Ver el código de «Shoulder dystocia»

==Background==
*Occurs in 0.2-3% of all births<ref name="Silver">Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.</ref>
*Anterior shoulder becomes impacted against maternal pubic symphysis

===Risk Factors===
*Pre-labor
**Previous shoulder dystocia
**Macrosomia
**[[Diabetes mellitus]]
**Maternal BMI > 30
**Induction of labor
**Advanced maternal age
**Short maternal stature
**Small maternal pelvis
**Significant post-dates delivery (>42 weeks gestation)
*Intrapartum
**Prolonged first or second stage
**Oxytocin augmentation
**Failure to restitute
**Failure of shoulder rotation on descent
**Assisted vaginal delivery
***Prolonged head to body delivery time >60 seconds

==Clinical Features==
*Obstructed labor
*"Turtle sign" - fetal head retracts against perineum after it appears (rare)

==Differential Diagnosis==
{{Emergency delivery DDX}}

==Evaluation==
*Clinical diagnosis

==Management==
[[File:Suprapubic-pressureforSD.jpg|thumb|Suprapubic pressure maneuver.]]
''No consensus on best treatment/maneuver or order of their application.''
'''HELPERR''' mnemonic - all maneuvers able to be performed by Emergency Physician, generally from least to most invasive
*'''H''' call for help
*'''E''' Evaluate for possible [[Episiotomy]] (or episioproctotomy) to increase the anteroposterior diameter of passage
*'''L''' Legs flex (McRoberts maneuver) - best first option - hyperflexion of legs with mild abduction and external rotation (successful in 40% of cases)<ref name="Silver" />
*'''P''' Pressure (suprapubic pressure, aka Rubin I maneuver) - apply pressure just proximal to pubic symphysis, either continuously or in rocking motion (in conjunction with McRoberts, increases success rate to 54%)<ref name="Silver" />
*'''E''' Entry maneuvers - Wood’s corkscrew maneuver by applying pressure to anterior aspect of posterior shoulder causing movement of shoulder into more oblique position in pelvis<ref name="Mercado">Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.</ref> '''or''' Rubin II maneuver - applying pressure to posterior aspect of most accessible shoulder (anterior or posterior)
*'''R''' Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face (effective in up to 84% of cases)<ref name="Silver" />
*'''R''' Roll on all fours (Gaskin position) - may relieve up to 83% of shoulder dystocia<ref name="Silver" />


'''ALARMER''' mnemonic is an alternative to the HELPERR mnemonic and provides a slightly altered sequence of interventions:
*'''A''' Ask for help
*'''L''' Legs to chest (McRoberts maneuver)
*'''A''' Anterior shoulder disimpaction by suprapubic pressure
*'''R''' Release posterior shoulder (attempt made to deliver posterior shoulder prior to anterior shoulder)
*'''M''' Maneuver of Wood
*'''E''' Episiotomy
*'''R''' Roll on all fours

==Disposition==
*Admit OB/GYN

==Complications==
[[File:ClavicleFractureSD.jpg|thumb|Fracture of both clavicles as a result of shoulder dystocia: acute (top) and after healing (bottom).]]
*Transient brachial plexus palsy (3.0 to 16.8%)
*Clavicular fracture (1.7 to 9.5%)
*Humerus fracture (0.1 to 4.2%)
*Permanent brachial plexus palsy (0.5 to 1.6%)
*Hypoxic-ischemic encephalopathy (0.3%)
*Death (0 to 0.35%)
*Fourth degree perineal lacerations
*Post-partum hemorrhage

==See Also==
*[[Emergent delivery]]

==External Links==
*[https://www.youtube.com/watch?v=YB3_fPhgmUM YouTube: Shoulder Dystocia Delivery, Manoeuvres, Management, Simulation]

==References==
<references/>

[[Category:OBGYN]]