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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Shoulder Dystocia
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9. Maneuvers of last resort
First, regroup, then repeat
It may be time to regroup now. You have performed a number of the first line maneuvers, so re-evaluate what resources you to work with to maximize success. In some cases you can just repeat one of the previous maneuvers, but it will suddenly work this time because there has been a subtle change in the fetal position.
It would be especially important to have tried all the internal maneuvers again if you have rolled the patient to hands and knees position, or Gaskin position.
Remember, it is not the number of procedures that you do which results in neonatal hypoxic-ischemic encephalopathy, but the time it takes you to extract the fetus. Extraction in less than 5 minutes is ideal, but good outcomes have resulted when several more minutes were necessary.
Someone in the room should be instructed to be “the clock watcher” so you know how much time has passed, and so you can try something different if one maneuver doesn’t seem to be working for you.
Maneuvers of last resort
In a rare case, none of the previous maneuvers will effect delivery. In that situation, and especially if you have access to prompt cesarean delivery, you may try cephalic replacement (the Zavanelli maneuver). It sounds horrendous, but it is possible.
You must flex the head (the reverse of how it delivered) and then reinsert it with upward pressure. This hopefully will decompress the occluded cord and allow time for intrauterine resuscitation until you can accomplish cesarean delivery.
Complications are high, but, as a life-saving maneuver, it is better to try than let the fetus die. Despite not wanting to try something you’ve never done before (!), it must be done relatively promptly if you hope to prevent permanent hypoxic injury, and your other maneuvers have failed.
Other maneuvers of last resort
Deliberate clavicle fracture:
Please note: this may not be as easy as it sounds - direct upward pressure on the mid-portion of the fetal clavicle; reduces the shoulder-to-shoulder distance.
General anesthesia:
The musculoskeletal soft tissue and uterus finally relaxes. This could also be a lead-in to the step below. Nitroglycerin is potent smooth muscle relaxant.
Abdominal surgery and hysterotomy:
Surgeon rotates fetus from above while vaginal operator completes extraction
Symphysiotomy:
Used in developing countries, but would be a ‘last ditch’ maneuver in settings with other resources.
