault for maneuvering the fetus.
The first maneuver that you should try is the McRoberts Maneuver. This is hyperflexion of the hips and abduction of the legs. This rotates the pelvis and helps the pubic symphysis slide over the anterior shoulder. It can also cause the posterior shoulder to drop into the sacrum which also allows the anterior shoulder to be more easily delivered. The success rate varies in the literature from 40-90%.
The next step is to apply suprapubic pressure with the patient in the McRoberts position. This is NOT fundal pressure. This is applied by applying pressure to the posterior aspect of the anterior shoulder of the fetus. This is an attempt to reduce the shoulder-to-shoulder width and to rotate the shoulders to an oblique orientation allowing delivery of the anterior shoulder. This can be done either with a continuous pressure or by a rocking pressure.
If these maneuvers have not delivered the anterior shoulder, the next is rotational maneuvers. The first is Rubin’s maneuver. This is performed by placing a finger into the vaginal vault and applying pressure on the back of the anterior shoulder. This attempts to reduce the shoulder-to-shoulder distance and to rotate the shoulders into an oblique position allowing delivery of the anterior shoulder.
The next step if the shoulder dystocia has not been relieved is the Wood’s Corkscrew Maneuver. You apply pressure to the posterior aspect of the anterior shoulder with one finger and with the other hand you apply pressure to the anterior aspect of the posterior shoulder. This will create a rotational force that will add more rotation to help deliver the shoulder. This can be done to perform 180 degrees of roatation within the vaginal vault. You can also perform a reverse corkscrew maneuver to rotate the baby in the opposite direction.
If these rotational maneuver fails, you can also attempt to deliver the posterior arm. This is done by tracing the posterior arm from the shoulder, down the humerus, and locating the forearm. Once the forearm is located you swipe the forearm across the chest and then out of the vagina. This will cause the posterior shoulder to deliver which will in turn allow the anterior shoulder to deliver. If you cannot find the forearm, you can apply pressure to the antecubital fossa causing the elbow to flex which will bring the forearm into reach.
If these maneuvers fail you can rotate the mother into a hands and knees position and attempt to deliver the baby.
One maneuver that is not taught frequently in the United States is axillary traction. This is performed by inserting the index or middle finger of both hands into the vaginal vault and hooking them under each axilla. This allows you to deliver either the anterior or posterior shoulder. If this fails you can perform the rotational maneuvers as above but this time with more outward traction. Take care to not apply too much traction as it can cause a humeral fracture.
The last resort that can be made is to fracture the clavicle. This reduces the shoulder-to-shoulder distance allowing for delivery of the baby. This often increases the risk of brachial plexus injuries and vascular injuries, therefore this should only be used as a last resort.
If all of the above maneuvers fail, the last step is the Zavanelli maneuver. This is performed by pushing the head back into the mother until a c-section can be performed. This is a difficult option in the small hospital as there may not be an obstetrician nearby.
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