Which of the following is not a maneuvre used for treatment of shoulder dystocia?
Correct Answer: Lovset's maneuvre
Description: Ans. d (Lovset's manoeuvre). (Ref. Williams Obstetrics 22nd/Ch.l7).MANAGEMENT OF SHOULDER DYSTOCIAShoulder dystocia cannot be predicted. Reduction in the interval of time from delivery of the head to delivery of the body is of great importance to survival. An initial gentle attempt at traction, assisted by maternal expulsive efforts, is recommended. Some clinicians have advocated performing a large episiotomy, and adequate analgesia is certainly ideal. After clearing the neonate's mouth and nose, a variety of techniques can be used to free the anterior shoulder from its impacted position beneath the symphysis pubis:1. Moderate suprapubic pressure can be applied by an assistant while downward traction is applied to the fetal head.2. McRoberts maneuver consists of removing the legs from the stirrups and sharply flexing them up onto the abdomen. They found that the procedure caused straightening of the sacrum relative to the lumbar vertebrae, rotation of the symphysis pubis toward the maternal head, and a decrease in the angle of pelvic inclination. Although this does not increase pelvic dimensions, pelvic rotation cephalad tends to free the impacted anterior shoulder.3. Woods corkscrew maneuver: by progressively rotating the posterior shoulder 180 degrees in a corkscrew fashion, the impacted anterior shoulder could be released.4. Delivery of the posterior shoulder consists of carefully sweeping the posterior arm of the fetus across the chest, followed by delivery of the arm. The shoulder girdle is then rotated into one of the oblique diameters of the pelvis with subsequent delivery of the anterior shoulder.5. Rubin recommended two maneuvers. First, the fetal shoulders are rocked from side to side by applying force to the maternal abdomen. If this is not successful, the pelvic hand reaches the most easily accessible fetal shoulder, which is then pushed toward the anterior surface of the chest. This maneuver most often results in abduction of both shoulders, which in turn produces a smaller shoulder-to-shoulder diameter and displacement of the anterior shoulder from behind the symphysis pubis.6. Deliberate fracture of the clavicle by pressing the anterior clavicle against the ramus of the pubis can be performed to free the shoulder impaction. In practice, however, it is difficult to deliberately fracture the clavicle of a large neonate. The fracture will heal rapidly and is not nearly as serious as a brachial nerve injury, asphyxia, or death.7. Hibbard recommended that pressure be applied to the fetal jaw and neck in the direction of the maternal rectum, with strong fundal pressure applied by an assistant as the anterior shoulder is freed. Strong fundal pressure, however, applied at the wrong time may result in even further impaction of the anterior shoulder and fundal pressure in the absence of other maneuvers result in more complications rate.8. Sandberg (1985) reported the Zavanelli maneuver for cephalic replacement into the pelvis and then cesarean delivery. The first part of the maneuver consists of returning the head to the occiput anterior or occiput posterior position if the head had rotated from either position. The operator flexes the head and slowly pushes it back into the vagina, following which cesarean delivery is performed. Terbutaline (250 pg subcutaneously) is given to produce uterine relaxation. Fetal injuries were common when the Zavanelli maneuver was used. Uterine rupture also was reported.9. Cleidotomv consists of cutting the clavicle with scissors or other sharp instruments and is usually used for a dead fetus.10. Sxmphxsiotomx also has been applied successfully, as described by Hartfield (1986). Goodwin and colleagues (1997) reported three cases in which symphysiotomy was performed after the Zavanelli maneuver had failed--all three neonates died and maternal morbidity was significant due to urinary tract injury.Summary: SHOULDER DYSTOCIA (an obstetric emergency)# It occurs when the fetal shoulders fail to spontaneously deliver secondary to impaction of the anterior shoulder against the pubic bone after delivery of the head has occurred.# A generous episiotomy should always be made to allow the obstetrician to have adequate room to perform a number of manipulations to try to relieve the dystocia.# Predisposing factors for shoulder dystocia:1) Foetal Macrosomia2) Obesity3) Excessive wt gain in pregnancy4) Midpelvic instrumental delivery5) Anencephaly6) Foetal Ascites7) Short cord or cord tightly around neck.# Such maneuvers include (Clue: Shoulder Dystocia Wale Maneuvers - GRZl)- Suprapubic Pressure: This pressure is at the pubic bone, not at the top of the uterus. This might altow the shoutder enough room to move under the pubis symphysis.- delivery of the posterior shoulder.- Woods Maneuver: This is also known as the corkscrew; the attendant tries to turn the shoulder of the baby by placing fingers behind the shoulder and pushing in 180 degrees.- McRobert's Maneuver: Flex the mother's legs toward her shoulders as she lays on her back, thus expanding the pelvic outlet. One study showed that this alleviated 42% of all cases of shoulder dystocia.- Gaskin Maneuver: Get the woman into a hands and knees position. This will also change the diameters of her pelvis, though is not always possible with epidural anesthesia.- Rubin Maneuver: Like the Woods maneuver, two fingers are placed behind the baby's shoulder; this time they are pushing in the directions of the baby's eyes, to line up the shoulders.- Zavanelli Maneuver: Pushing the baby's head back inside the vagina and doing a cesarean. This is the mostly frequently asked about method, but also one of the most dangerous.# There is no role for fundal pressure because this action further impacts the shoulder against the pubic bone and makes the situation worse.
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Gynaecology & Obstetrics
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