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Abdominal Access for Shoulder Dystocia As a Last Resort – a Case Report Abdominaler Zugang Bei Schulterdystokie Als Ultima Ratio – Ein Fallbericht

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Abdominal Access for Shoulder Dystocia As a Last Resort – a Case Report Abdominaler Zugang Bei Schulterdystokie Als Ultima Ratio – Ein Fallbericht 634 GebFra Science Abdominal Access for Shoulder Dystocia as a Last Resort – a Case Report Abdominaler Zugang bei Schulterdystokie als Ultima Ratio – ein Fallbericht Authors A. Enekwe1, R. Rothmund2, B. Uhl1 Affiliations 1 Gynaecology Deparment, St-Vinzenz-Hospital Dinslaken, Dinslaken, Germany 2 University Hospital of Obstetrics and Gynaecology, Tübingen, Germany Key words Abstract Zusammenfassung l" shoulder dystocia ! ! l" abdominal rescue Shoulder dystocia is the term used to describe Die Schulterdystokie beschreibt einen Geburts- l" ʼ Erb s palsy failure to progress in labour after the head has stillstand nach Geburt des Kopfes aufgrund unzu- Schlüsselwörter been delivered due to insufficient rotation of the reichender Schulterdrehung. Das Ereignis trifft l" Schulterdystokie shoulders. It is unpredictable and cannot be pre- die geburtshilflich tätige Person in der Regel völ- l" abdominaler vented by the midwife or the obstetrician. We lig unerwartet. Es wird hier über einen Fall einer Rettungsversuch report here on a severe case of shoulder dystocia, schweren Schulterdystokie berichtet, bei dem die l" Armplexusparese where delivery of the shoulder was finally Schulterlösung durch direkten Druck auf die vor- achieved through direct pressure on the anterior dere Schulter nach Laparotomie und Uterotomie shoulder after laparotomy and uterotomy with bei gleichzeitigem Woods-Screw-Manöver von concurrent vaginal Woods screw manoeuvre and vaginal mit anschließender vaginaler Entbindung was followed by vaginal delivery. The patient pre- gelang. Die Patientin wies eine Adipositas und die sented risk factors like maternal obesity and ad- Gabe von wehenfördernden Mitteln als Risikofak- ministration of labour-inducing drugs. After dif- toren auf. Nach erfolgloser Ausführung des McRo- ferent manoeuvres like McRoberts manoeuvre berts-Manövers und diverser Manöver zur inne- and several manoeuvres for internal rotation ren Rotation wurde eine Notlaparotomie durch- were carried out unsuccessfully, an emergency geführt. Das Neugeborene musste direkt postpar- laparotomy was performed. The newborn was in tal reanimiert und für einige Stunden beatmet need for reanimation and artifical ventilation werden, erholte sich im weiteren Verlauf jedoch postpartum but recovered fast during the follow- rasch. Eine Erbʼsche Armplexuslähmung des hin- ing days. An Erbʼs palsy of the posterior arm im- teren Armes besserte sich während des stationä- proved during the hospital stay. The German ren Aufenthalts. Die Leitlinie der DGGG [8] sieht Guideline of the DGGG [8] recommends a risk einen Risikomanagement-Plan sowie regelmäßi- management plan and regular training to all birth ges Training aller beteiligten Personen für alle ge- attendants for obstetric clinics. Beside the vaginal burtshilflich tätigen Kliniken vor. Hierbei sollten manoeuvres one should have at least theoretical nicht nur die vaginalen Manöver geübt werden, received 24.2.2012 expertise in operative manoeuvres to be able to sondern auch zumindest theoretische Kenntnisse revised 1.5.2012 perform them in emergency cases. der operativen Manöver vermittelt werden, um accepted 6.5.2012 sie im Notfall anwenden zu können. Bibliography DOI http://dx.doi.org/ 10.1055/s-0032-1314962 Introduction The diagnosis is usually made based on manual Geburtsh Frauenheilk 2012; 72: ! examination. 634–638 © Georg Thieme Verlag KG Stuttgart · New York · Shoulder dystocia is the term used to describe Shoulder dystocia is unpredictable and cannot be ISSN 0016‑5751 failure to progress in labour after the head has prevented by the midwife or the obstetrician. been delivered due to insufficient rotation of the Most cases of shoulder dystocia are delivered Correspondence Antje Enekwe, PhD shoulders. It is necessary to differentiate between safely using well-known manual manoeuvres, St-Vinzenz-Hospital Dinslaken high shoulder dystocia where the shoulder is di- and delivery is by vaginal birth. In the few cases Gynaecology Department rectly above the pelvic inlet, and low shoulder where this is not possible, the midwife must Dinslaken Germany dystocia where the shoulders remain stuck in the quickly decide on the appropriate method with [email protected] pelvic cavity in the anteroposterior diameter [1]. which to release the shoulder; this may require Enekwe A et al. Abdominal Access for… Geburtsh Frauenheilk 2012; 72: 634–638 Case Report 635 an operative intervention and is therefore associated with an in- creased risk of morbidity for mother and baby and may not have been practiced previously. We report here on a severe case of shoulder dystocia in our clinic. Delivery of the shoulder was finally achieved through direct pres- sure on the anterior shoulder after laparotomy and uterotomy with concurrent vaginal Woodsʼ screw manoeuvre, and was fol- lowed by vaginal