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Labor Stage 2: Shoulder Dystocia

by Veronica Gillispie, MD, FACOG
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    Now let's discuss episiotomy and laceration. So there's 4 types of episiotomy or lacerations that we can see. And we're going to go through the classification. Now this can result from a episiotomy that tears further or laceration that happens spontaneously. First degree means you have injury to the vagina to the epithelium that's there. And the vulva skin only. Second degree means we have injury to the perineal muscles, but not the anal sphincter. Third degree means injury to the perineum and involves the anal sphincter. And then fourth degree our highest degree is injury to the perineum involving the anal sphincter all the way through to the rectal muscosa. So here's a high yield slide to help you remember those 4 classifications. Now episiotomies are performed if more room is needed to deliver the baby or to perform maneuvers to relieve a shoulder dystocia. It is no longer recommended to routinely perform episiotomy at the time of delivery. In the picture here, the operator is cutting a mediolateral episiotomy. This can be done to the left or the right, so you can have what's called a "Left Mediolateral Episiotomy or LML" or a "Right Mediolateral Episiotomy (RML). Though which way you cut it left or right is really depended on the physician of what he's comfortable with. The episiotomy can also be cut straight down the mid line. Now with the RML and the LML patients sometimes have more pain with healing but with the midline episiotomy, that one is more likely to extend into a third or fourth degree laceration. ...

    About the Lecture

    The lecture Labor Stage 2: Shoulder Dystocia by Veronica Gillispie, MD, FACOG is from the course Intrapartum Care. It contains the following chapters:

    • Abnormal Labor – Shoulder Dystocia
    • Shoulder Dystocia – HELPERR
    • Common Complications of Shoulder Dystocia

    Included Quiz Questions

    1. Episiotomy can release the impacted shoulder and directly relieve a shoulder dystocia.
    2. Shoulder dystocia is unpredictable and one must always be prepared.
    3. Shoulder dystocia is when the anterior shoulder of an infant is impacted behind the maternal pubic symphysis.
    4. Appropriate shoulder dystocia management requires more than one delivering provider.
    5. Maternal obesity is a risk factor for shoulder dystocia.
    1. Call for help
    2. Apply fundal pressure
    3. Zavinalli's maneuver
    4. Symphysiotomy
    5. Apply vacuum to help downward traction of the head
    1. C5-C6 nerve damage due to over extension of the infant's neck during delivery
    2. C8-T1 nerve damage due to excessive downward pressure on the infants head during delivery
    3. C6-C7 nerve damage associated with clavicular fracture
    4. Humeral head fracture
    5. Intracranial hemorrhage due to protracted labor and operative vaginal delivery
    1. Place finger under the clavicle and pull outward to avoid lung puncture
    2. Place finger under the clavicle and pull outward to avoid brachial plexus injury
    3. Place finger over the clavicle and push inward to avoid injury the the vasculature in the neck
    4. You should never intentionally break the infants clavicles
    5. Place finger over the clavicle and push inward to avoid injury to the humeral head
    1. The assisting provider should stand on a stool at the side of the mother and place both heels of their hands above the maternal pubic bone and BEHIND the anterior shoulder of the infant and apply downward and forward pressure
    2. The delivering physician should apply DOWNWARD pressure over the maternal pubic bone while keeping one hand ready to catch the baby.
    3. The assisting provider should apply downward pressure DIRECTLY over the paternal pubic bone.
    4. The assisting provider should stand on a stool at the side of the mother and place both heels of their hands above the maternal pubic bone and in FRONT the anterior shoulder of the infant and apply downward and forward pressure.
    5. The assisting provider should stand at the side of the mother and apply downward presure over the anterior shoulder of the infant with one hand while applying caudal fundal pressure with the other hand.
    1. Lower the head of the bed and elevate the mother's legs while pulling them towards the chest to open up the pelvis
    2. Elevate the head of the bed and pull legs toward the chest to increase expulsive force in the pelvis
    3. Rotate the mom on hands and knees for delivery
    4. Insert 2 fingers behind the posterior shoulder and 2 fingers in front of the anterior shoulder and rotate the baby to a new angle
    5. Insert 2 fingers behind the posterior shoulder and fold the shoulder inward to decrease the width between the shoulders
    1. No, this patient has multiple risk factors for a repeat shoulder dystocia. Cesarean section is the better option at this point.
    2. Yes, this patient has arrest of the second stage of labor and should have an assisted vaginal delivery.
    3. No, this patient should be encouraged to continue pushing until there are signs of fetal intolerance of labor.
    4. Yes, even if she gets a shoulder dystocia, maneuvers can be done to undo it. Cesarean section should be avoided as much as possible.
    5. Cesarean section or vacuum assisted delivery have equal risk in this situation and either would be the correct decision.
    1. ...advanced maternal age
    2. ...maternal obesity.
    3. ...fetal macrosomia.
    4. ...gestational diabetes.
    5. ...history of prior shoulder dystocia.

    Author of lecture Labor Stage 2: Shoulder Dystocia

     Veronica Gillispie, MD, FACOG

    Veronica Gillispie, MD, FACOG


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