Saturday, March 14, 2015

Managing a Shoulder Dystocia

Good afternoon, doctor.  Are you enjoying your quiet Sunday afternoon shift with this snowstorm outside (just playing odds this year)?  That's great.  Well, I hate to break up the calm, but I have this patient out here in the waiting room?   She says she's like a G8P5 or something, and she's 38 weeks, and she thinks she's in labor?  She's in a lot of pain and it appears that her contractions are occurring every minute or so.

Maybe you  have obstetrical capabilities at your hospital or maybe you don't.  In this case it doesn't matter as there is no time.  You get the patient into the stirrups and have her push.  The head starts coming nicely and quickly, but then everything....stops...all...of...a...sudden.  It would appear that this large child has become stuck on the pelvic brim, and is "turtling" back into the womb!

Deliveries in the ED are obviously a rare event, and dystocias are a rarity inside of this rarity (representing about 0.6% to 1.4% of deliveries), but they still happen, and you need to know what to do if you end up with the catcher's mitt.

First of all, you'll need help.  A HELPERR to be exact!  





This is a great mnemonic to run through the initial algorithm. (ALARMER is another good one).  But seriously, first step--call for some help.  You will need at least two additional pair of hands regardless  of how
Han Solo you like to be in your shop. On top of that, get someone else on the phone. If there's an obstetrician in house, call them.  If there's a neonatologist in house, call them.  If there's an anesthesiologist in house....you get the idea.  

Tell your patient to stop pushing--her Valsalva'ing may potentially worsen the situation so you'll need to take over.  Have a look at the perineum--will a quick episiotomy let the baby fall out?  The answer is probably not, and it's controversial (some studies have shown that it increases risk for severe perineal trauma), but it's always good to have a look.  



The money will likely be in the McRoberts maneuver.  Studies have shown that this alone will solve the problem in almost half of cases, so do it right!  You'll need an assistant on either side to get the patient's legs back in extreme, extreme super lithotomy to rotate the pubic symphysis superiorally.  Have them hyperflex the hips with the knees pushed to the chest.

Supplement this with suprapubic (not fundal!) pressure directed inferiorally to hopefully push the anterior shoulder out.  This is also known as the Mazzanti maneuver--dystocia is just crawling with eponyms. 

If unsuccessful, try rotational maneuvers like the famous Woods' Screw, aka the Rubin Technique.  Essentially you'll want to place a finger into the vagina, anterior to the infant's posterior shoulder.  Then rotate 180 degrees, like a big old screw in the wall.  The reverse Woods' is as expected, and involves the posterior aspect of the shoulder (and theoretically should be more effective).

Continuing on, you can try to deliver the posterior shoulder by flexing the arm, gripping the humerus (gently and evenly of course) and then sweeping it across the chest and then out the vagina.  No luck?  We move on to the last "R" of HELPERR, which stands for"roll onto all fours."  This refers to the Gaskin maneuver, which utilizes downward traction on the head to allow the posterior shoulder to descend and be delivered.  You can also deliver the posterior arm in this position.



There are a number of remaining last resorts, like fracturing the fetal clavicle, or the ultimate Zavanelli, but they are so incredibly risky and controversial we won't even begin to describe them.  

Here's a very calm (unlike the real thing) demonstration on a model:


As always, these posts are for EDUCATIONAL PURPOSES ONLY.  If you have to catch a baby and you're in trouble, call for help if it's available.  Don't try to be a hero.  Seriously.


Sources:

del Portal MD, D. A., MD, A. E. H., MD, G. M. V., MD, T. C. C., & MD, J. W. U. (2014). Technical Tips. Journal of Emergency Medicine, 46(3), 378–382. doi:10.1016/j.jemermed.2013.08.110

Gherman, R. B., Goodwin, T. M., Souter, I., Neumann, K., Ouzounian, J. G., & Paul, R. H. (1997). The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it? American Journal of Obstetrics and Gynecology, 176(3), 656–661.

Roberts and Hedges Clinical Procedures in Emergency Medicine, Sixth Edition. Chapter 56.