delivery. Case Report ! A 30-year-old woman presented to the labour room with the on- set of contractions in her 39th week of pregnancy after an un- eventful pregnancy. This was her second full-term pregnancy. The woman had last given birth 2 years earlier. According to the Fig. 1 Shoulder dystocia. hospital records, the previous birth was normal. The first child had a birth weight of 3780 g, a length of 51 cm, and a head cir- cumference was 34 cm, (i.e. all were within normal ranges). Ap- gar scores were 8–10–10 and arterial pH was 7.24. A grade 2 perineal tear was sutured after birth. The postpartum period was uneventful. At the most recent presentation the patient was obese, with a body weight of 99 kg, a height of 159 cm and a calculated body mass index (BMI) of 39. Ultrasound done on admission showed a vital foetus in cephalic presentation, 2nd position, with a nor- mal quantity of amniotic fluid; biometric measurements gave an estimated foetal weight of 3800 g (calculations according to Had- lock [2]). On initial examination, the cervical length was 2 cm in a mid-sacral position, and the cervix was 2 cm dilatated; the head was 2 cm above the interspinal level, and the amniotic sac had not ruptured. An epidural catheter was placed for epidural analgesia two hours after admission at the patientʼs request. Initially, the birth ap- peared to be progressing normally. When the contractions de- Fig. 2 Abdominal access with pressure exerted against the anterior creased, oxytocin administration (15 ml/h, 6 IE in 500 ml glucose shoulder and a Woodsʼ manoeuvre performed vaginally to rotate the 5%) was started 10 minutes after placing the epidural catheter posterior shoulder. and administration was later briefly increased to 30 ml/h 30 min- utes before the head was born. The records provide no informa- tion on bladder emptying after the epidural catheter was placed. The head was born after 4.5 hours. When this was not followed by the shoulders and the head remained retracted, pressing tightly against the vulva (“turtle sign”), a mediolateral episiotomy was done. This still did not result in birth of the body. The attend- ant physician diagnosed a shoulder dystocia. Oxytocin infusion was immediately stopped. The McRobertsʼ manoeuvre was then performed together with suprapubic pressure. This was followed by manoeuvres to internally rotate the baby (Woodsʼ screw ma- noeuvre, Rubin manoeuvre) and delivery of the posterior arm, which were performed correctly but were unsuccessful. General anaesthesia was then administered. A further attempt at internal shoulder rotation after the maternal muscles had relaxed was also unsuccessful. Nine minutes after delivery of the head, an emergency laparotomy was performed via Pfannenstiel incision through all layers and uterotomy to obtain direct access to the baby and the trapped shoulder. Pressure was exerted on the an- Fig. 3 Child development. terior left trapped shoulder with simultaneous pressure exerted vaginally against the posterior right shoulder (Woodsʼ screw ma- noeuvre) (l" Figs. 1 to 3). This manoeuvre rotated the infant suffi- ciently to deliver the anterior shoulder, and the baby was deliv- ered vaginally 11 minutes after the birth of the head. Arterial pH on delivery was 7.12, and base excess was − 12 mmol/l. The baby Enekwe A et al. Abdominal Access for… Geburtsh Frauenheilk 2012; 72: 634–638 636 GebFra Science weighed 4180 g at birth with a height of 58 cm and a head cir- 5,0 cumference of 34.5 cm. The infant was initially born without vital 4,5 signs; the skin colour was pale, the muscle tone was flaccid, and 4,0 the infant had apnoea and asystolia. The infant was immediately given to the attendant neonatal clinician. Nose, throat and stom- 3,5 ach were suctioned, and bag and mask ventilation were started 3,0 e(%) immediately. When asystolia persisted for more than 30 seconds, 2,5 cardiac massage was initiated until the heart began beating. The 2,0 infant was intubated at 3 minutes. At age 10 minutes the skin Incidenc 1,5 turned rosy and the baby was transferred to the neonatal inten- 1,0 sive care unit. Neonatal lactate was 66 mg/dl 4 hours after birth 0,5 and decreased to 39 mg/dl 6 hours post partum. During the in- ʼ 0 fant s subsequent stay in hospital, a perinatal infection with <4000 4000–4499 >4499 Staphylococcus epidermidis and Enterococcus faecalis was suc- Birth weight (g) cessfully treated with cefotaxime and gentamycine. Erbʼs palsy of the right arm (the posterior arm during the birth) was noted; Fig. 4 Incidence of shoulder dystocia as a function of birth weight (after however this had already began to improve during the infantʼs Berle et al. [3], n = 222519 births). stay in hospital. A cut on the infantʼs left calf caused by the uterot- omy was treated conservatively. The infant did not develop hypoxic ischaemic encephalopathy. The baby recovered after treatment in the neonatal unit, and was discharged home 16 days drugs. The expulsion phase until the head was born was only 13 later. Data from subsequent paediatric examinations showed that minutes. There is no data on maternal weight gain during preg- the infant continued to develop normally.
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