5 Physical examinationGeneral appearance : A middle age pregnant woman, alertHeight 154 cm BW 75 kgVital sign : BT 37 c PR 84 bpmRR 20 tpm BP 112/62 mmHgHEENT : Pink conjunctivae, Anicteric scleraeHeart : Normal S1S2Lung : ClearBreasts : No nipple retraction, no mass
8 การดำเนินการคลอด9/5/ : sterile dry speculum: seen clear AF in posterior fornix, cough test+, pH8 Fern test PV 2 cm 50% MR IPM: normal contraction D 35” I>10’10/5/ : PV 2 cm 50% MR 010/5/ : Syntocinon IV drip10/5/ : contraction D 35” I 2’50”10/5/ : PV 3 cm 50% MR contraction D 35” I 3’20”
9 การดำเนินการคลอด 10/5/51 11.00 : good contraction IPM-normal 10/5/ : PV 4 cm 100% MR 010/5/ : PV 9 cm 100% MR +110/5/ : PV fully dilatation MR+2ย้ายห้องคลอด
20 Brachial plexus injury Usually results from downward traction on the brachial plexus during delivery of anterior shoulderErb palsy : Injury to the upper part of the brachial plexus (C5-6s ometimesC7 )Klumpke palsy : Injury to the lower nerves of the plexus: Involvement of C7 – T1
21 Brachial plexus injury 80% had complete recovery by 13 months andnone with residual defects had severe sensory ormotor deficits in the handBPI may precede delivery itself and may occurprior to laborUnpredictable before birth
22 Clavicular fracture The second most common injury and have been diagnosed in 0.4% of newborns deliveredvaginally at Parkland hospitalOften fractures without any suspect clinicaleventsIsolated fx clavicles are unavoidable,unpredictable and of no clinical consequence
23 Risk factors Maternal risk factors Obesity Multiparity Diabetes Posttermassociated with increased birth weightRecurrent shoulder dystocia : Incidence 1 to 17 percent in retrospective studies
24 Incidence of shoulder dystocia according to birthweight grouping in Singleton Neonates Delivered Vaginally in 1994 at Parkland HospitalBirthweight groupBirthsShoulder dystocia (%)<= 3000 gggg> 4500 gAll weights2,9534,3092,8397049110,89614 (0.3)28 (1.0)38 (5.4)17 (19.0)97 (0.9)
25 SummaryThe American College of Obstetricians and Gynecologists (2002) conclude thatmost cases of shoulder dystocia cannot be accurately predicted or preventedElective induction of labor or elective cesarean delivery for all woman suspected of carrying a macrosomia fetus is not appropiatePlanned cesarean delivery may be considered for the non-diabetic woman carrying a fetus with EFW exceeding 5000 g or the diabetic woman whose fetus EFW more than 4500 g
26 Management shoulder dystocia drill Call for help Suprapubic pressure can be applied by assistant while downward traction is applied to the fetal head
27 Management 2.The McRoberts maneuver This procedure involves flexing and abductingthe maternal hips, positioning the maternalthighs up onto the maternal abdomen.This position straightening of the sacralpromontory , results in cephalad rotation of thepubic symphysis and decrease in the angle ofpelvic inclination
28 Management 2.The McRoberts maneuver The McRoberts maneuver alone is believed torelieve more than 40 percent of all shoulderdystocias and, when combined with suprapubicpressure, resolves more than 50 percent ofshoulder dystocias. [SOR evidence level B,retrospective cohort study]
29 The McRoberts maneuver and suprapubic pressure.
31 Management 3. Woods corkscrew maneuver Progressively rotating the posterior shoulder 180 degree in corkscrew fashionThe impacted anterior shoulder could be release
32 Management 4. Delivery of the posterior shoulder Sweeping the posterior arm of the fetus across the chest followed by delivery of the armThe shoulder girdle is then rotate into one of the oblique diameter or the pelvisWith subsequent delivery of anterior shoulderThe major risk of this procedure is that of fracturing the humerus
34 Management 5.Rubin 6.Fracture of the clavicle first: apply force to maternal abdomensecond : pushed toward the anterior surface of the chest, result in abduction of the shoulder,reducing shoulder-to-shoulder diameter 6.Fracture of the clavicledecrease the transverse diameter of the chest and shoulders
35 Management 7.Hibbard 8.Zavanelli maneuver apply pressure to fetal jaw and neck in the direction of maternal rectum with strong fundal pressure8.Zavanelli maneuverflexing the fetal head and pushing it back up into the vagina to get the fetal head back into the pelvis, perform an emergency cesarean section, and deliver a live baby.Success 91% , fetal injuries were common (neonatal death, stilbirth,brain damage,uterine rupture)
36 Management 9. Cleidotomy 10.Symphysiotomy cut the clavicle with the scissors10.Symphysiotomyhad been performed in the past and is now performed only in areas remote from the ability to perform Cesarean sections on a rapid basis.
37 ConclusionShoulder dystocia is defined as failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head.The occurrence cannot be accurately predicted. Therefore, the clinician should be prepared for possible shoulder dystocia in all vaginal deliveriesNo maneuver is clearly superior for resolving the dystocia and preventing injury.
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