1. Dystocia caused by fetal anomalies

2. Dystocia means "slow or difficult labor or delivery."
Fetal dystocia is abnormal fetal size or position resulting in difficult delivery
Fetal dystocia may occur when the fetus is too large for the pelvic opening (fetopelvic disproportion) or is abnormally positioned (eg, breech presentation, shoulder dystocia).

3. Macrosomia
Abnormally large size baby weighing more than 4kg is considered macrosomic.
(D.C Dutta)

4. Causes
Hereditary , race , size of the parents – particularly the mother (obesity).
Poorly controlled maternal diabetes and gestational diabetes.
Post maturity
Multi parity
Male fetus

5. Diagnosis Disproportionate increase in uterine size.
Clinically the fetus is felt big
Ultrasonographic measurement of fetal
- BPD
- HC
- FL
- AC
Are done to predict the estimated fetal weight

6. Dangers
Involves both the fetus and mother.
Fetal hazards:
Surprise dystocia due to cephalopelvic disporption.
Brachial plexus injury
Asphyxia
Birth trauma
Meconium aspiration.

7. Injury to the maternal soft tissues (vagina, perineum)
Cont…
Maternal hazards:
Injury to the maternal soft tissues (vagina, perineum)
PPH and puerperal sepsis
Management
Prophylactic induction of labour (pre term) to reduce the risk of shoulder dystocia
Elective caesarean delivery in diabetic women.

8. Shoulder Dystocia

9. Definitions Difficulty in the birth of the shoulder (Varney)
Vertex delivery in which genital lateral head traction and normal maternal pushing efforts fail to deliver the shoulders, in the absence of causes of dystocia or slow progress. (Piper and Mc donald 1994)
Further progress delivery is prevented by impaction of the fetal shoulder within or above the normal pelvic. (seeds 1991)

10. Signs of shoulder dystocia
Turtle necking: This occurs as the baby’s chin retracts into the mother’s perineum
Head bobbing describes jerking movement of the head as it stretches forward to attempt delivery but moves back to the perineum as the shoulder is trapped.
Gentle traction to facilitate delivery does not work.

11. Normal labour and Shoulder dystocia
Birth At birth (turtle
sign)

12. Predisposing factors
Fetal macrosomia – 50% of cases of shoulder dystocia occur with normal sized baby.
Obesity
Diabetes
Mid pelvic instrumental delivery
Post maturity
Multi parity
Anencephaly
Fetal ascites

13. Fetal hazards:
Fetal asphyxia
Injury to the brachial plexus
Fracture hummers
Clavicle or sternomastoid haematoma during delivery
Perinatal morbidity and mortality are high.

14. Maternal hazards:
Increased operative delivery and morbidity.
Prevention:
Prediction of shoulder dystocia is not possible accurately.
So care is to be taken to reduce the time internal delivery of the head to that of the body.

15. Diagnosis:
1.Define recoil of the head back against the perineum.
2. Inadequate spontaneous restitution.

16. Management principles
DONT’s
Do not be panicky
Do not give traction over baby’s head
Do not apply fundal pressure.
DOS’s
Call for extra help
Clear the infant’s mouth and nose
Involve the anesthetist and the pediatrician
Perform a wide mediolateral episiotomy.

17. Intervention maneuvers
Unilateral shoulder dystocia is usually easily dealt by standard technique.

18. c
Gentle pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow , usually resulting in easy delivery of the anterior shoulder. Excessive angulation(>45 degree)is avoided.

19. Increase relative pelvic space:
- Fetal shoulder rotation to the oblique

20. Altering pelvic angles
Mc Roberts maneuver
Sharply flex the mother’s thigh on to her abdomen. This will result in cephalic rotation of the pelvis , releasing the shoulder.

22. Decreasing passenger shoulder diameter
Suprapubic pressure
Delivery of the posterior arm
Wood’s or Rubin’s screw maneuver

23. Moderate supra pubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder.
Stronger pressure can only be exerted by an assistant.

24. After proper suprapubic pressure,the fetal head will reassume a natural relationship to the shoulders which are in the opposite oblique diameter of the maternal pelvis

25. This type of suprapubic pressure by an assistant may reduce the impaction in some cases.

26. Best method for supra pubic pressure .
This demonstrates the use of palm of the hand giving lateral pressure.

27. Supra pubic pressure

28. Supra pubic pressure is applied by an assistant.
Midwife to direct the assistant to baby’s back.
Hand’s are held in CPR style’s position
Pressure is applied above the symphysis pubis to adduct the anterior shoulder.
Initially continuously, then in a rocking motion for seconds.

29. Wood’s corkscrew maneuver.
Place the hand behind the posterior shoulder and rotate in 180degree towards the anterior shoulder

30. Wood’s screw maneuver. The shoulder must be rotated utilizing pressure on the scapula and clavicle. The head is never rotated.

31. If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum

32. Rubin technique
Move to the side of the bed opposite to the infants face.
Instruct the mother to stop pushing.
Apply firm pressure on the back side of the infant’s anterior shoulder and shove in the direction’s of infants face.
Decreases shoulder to shoulder diameter.

33. Hibbard maneuver
Release the anterior shoulder is initiated by firm pressure against the infant’s jaw and neck in a posterior and upward direction.
An assistant is poised , ready to apply fundal pressure after proper suprapubic pressure.

