Managing Shoulder Dystocia :: Tips to manage Shoulder Arrest/ Dystocia at brim with elongated foetal neck - a nightmare for all obstetricians globally : How best to tackle shoulder Dystocia at Labour Room ? To be pasted / hanged in a typed way in LR as new medico / RHM batch come each yr and S Dystocia may occur when vesting are unavailable .To put on duty Interns at LR RMO too may be unavailable by 2- 5 minutes time. At W Bengal the post of RMO are residential assignments after MD who is in hose quarter is in toilet for a bath and therefore unavailable to LR for about say 20 minutes !!! I was in this capacity for 5 yrs 1980 to 1985. However ,S Dystocia may have to ,on occasions be tackled by Sr. House officers. The cause of S arrest is due to the fact that largest diameter of foetus is the bisacromial diameter ..There are four recognized methods of delivery of such a foetus where shoulder is stuck at brim but head is visible at lower stratum of pelvis / at perineum with much elongated neck at vagina low down. Such globally recognised four methods are :- The following are the four methods which may be adopted managing S Dystocia .These go by the names of 1) McRoberts h Maneuver 2) Rubin II maneuver 3).Wood Screw maneuver 4) Combination of Rubin II & Wood Screw method . The less commonly used other methods are 5) Gaskin method 6) Zavanelli maneuver 7) Deliberate fracture of clavicle along with supra pubic pressure ---vaginal delivery. 8) Syphysiotomy..The following lines describes the McRoberts maneuver in details which should be initial step & if done properly can succeed in 50 % of cases. The steps are firm flexion of maternal thighs over her abdomen This alone-'helps in rotation of the pelvis favorably. Therefore exact steps are a) to flex the maternal thighs firmly as much as possible towards her abdomen by nurses at LR. . This along with firm downward Suprapubic pressure helps the stuck ant shoulder to pass in .This maneuver (flexion of maternal thighs) will help to increase the all the AP diameter of pelvis thereby allowing the anterior shoulder which was so long stuck at ant pubis at brim to just slip or enter into the wide pelvic cavity just like a magic. Both the procedures like firm flexion of thighs of mother to mat abd along with gentle backward pressure of should will solve the problem. Occasionally I had to digital rotation of anterior shoulder from AP dia of pelvis to any oblique dia of pelvis which is lather than AP dia.
This digital rotation is the third step of McRoberts method. Sustained supra pubic pressure increases the soft tissue of bisacromial length of shoulder
Step 3 of Mc Roberts - To rotate the ant shoulder abdominally which was stuck in the AP diameter to move to any of the oblique diameter of pelvis which is larger than short AP diameter.
What is Rubin II Maneuver used in shoulder arrest disorder? : The next popular method if McRoberts fails -or accoucheur is unfamiliar with McRoberts method: It consists of placing two fingers of accocheur vaginally behind the posterior aspect of the anterior shoulder of the fetus and then digitally rotating the shoulder toward the fetal chest . This motion will adduct the fetal not hands but ant shoulder to his / her chest & reduce the diameter of foetal S girdle and allowing the bisacromial dia to avail wide oblique dia of inlet..This will also help to pass the so long stuck shoulder to come down but not like magic as usually occurs in McRoberts maneuver .Dr Pal has tried both methods since 1966 and according to Dr Pal McRobetts is best and safe. Unfortunately in McRoberts what happens is that some laboring women don’t cooperate and or nurse fail to apply digital pressure on ant should at Suprapubic area. A note of caution to Junior member.: Never, I repeat never, put fundal pressure in cases of S arrest. To also remember in cases of Shoulder Dystocia God will allow us sufficient time to deliver the foetus in contrast to cord prolapse where every seconds count. So no hurry in S Dystocia as in most cases foetus will be able to breathe but not always.
What is the third popular method of relieving shoulder arrest at brim. :Wood Screw Maneuver : .In this method two fingers are passed gently vaginally and such fingers press on the anterior aspect of the fetal posterior shoulder. By applying gentle upward pressure around the circumference of the arc in the same direction the ant shoulder is dislodged from AP dia of inlet to oblique diameter followed by Suprapubic pressure & gentle traction on head I had no experience of using this method in lifetime. .
No comments:
Post a Comment