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Get experienced help for unexpected shoulder dystocia. (Without Macrosomia).

CANCUN, MEXICO -- Macrosomia is not the only route to shoulder dystocia.

"The problem with shoulder dystocia is that not all cases involve babies who are more than 4,500 g or even more than 4,000 g," Dr. John T. Queenan said at a conference on obstetrics, gynecology perinatal medicine, neonatology and the law.

'About 40%-50% of shoulder dystocia cases involve babies without macrosomia"--a mother with an abnormally shaped pelvis, for example--which means that "no matter what an obstetrician does, there occasionally will be infants born with shoulder dystocia," he noted.

It's these unanticipated cases of shoulder dystocia that can cause real trouble. "V/hen a fetus is more than 4,500 g you can make plans, but with smaller babies you won't know until it occurs. It's virtually impossible to screen for all shoulder dystocia," said Dr. Queenan, professor of ob.gyn. at Georgetown University, Washington.

The upshot is that shoulder dystocia is bound to appear unexpectedly and when it does it's a "true medical emergency" that requires an obstetrician to get all the help available, he said.

"Once shoulder dystocia occurs, the physician needs to make everything else as optimal as possible and that includes getting help from people with as much experience with dystocia as are available," Dr. Queenan told this newspaper. Some options for dealing with shoulder dystocia include the McRoberts' maneuver, episotomy, suprapubic pressure, posterior arm delivery, Woods maneuver, and cephalic replacement.

When macrosomia occurs, the risk of shoulder dystocia is much more obvious, especially for fetuses that weigh more than 4,500 g. The standard of care is to offer the mother cesarean delivery Dr. Queenan said at the conference, which was sponsored by Boston University and the Center for Human Genetics.

But the best mode of delivery for large fetuses that are less than 4,500 g is not as clearcut. A cesarean delivery for fetuses that weigh less than 4,500 g must be based on a physician's clinical judgment, taking into account factors such as the mother's history of prior deliveries.

Physicians should also keep in mind that ultrasound measurements tend to underestimate the size of fetuses that are already large (although ultrasound tends to overestimate the size of small fetuses near term).
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Author:Zoler, Mitchel L.
Publication:OB GYN News
Date:Apr 15, 2003
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