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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Shoulder Dystocia
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6. Maneuvers
If your patient has risk factors for SD, have your backup standing by to be able to help you with the mother, as well as to be able to help resuscitate the potentially depressed infant after birth. If SD occurs unexpectedly at the time of delivery, certainly put in that “911 call” to get all the help you can quickly. As the delivery progresses, attempt the C C C ‘Deliver Through’ maneuver. If unsuccessful, then proceed with the following.
First, don’t panic! Remember, if you’re alone at the time, it’s going to be up to you to resolve the situation, and you need to be calm to think clearly, and to be able to communicate reassurance to the mother and enlist her cooperation. The “3 P’s of Panic” in SD are: “pulling, pushing, and pivoting”. Don’t!
In the short time available to you to obtain a good outcome, act decisively and effectively, and remember to be gentle.
If you don’t have the patient in stirrups, it is okay, just move her to the edge of the bed. Laying on her side (Sims position) at the edge of the bed, pulling her knees up onto her abdomen, is often a good maneuver.
You might also consider having the patient turn to her hands and knees (the Gaskin position), a posture that will often give you that extra centimeter or two that will allow delivery.
Now back to step 1
If the woman is in lithotomy position, have her, or two attendants, draw her knees up onto her abdomen, the McRobert’s maneuver (see diagram below), another maneuver that will often give you that little bit of extra room necessary.
Next, apply suprapubic pressure. Remember, the problem is that the anterior shoulder is impacted behind the symphysis pubis.
This is “orthopedic” type pressure to reduce the impaction, not gentle “two-finger” pressure, but rather using your fist to reduce the shoulder under the symphysis. It is of course uncomfortable for the mother, so warn her about what you’re going to do and enlist her help. The problem is anterior, not posterior, so at this point don’t waste time doing an episiotomy. Almost 80 per cent of SD will resolve with these two simple maneuvers alone.
Remember, don’t apply fundal pressure; that may make the impaction worse. You may apply gentle downward traction, but don’t pull on the fetal head or neck; that may well result in brachial plexus injury.
