Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Basic Obstetrics and Obstetric Surgery in a Mission Setting
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physiotomy may be appropriate if the cause is clearly mild CPD. In the face of failed
vacuum-assist or severe CPD, you must go to Cesarean section.
Shoulder Dystocia
By definition, shoulder dystocia is the failure of the shoulders to deliver spontaneously
after delivery of the head. This is a true obstetric emergency. It may occur in
from 1-5% of deliveries and is very unpredictable. Anticipate dystocia in cases of
known fetal macrosomia or maternal diabetes. Begin to suspect a developing dystocia
in cases of prolonged second stage labor. In all cases, your patient should begin
her delivery with an empty bladder. Recognize dystocia when the head is delivered
(with or without difficulty) and the ring of vulvar tissue then appears to form a snug
collar around the neck of the fetus. The head appears to be held tightly against the
vulva and/or appears to retract (the “turtle sign”). The usual amount of gentle downward
traction will not disimpact the anterior shoulder, which is stuck behind the
pubic symphysis.
You or your assistant should begin to count time upon delivery of the head. If
you encounter the “turtle sign” or encounter difficulty delivering the anterior shoulder
within the first 30 seconds, declare a dystocia. Do this without conveying a sense
of panic to your patient. Your assistants should have been drilled in the responses
that you will now direct.
Your next actions will depend upon whether or not you anticipated the dystocia
(in cases of fetal macrosomia and/or maternal diabetes), and upon whether or not
the patient has received epidural anesthesia. A suggested sequence would be as follows:
1. At 30 seconds, if the shoulders are not delivered with ease or a “turtle sign”
is encountered, inform your assistants that you are managing a dystocia.
DO NOT employ fundal pressure, DO NOT increase your traction on the
head and neck of the fetus.
2. Evaluate the need for an episiotomy, which may be helpful if there is a
component of perineal resistance as well. Try to accomplish delivery with
the next uterine contraction using the following maneuvers.
3. McRobert’s maneuver: Your assistants should immediately see that the
patient’s hips are sharply flexed into an exaggerated lithotomy position -
help her to grasp her legs and pull her knees towards her chest. Maintain
your grasp of the baby’s head and watch and feel for any signs of spontaneous
restitution.
4. Suprapubic pressure: Simultaneous with the maneuver above, the assistant
standing on that side of the patient where the fetal spine is thought to lie
should deliver suprapubic pressure in an oblique and cephalad direction,
attempting to disengage the impacted shoulder from the symphysis pubis
while you continue to apply gentle downward traction on the head and
neck.
5. If unable to deliver with McRobert’s maneuver and suprapubic pressure,
turn the patient from the supine lithotomy position to assume a
hands-and-knees position (Gaskin’s maneuver). In this case, DO NOT allow
her hips to flex sharply. Redirect your traction appropriately to lift the
anterior shoulder away from the symphysis and deliver the fetus. (It would
also be reasonable to employ Gaskin’s maneuver as your first intervention,
especially in cases where you have anticipated a dystocia, rather than discovered
one intrapartum.)
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