By Jenny Farah, MD
29F, G3P2, at 37 weeks, presents with gradually worsening abdominal pain and the sensation that she needs to push. You go to do a pelvic exam and see this…
Both shoulder dystocia and breech presentations can be scary and stressful. Many residents can go through residency and never encounter one of these cases. Thus, it’s essential we review strategies for successful delivery.
What is Shoulder Dystocia?
– Failure of the anterior shoulder to pass below the pubic symphysis
How can I detect it?
– Protracted labor: The stages of labor are not progressing as planned
– Turtle Sign: Appearance and retraction of the fetal head
– Facial flushing: Erythematous and puffy fetal face
What should I do if I detect Shoulder Dystocia?
Management is separated by maternal and fetal maneuvers.
Remember… Avoid the 3 P’s – Pushing, Pulling & Pivoting!!!
1) Place a Foley: This decompresses the bladder and gives you more room to manipulate the baby’s position.
2) McRoberts Maneuver + Suprapubic Pressure: With an assistant applying suprapubic (not fundal!) pressure, place mom’s legs in hyperflexion. This will widen the pelvic basin.
3) Place on “all-fours:” If you still need to widen the pelvic space, you can place mom on “all-fours” while applying your fetal maneuvers.
4) Episiotomy: Only if necessary, cut a lateral incision to provide more space in the vaginal vault.
1) Rotation Maneuvers (Woods + Rubin): Place your fingers on the posterior shoulder and rotate the baby to help dislodge the stuck anterior shoulder into the posterior plane.
2) Posterior arm delivery: Delivering the posterior arm can help expand your space. The arm is usually flexed at the elbow. If it is not, apply pressure in the antecubital fossa which will cause a reflexive flexion at the elbow. The hand is then grasped, swept across the chest and delivered.
3) Fracture Clavicle: Only if absolutely necessary, you may fracture the baby’s anterior clavicle to reduce the shoulder-to-shoulder distance. This can be accomplished by applying direct upward pressure on the mid-portion of the fetal clavicle.
Posterior Arm Delivery
Fracturing the Fetal Clavicle
What are the different types of breech pregnancies?
-Frank breech (50-70%): Hips flexed, knees extended (pike position)
-Complete breech (5-10%): Hips flexed, knees flexed (cannonball position)
-Footling or incomplete (10-30%): One or both hips extended, foot presenting
What should I do if I encounter a breech delivery?
Most of these cases will be managed by an OBGYN and involve a C-section. However, if you are faced with a breech presentation, and labor is progressing, here are some helpful tips to ensure successful delivery.
Once the presenting part has delivered, such as a foot, one may be tempted to pull on it. However, this should be avoided as it can precipitate 2 things: head entrapment in an incompletely dilated cervix or the raising of the baby’s arms, which will complicate delivery even further. Thus, as long as the baby’s vitals remain normal, allow for delivery to progress naturally.
Do not apply any downward traction until the umbilicus is reached.
After the scapula is reached, rotate the fetus 90 degrees to deliver the anterior arm.
Once both arms are delivered, and the head is the only part that has not presented, wrap a towel around the fetal hips, and apply gentle downward and outward traction (see below).
At this stage, support the fetal body in a neutral position and maintain flexion of the head with the Mauriceau maneuver.
The Mauriceau maneuver includes the following:
- Have an assistant apply suprapubic pressure
- Apply gentle pressure on the fetal maxilla with your index and middle fingers, bringing the neck to moderate flexion
- Use your other hand to grab the shoulders and pull them in the direction of the fetal pelvis.
A key goal is to keep the baby’s head flexed during this procedure. This can be aided by the use of Piper forceps if necessary.
Remember, like with shoulder dystocia, avoid the 3 P’s… Pushing, Pulling & Pivoting!!!
Congratulations! You now are ready to tackle these delivery complications!