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Shoulder dystocia
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Randall C. Floyd, James S. Smeltzer
An average-sized assistant can effectively apply the maneuver with correct application of force and mass to mechanical advantage in the following fashion: (i) face the patient’s head from near the stirrup, (ii) place her knee on your inboard shoulder, and (iii) lock your hands or forearms around the upper thigh and pull the upper thigh snugly against your hip and bend forward, using your mass to flex the hip. The McRoberts maneuver works most of the time if it is used in experienced hands (41) and over 80% of the time at many institutions.
Management of pregnancy with a history of shoulder dystocia and difficult delivery
Published in Minakshi Rohilla, Recurrent Pregnancy Loss and Adverse Natal Outcomes, 2020
A literature search shows scant scientific data that favor the universal practice of episiotomy in all cases of shoulder dystocia [28] (Figure 11.1). Regarding the role of the obstetrician in this challenging situation, the literature does not favor one maneuver over another for managing this complication. It is well documented in the trials that the dreaded complication of neonatal BPI may result from any maneuver in carrying out shoulder disimpaction and thus causing stretch on the nerves of the brachial plexus [2]. There are various maneuvers that can be of help when shoulder dystocia occurs at the time of delivery. The first maneuver that should be put into practice is the McRoberts maneuver as it is quite simple and entails hyperflexion of the maternal thighs onto her abdomen. It is successful in a significant number of cases, and the shoulders can usually be disimpacted without much trauma to the infant as well as the parturient [29]. Simultaneously, suprapubic pressure is given by the assistant with the palm so as to abduct and rotate the anterior shoulder in a downward and lateral direction that resolves its impaction. Use of fundal pressure worsens the shoulder impaction, and uterine rupture may occur due to undue force; therefore, this should not be employed at any time in these cases [12]. If still not successful, one can attempt delivery of the posterior arm instead of the anterior arm, which has been shown to be highly successful in alleviating dystocia and achieving vaginal delivery [30]. In almost all such cases, the complications of shoulder dystocia can be resolved within a time frame of less than 5 minutes with the help of these maneuvers [29].
Mirror Syndrome with Severe Postpartum Presentation following Stillbirth and Shoulder Dystocia
Published in Fetal and Pediatric Pathology, 2020
Pawel Bartnik, Joanna Kacperczyk-Bartnik, Aneta Malinowska-Polubiec, Ewa Romejko-Wolniewicz
A 33-year-old patient G3P0A2 at 34 weeks of gestation was referred to the hospital with a fetal ultrasound diagnosis of Ebstein anomaly and fetal hydrops. The reason for hospitalization was to monitor the fetus until delivery with cardiotocography (CTG) and ultrasound examinations. On admission, the mother manifested no significant abnormalities despite mild swelling of lower extremities. Routine laboratory results showed anemia (hemoglobin concentration = 8.6g/dL; hematocrit = 26.8%), however it was present and treated with iron supplementation from the early second trimester. Digoxin was administered in order to enhance fetal heart function. During the hospitalization patient was monitored by a Doppler ultrasound examination twice a week and cardiotocography. No placental edema was observed in the routine ultrasound scans. At 36 weeks of gestation CTG showed deep and repeated fetal heart rate decelerations and after a rapid consultation with the mother, an emergency cesarean section was planned. Short CTG monitoring routinely performed in the operating room moments before the c-section showed no fetal heart rate and ultrasound examination confirmed fetal demise with placental hydrops. The decision for a c-section was withdrawn and labor was induced with misoprostol. No risk factors for shoulder dystocia were present. The placenta was located on the anterior uterine wall. The mother delivered a stillborn male child weighting 4180 g. Birth was complicated by shoulder dystocia with McRoberts maneuver, anterior shoulder disimpaction and manual posterior shoulder delivery. Twelve hours after delivery, the mother developed massive subcutaneous edema of the whole body, oliguria and increased serum creatinine level (CrL) along with laboratory abnormalities typical for MS (Table 1). Patient was treated with furosemide combined with intense hydration. No hypertension at any point during observation, nor epigastric pain was present. Five days postpartum serum CrL peaked and soluble fms-like tyrosine kinase 1 (sFlt-1)/placental growth factor (PlGF) were measured (Table 1). Twelve days after delivery CrL normalized and edema resolved. Histopathological examination results confirmed placental hydrops with placental weight of 1330 g, diameter of 23 cm and thickness of 4 cm. No vascular nor inflammatory changes in the placental microscopic examination such as erythroblastosis, trophoblastic hyperplasia, avascular villi, villitis, intervillositis were observed. There were no features of placenta accreta. The only microscopically identified pathology was the general placental hydrops. Consent for autopsy was refused.