Suspect in case of big infant especially diabetic and obese mothers. The risk for reaching critical and potentially inreversiable status after 6-8 minuts. To remember H - Call for Help E - Episiotomy L - Legs (McRobert) P - Suprapubic Pressure E - Extend post-arm R - Rotate post shoulder McRobert maneuver and suprapubic pressure: Dorsal position, the knees adducted against the breast use fundal pressure or suprapubic pressure behind (Mazzanti) or pressure from one side to other (Rubin) with gentle downward pressure on the head. If no success, perform episiotomy to get place for your hand. Reverse Lovset (Wood Screw): Do not use fundal pressure and do not let the patient push. Put the hand behind the symphysis on the dorsal side of the child and press on the scapula to an oblique position or rotate 180o use eventually the other hand and press under the clavicular of the posterior shoulder in the opposite direction. If no success, deliver the posterior arm by taking your hand in the vagina posterior in front of the baby. Take the hand or under arm and let it pass over the baby's chest whereby the shoulder and arm is delivered. Humerus normally fracture. Rotate the delivered posterior shoulder anteriorly (rotating in the direction of the baby's back so as to keep the delivered arm in front of baby's chest). This should enable delivery of the other arm which was originally anterior. Knee - hand position. The mother is turnover and the posterior shoulder which is now the upper is attempted to be delivered. Has been advocated by some. I don't think it works if the above procedures has failed. Symphysiotomy: Effective but seldom used because of fear for maternal morbidity. Fracturing of the claviculae normally the anterior by pressure of the thumb. If no success, give tocolysis (Terbutaline 0.25 mg) or Nitroglycerin spray 0.4 mg Sublingual IV replaced caput in flex position push it up and then cesarean section (Zavanelli maneuver) References: (1) Bruner, JP, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998; (48):439-443. (2) Dildy GA. Shoulder dystocia: risk identification. Clin Obstet Gynecol. 2000 June;43(2):265-82. Review. (3) Gurewitsch ED. Optimicing shoulder dystocia management to prevent births injury. Clini Obstetric Gynecol 2007 Sep;50:592-606. (4) Romoff A. Shoulder dystocia: Lessons from the past and emergings concepts. Clin Obstet Gynecol. 2000 June; 43(2):226-35. Review. (5) Sandberg, EC. The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol 1999; 93(2):312- 317.
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