Case presentation Shoulder dystocia ผู้นำเสนอ พญ. ศิริฤทัย อำนาจบุดดี ที่ปรึกษา รศ.นพ.วิทูรย์ ประเสริฐเจริญสุข

มารดาอายุ 26 ปี G1P0 GA 39 wks LMP 9/8/50 EDC 16/5/51 contraception : no CC : มีน้ำใสๆไหลออกมาจากช่องคลอด 30 นาที PI : 30 นาที ก่อนมารพ. มีน้ำใสๆไหลออกมาจากช่องคลอด เปื้อนผ้าถุง ไม่มีกลิ่น กลั้นไม่ได้ ไม่มีมูกเลือดออกจากช่อง คลอด ไม่เจ็บครรภ์ ลูกดิ้นปกติ

PH : ปฏิเสธโรคประจำตัว ไม่เคยแพ้ยา ไม่เคยผ่าตัด FH : ปฏิเสธโรคถ่ายทอดทางพันธุกรรม การตั้งครรภ์ผิดปกติ

ANC. : ANC รพ. นพรัตน์ 4 ครั้ง , รพ. ศรีนครินทร์ 7 ครั้ง ANC : ANC รพ.นพรัตน์ 4 ครั้ง , รพ.ศรีนครินทร์ 7 ครั้ง ANC ครั้งแรก GA 9+2 wk : BW ก่อนตั้งครรภ์ 49kgBWก่อนคลอด75kg รวมน้ำหนักตลอดการตั้งครรภ์ขึ้น 26 kg ส่วนสูง 154 cm : TT ครบ 2 ครั้ง : Blood Group A Hct32.5Hb 10.9 VDRL:NR HBsAg:neg AntiHIV:NR : ไม่มีภาวะแทรกซ้อนระหว่างตั้งครรภ์

Physical examination General appearance : A middle age pregnant woman, alert Height 154 cm BW 75 kg Vital sign : BT 37 c PR 84 bpm RR 20 tpm BP 112/62 mmHg HEENT : Pink conjunctivae, Anicteric sclerae Heart : Normal S1S2 Lung : Clear Breasts : No nipple retraction, no mass

Abdomen : FH ¾ > umbilicus Presentation : vertex Position : OR FHS : 156 bpm Engagement : HE EFW : 3200 gm Extremities : No edema

PV : Cervical dilatation 2 cm Effacement 50% Station 0 Membrane ruptured Posterior position Adequate pelvicmetry

การดำเนินการคลอด 9/5/51 20.05 : sterile dry speculum: seen clear AF in posterior fornix, cough test+, pH8 Fern test+ PV 2 cm 50% MR 0 IPM: normal contraction D 35” I>10’ 10/5/51 6.35 : PV 2 cm 50% MR 0 10/5/51 7.10 : Syntocinon IV drip 10/5/51 7.35 : contraction D 35” I 2’50” 10/5/51 9.15 : PV 3 cm 50% MR 0 contraction D 35” I 3’20”

การดำเนินการคลอด 10/5/51 11.00 : good contraction IPM-normal 10/5/51 12.15 : PV 4 cm 100% MR 0 10/5/51 13.25 : PV 9 cm 100% MR +1 10/5/51 13.55 : PV fully dilatation MR+2 ย้ายห้องคลอด

Partograph

การดำเนินการคลอด NL c RML ระหว่างทำคลอด ทำคลอดไหล่ยาก ติดนานประมาณ 30 วินาที เด็กเกิดเวลา 14.34 น. วันที่ 10 พ.ค 51 ได้ female baby , BW 3490 gm Apgar 7,10 แรกเกิดตัวซีดtoneน้อย ไม่ร้อง หายใจ irregular HR>100 ให้ oxygen flow, suction, กระตุ้น ที่ 4 นาที ตัวแดงดี อวัยวะครบ cord+anus ปกติ ศีรษะมี caput ยาว แขนขวายกได้น้อยกว่าแขนซ้าย รกคลอดเวลา 14.39 น.

