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Managing Shoulder Dystocia: Don't Panic.

ASHEVILLE, N.C. -- Time may seem to fly during an obstetrical emergency such as shoulder dystocia, but don't panic--with a healthy baby you still have a good 5 minutes before you have to start worrying about hypoxic injury.

Use that time to think about maneuvers and to systematically plan your approach, Dr. Sharon T Phelan said at the annual Southern Obstetric and Gynecologic Seminar.

"As soon as you recognize that you have shoulder dystocia, have a nurse call out the time," said Dr. Phelan of the University of Alabama, Birmingham.

The turtle sign should alert you to the problem. Don't panic. At this time, alert the staff and tell the patient you will need her full cooperation and then perform the McRoberts' maneuver, Dr. Phelan said.

Some people argue that this should be done later, but it's a simple noninvasive maneuver that may work. The patient can pull back her own legs, or a nurse can pull back one, while whoever is attending the patient can pull back the other. The legs should be pulled back from the midline. This may disengage the shoulder.

If it does not, episiotomy may help by providing more room to work. Applying suprapubic pressure may also help.

If that doesn't work, rotational measures must be used.

While your instincts say to pull on the head, resist that urge, Dr. Phelan warned. The focus should be on the shoulders until they are free; only then is it safe to pull on the head.

The baby can be rotated in either direction. The shoulder should be adducted, and two hands, if necessary can be used for rotation. If this doesn't work, the next option is delivery of the posterior shoulder.

There is nothing simple about this, Dr. Phelan stressed, and in up to half of all cases, a bone gets broken.

If none of these maneuvers works, some physicians have been known to completely or partially cut the pubic symphysis, which allows more room for the baby to be delivered. An audience member described this procedure, saying she had successfully performed it outside the United States. However, it is not a widely accepted practice in this country.

If all options have been exhausted within the 5-minute window, cephalic replacement and cesarean section are necessary to avoid hypoxic injury to the infant.

Injury to the mother as a result of shoulder dystocia is a common occurrence. Uterine rupture, postpartum atony, vaginal lacerations, and bladder atony are among the potential problems.

The best bet is to avoid shoulder dystocia altogether, but this is easier said than done, Dr. Phelan said.

Looking for possible risk factors may help by better preparing you for the situation. These include pelvic deformities, macrosomia, labor dysfunction, and a history of shoulder dystocia in previous deliveries.

Elective C-section for risk factors such as macrosomia has not been shown to be effective for improving outcome except in diabetic patients.

"In these cases, it is probably worthwhile," she added.
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Publication:OB GYN News
Article Type:Brief Article
Geographic Code:1U5NC
Date:Oct 1, 1999
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