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Many people believe that cardiac arrest is the scariest event that occurs in a hospital. I disagree. More often than not a code blue involves a frail elderly patient who was in critical condition long before the code.

In contrast, shoulder dystocia generally involves a healthy term baby with its entire life ahead of it. While I don't mean to belittle the challenge that confronts internists and others when their code-blue beepers go off, I believe that we obstetricians face an even greater challenge.

Simply stated, shoulder dystocia is our worst nightmare. Some "experts" claim that shoulder dystocia can generally be prevented, but large studies clearly prove them wrong. Some of these experts go so far as to claim shoulder dystocia is easy to manage and that Erb's palsy or brain damage is proof that the case was mismanaged. What a bunch of baloney! These so-called experts would probably wet their pants if faced with a shoulder dystocia that didn't quickly respond to basic maneuvers.

While there is no reliable way to predict or easy way to manage this emergency, there are several concepts that may help.

* In an emergency, take your own pulse first.

Dr. Rebecca Ryder from Chesapeake, Va., sent in this pearl that aptly applies to many difficult situations in obstetrics and particularly well to shoulder dystocia. When an impacted shoulder does not respond to the McRoberts maneuver, you know you have a problem. But even in an emergency, you do have time to take a few deep breaths, gather your thoughts, and focus on staying calm. What are you going to try first, second ... fifth? Knowing that you have many techniques to try will help you to stay calm when the first one or two don't do the job.

* Look for the mini-turtle sign.

Dr. Marshall Matthews of Moses Lake, Wash., sent in a pearl that seems to make a lot of sense. If there is no urgent need to deliver the baby, he tries not to apply forceps or vacuum or even cut an episiotomy until the head comes down to the introitus and stays there between contractions. He has not had a shoulder dystocia in many years by following this policy.

We've all seen the turtle sign where the head delivers and then retracts. Perhaps intermittent retraction between contractions reflects a mild version of the same process. I have not seen a formal study on this concept, and if it hasn't been done, it would be a valuable project.

* Twist the shoulders, not the head.

Many rotational techniques, including the famous Woods maneuver, have been described as methods that attempt to move the impacted anterior shoulder out from under the symphysis. They vary in amount of rotation (a few degrees to 180 degrees or more) and direction (pushing on the front or back of the upper or lower shoulder).

But unless I'm mistaken, all rotational techniques involve pressure on the shoulders, not the head. Some doctors say, "never touch the head" once shoulder dystocia has been diagnosed. This is not realistic, and most articles and texts state that gentle traction to the head is quite appropriate. But avoid excessive twisting when traction is used.

DR. BRUCE L. FLAMM is area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif.
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Publication:OB GYN News
Date:Apr 15, 2001
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