34. Proper supra pubic pressure is continued.
As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly towards the rectum.
Proper supra pubic pressure is continued.
Shifted sightly

35. Continued fundal and suprapubic pressure results in an upward – inward rotation of the newly freed anterior shoulder and a further decent in a position beneath the pubic symposia

36. As a result of the previous maneuvers ,the transverse diameter of the shoulder is reduced.
The lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum

37. With both shoulders freed, delivery is accomplished without the necessity of additional fundal pressure.

38. Internal maneuvers ( wood screw & rubin technique)

39. Internal maneuvers( delivery of the posterior shoulder)

40. Mazzanti technique
Instruct the mother to stop pushing until supra pubic pressure has been applied.
Apply direct downward pressure above the maternal symphsis
-Dislodges the anterior shoulder by pushing it under the maternal symphysis
Do not use fundal pressure.

41. Cleidotomy
One or both clavicles may cut with scissors to reduce the shoulder girth.
This is applicable to an anencephalic baby as a first choice or to a dead baby.

42. Zavanelli maneuver.
The fetal head is flexed and the fetus is replaced to the uterus.
Thereafter the baby is delivered by emergency caesarean section.
This maneuver is not practical

43. Nursing implications Intrapartum: Identify ante partum risk factors
Identify and report deviations from normal labour progress.
Prepare for potential shoulder dystocia.
* personal
* supplies
* empty maternal bladder
* Maternal positioning for birth

44. Birth: Observe for turtle sign Document emergence of head
Call for if not already there
Document any additional maneuvers attended.
Assist with maternal position
Support the mother about bearing down when instructed.
If vaginal birth is not successful
Prepare for the surgical birth
Continuously monitor the fetus

45. Post birth
Assess for-
- Hematoma
-Uterine atony
- excessive bleeding
- Bladder injury
- Rectal injury
Provide explanations to family as needed.
Document birth events

46. Broken clavicle management -Minimize pain or discomfort
Neonatal:
Neonatal resuscitation as needed
Assess for broken clavicle
Asses for brachial plexus injury
Broken clavicle management
-Minimize pain or discomfort
Immobilize the affected arm.
Brachial plexus injuries
-weakness or total paralysis of the muscle
- 0.5to 2.0% per 1000 live births

47. Hydrocephalus
Excessive accumulation of CSF ( L) in the ventricles with consequent thinning of the brain tissue enlargement of the cranium.

48. Minor degree may escape attention
Diagnosis
Antenatally:
Minor degree may escape attention
Severe degree presents with following features:
The head is felt larger, globular and softer than the normal head
The head is high up and impossible to push down to the pelvis.
FHS is felt high up above the umbilicus.
X-ray ; Cranial shadow is globular rather than the normal ovoid.
Fontanels and sutures are wide.

49. Internal examination during labour reveals
Cont..
Vault bones thinner
Sonography: Dilatation of the lateral ventricles, dangling choroid plexus, and thinning out of the cerebral cortex.
Internal examination during labour reveals
Gaping sutures and fontanells
Crackling sensation on pressing the head.

50. Prognosis
Fetal outlook is extremely poor expect in mild variety
The fetus is either delivered stillborn or dies in neonatal period.
Babies which survive may be mentally defective.
Maternal prognosis is not unfavorable in diagnosed cases but in undiagnosed cases and cases left uncared for during labour, obstructed labour with its consequence may occur.
Rupture may occur even before the cervix is fully dilated because of too much distension of the lower segment by the head.

51. Management
The pregnancy is to be continued until a stage (beyond 36 weeks) when induction can be achieved sucessfully.
Induction is done by low rupture of the membranes.
As soo as the labour is established and the cervix is 3-4 cm dilated, decompression of the head is done by a sharp pointed scissors or with bore (17 gauge) long needle.

52. Anencephaly Incidence 1 in 1000 live births.
The anomaly results from deficient development of the vault of the skull and brain tissue but the facial portion is normal.

53. About 70% of anencephalic fetuses are females.
Cont..
About 70% of anencephalic fetuses are females.
More prevalent in first birth and in young and elderly mothers.
Genetic and environmental factors are probably involved.
Diagnosis:
Alpha-feto protein in amniotic fluid and confirmed by sonography.

54. Tendency of post maturity Shoulder dystocia Obstructed labour.
complications
Hydramnios (70%)
Malpresentation
Premature labour.
Tendency of post maturity
Shoulder dystocia
Obstructed labour.

55. Management
If confirmed before 20 weeks by high alpha – fetoprotein level in liquor amnii and supplemented by sonography termination of pregnancy is to be done.
The couples are counselled in either situation.
During labour if tendency of delay, shoulder dystocia should be managed by cleidotomy.

56. Prevention Pre-pregnancy counseling is essential
Folic acid supplementation beginning 1 month before conception to 12 weeks reduce the incidence of NTD significantly.
A dose of 4mg daily is recommended.
Risk of recurrence is about 2% in subsequent pregnancy.

57. Enlargement of fetal abdomen
The enlargement of fetal abdomen sufficient to produce dystocia may be due to ascites, distended bladder or enlargement of kidney by a tumour or an umbilical hernia.

58. Antenatal diagnosis can be made accidently by sonography which shows an appearance resembling that of the “buddha position”
Usually the diagnosis is made when there is difficulty in delivery of the trunk following birth of the head.
Confirmation is done by introducing the hand and palpating the huge distended abdomen
The decompression of the abdomen is done by simply puncture with a wide bore needle which is soon followed by spontaneous delivery

59. Conjoined twins

60. Diagnosis Ultrasonography Radiological examination. Managemnent
Destructive operation when the fetus is dead.
Caesarean section offers best chance for fetal survival.

61. Thank you