Dystocia, refers to an abnormal or difficult childbirth or labor. According to Lexology.com about 1 in every 5 human labors have dystocia. Dystocia occurs when there is an incoordinate uterine activity, abnormal fetal life or presentation, absolute or relative cephalopelvic disproportion, etc. Shoulder dystocia is a type of dystocia where the anterior of the infant cannot pass below the pubic symphysis or requires a significant amount of manipulation to pass. Shoulder dystocia, just like dystocia, occurs during childbirth or labor. And it is diagnosed when the shoulders of the infant's shoulders fail to be delivered shortly after the fetal head. If the infants shoulder is unable to be freed within minutes, the infants will suffer irreversible brain damage or death.
Some signs to look for regarding shoulder dystocia are; the turtle sign-- this is the appearance and retraction of the fetal head (much like a turtle going back into its shell) and a red puffy face indicative of facial flushing.
When presented with this complication in the delivery room, there are a few procedures that can be done to try and ensure a safe delivery of the infant. It is reported that if the physician delivering the baby suspects shoulder dystocia, they are to follow the ALARMER mnemonic first before any of the listed procedures below, are followed. The ALARMER mnemonic stands for; Ask for help, Leg hyperfelxion, Anterior shoulder disimpaction, Rubin maneuver, Manual delivery of posterior arm, Episiotomy, and Rollover on all fours. After the ALARMER is followed, here are some of the different types of procedures the obstetrician or physician can perform:
- McRoberts Maneuver-- this involves hyper flexing the mother's leg tightly to her abdomen. This widens pelvis, and flattens the spine in the lower back.
- Suprapubic Pressure (Rubin I)--
- Rubin II-- posterior pressure on the anterior shoulder. This would bring the fetus in an oblique position with the head towards the vagina.
- Wood's screw-- which leads to turning the anterior shoulder to the posterior and vice versa.
- Jacquemier's Maneuver-- delivery of the posterior shoulder first. The forearm and hand are identified in the birth canal and gently pulled.
- Gaskin Maneuver-- moving the mother to an all fours position with the back arched, widening the pelvic outlet.
- Zavanelli's Maneuver-- pushing the fetal head back in, and performing a cesarean section or internal cephalic replacement by c-section.
- Intentional fetal clavicular fracture-- reduces the diameter of the shoulder girdle that requires to pass through the birth canal.
- Abdominal rescue-- hysterectomy facilitates vaginal delivery of the impacted shoulder.
- Maternal symphysiotomy-- makes an opening of the birth canal by breaking connective tissue between the two pubic bones, allowing the shoulders to pass through.
In the ALARMER mnemonic goes from the least invasive to the most invasive procedures, reducing the harms to the mothers in the even that the infant is to delivered with one of the earlier maneuvers. If these maneuvers are unsuccessful, then the skilled obstetrician is to begin performing the additional procedures.
The major concerns regarding shoulder dystocia is the damage to the upper brachial plexus nerves. The brachial plexus nerves supply the sensory and motor components of the shoulder, arm and hands. Moreover, excess tension may physically tear the nerve roots from out of the neonatal spinal column and resulting in total dysfunction.The ventral roots (motor pathway) are the most prone to injury, because they are in the plane of the greatest tension. Other concerns coming from shoulder dystocia are:
- Klumpke paralysis
- Erb's Palsy
- Fetal hypoxia
- Fetal Death
- Cerebral Palsy
- Maternal post partum hemorrhage
Did you suffer from a difficult delivery or labor? Does your child suffer from any of the above condition due to what you believe was caused by shoulder dystocia? Call or email us for a confidential consult at (202) 393-3200 and [email protected]. Please watch our video on shoulder dystocia and do not forget to get your Free copy of Picking up the Pieces after Medical Malpractice: A Parent's Guide for more information on how cope after you suspect your child was a victim of medical malpractice.