Shoulder dystocia

Shoulder dystocia Defined as the need for additional obstetric maneuvers to effect delivery of the fetal shoulders at the time of vaginal delivery

Incidence occurs in 0.2 to 3 percent of all births Incidence increased from birth weight

Maternal consequences Postpartum hemorrhage Usually from uterine atony Vaginal and cervical laceration

Fetal consequences Gherman and co-worker reviewed 285 cases of shoulder dystocia and found 25 percent were associated with fetal injuries. Most common: transient Erb or Duchenne brachial plexus palsies 38% clavicular fracture 17% humeral fracture One neonatal death 4 newborns had persistent brachial plexus injuries

Fetal consequences ½ required a direct fetal manipulation such as Woods maneuver, in addition to McRoberts procedure That was not associated with an increase rate of fetal injury

Brachial plexus injury

Brachial plexus injury

Brachial plexus injury Usually results from downward traction on the brachial plexus during delivery of anterior shoulder Erb 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

Brachial plexus injury 80% had complete recovery by 13 months and none with residual defects had severe sensory or motor deficits in the hand BPI may precede delivery itself and may occur prior to labor Unpredictable before birth

Clavicular fracture The second most common injury and have been diagnosed in 0.4% of newborns delivered vaginally at Parkland hospital Often fractures without any suspect clinical events Isolated fx clavicles are unavoidable, unpredictable and of no clinical consequence

Risk factors Maternal risk factors Obesity Multiparity Diabetes Postterm associated with increased birth weight Recurrent shoulder dystocia : Incidence 1 to 17 percent in retrospective studies

Incidence of shoulder dystocia according to birthweight grouping in Singleton Neonates Delivered Vaginally in 1994 at Parkland Hospital Birthweight group Births Shoulder dystocia (%) <= 3000 g 3001 - 3500 g 3500 - 4000 g 4001 - 4500 g > 4500 g All weights 2,953 4,309 2,839 704 91 10,896 14 (0.3) 28 (1.0) 38 (5.4) 17 (19.0) 97 (0.9)

Summary The American College of Obstetricians and Gynecologists (2002) conclude that most cases of shoulder dystocia cannot be accurately predicted or prevented Elective induction of labor or elective cesarean delivery for all woman suspected of carrying a macrosomia fetus is not appropiate Planned 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

Management shoulder dystocia drill Call for help Suprapubic pressure can be applied by assistant while downward traction is applied to the fetal head

Management 2.The McRoberts maneuver This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position straightening of the sacral promontory , results in cephalad rotation of the pubic symphysis and decrease in the angle of pelvic inclination

Management 2.The McRoberts maneuver The McRoberts maneuver alone is believed to relieve more than 40 percent of all shoulder dystocias and, when combined with suprapubic pressure, resolves more than 50 percent of shoulder dystocias. [SOR evidence level B, retrospective cohort study]

The McRoberts maneuver and suprapubic pressure.

McRoberts maneuver

Management 3. Woods corkscrew maneuver Progressively rotating the posterior shoulder 180 degree in corkscrew fashion The impacted anterior shoulder could be release

Management 4. Delivery of the posterior shoulder Sweeping the posterior arm of the fetus across the chest followed by delivery of the arm The shoulder girdle is then rotate into one of the oblique diameter or the pelvis With subsequent delivery of anterior shoulder The major risk of this procedure is that of fracturing the humerus

Delivery of the posterior shoulder

Management 5.Rubin 6.Fracture of the clavicle first: apply force to maternal abdomen second : pushed toward the anterior surface of the chest, result in abduction of the shoulder,reducing shoulder-to-shoulder diameter  6.Fracture of the clavicle decrease the transverse diameter of the chest and shoulders

Management 7.Hibbard 8.Zavanelli maneuver apply pressure to fetal jaw and neck in the direction of maternal rectum with strong fundal pressure 8.Zavanelli maneuver flexing 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)

Management 9. Cleidotomy 10.Symphysiotomy cut the clavicle with the scissors 10.Symphysiotomy had been performed in the past and is now performed only in areas remote from the ability to perform Cesarean sections on a rapid basis.

Conclusion Shoulder 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 deliveries No maneuver is clearly superior for resolving the dystocia and preventing injury.