Shoulder dystocia

Classification according to ICD-10
O66.0	Obstacle to birth due to shoulder dystocia
ICD-10 online (WHO version 2019)

As Schulterdystokien setting anomalies are collectively referred that after the birth of the head impede the child's full development, it is an irregular adjustment of the shoulder girdle, depending on the ride height in front of the head.

Shoulder dystocia is an unpredictable obstetric emergency that requires immediate action, as child hypoxia (lack of oxygen) occurs almost at the same time . The frequency is given as 0.2 to 3% of all births , depending on the birth weight of the children.

Classification

A distinction is made between a high shoulder straight stand and a deep shoulder transverse stand.

When the shoulder is straight, the shape has not been adapted to the pelvic entrance . Instead of adjusting transversely, according to the shape of the pelvic entrance, the shoulder girdle has adjusted itself in a straight diameter. Stepping deeper is hindered by the symphysis (pubic bone) because it does not release the front shoulder.

In the case of the deep transverse shoulder stance, the shape of the shoulder did not adapt to the longitudinally oval pelvic exit space. It has settled in the transverse diameter and hinders the birth of the following body after the head has already been born.

Diagnosis

Often the expulsion period was previously extended or the passage of the head was already difficult. After the birth of the head, it pulls back and seems to be literally pressed onto the pelvic outlet (so-called "turtle phenomenon"), an apparently physiological second rotation (see birth mechanics ) can occur, as the child tries to remove the strong neck tension, caused by the head rotated by 90 ° compared to the trunk. In the further course of the disease, a bluish-livid skin discoloration of the face occurs in the child, which is caused by venous congestion and initially does not represent a sign of fetal hypoxia. This does not develop until the shoulder dystocia has persisted for a long time; however, an approximate time of when manifest brain damage will occur cannot be given.

causes

The cause is usually an oversize child (more than 4000 g), often in children of diabetic mothers , who usually have a macrosomia , as the shoulder width is larger than the head circumference. However, there is also evidence that macrosomia in children of diabetic mothers is less of a problem than a disproportionate growth of insulin-sensitive tissue, including the trunk and shoulder area.

The cause can also be forced birth management (premature pressing, massive use of the Kristeller handle and vaginal-operative deliveries ( suction cup , forceps )), in which the trunk did not have enough time to find a proper setting.

therapy

Making a perineal incision is controversial in specialist circles, as a perineal incision only expands the vaginal exit and not the pelvic entrance. Other known measures for releasing the shoulder are:

Changing the position of the mother (e.g. from sitting to the side), which in many cases can loosen the shoulder that is stuck to the symphysis.
McRoberts maneuver : Both legs of the mother are bent and led downwards, which results in a slight elevation of the symphysis axis. This maneuver can be combined with suprasymphyseal pressure.
Gaskin maneuver : the mother goes into the quadruped position, which widens the distance between the symphysis and coccyx .
Rubin's maneuver : the obstetrician tries to push the front shoulder of the child into the oblique diameter below the symphysis.
Woods maneuver : the obstetrician tries to bring the child's back shoulder into the transverse diameter.
Solution of the rear arm according to Jacquemier : The obstetrician tries to dislocate the rear upper arm of the child via the thorax.

More invasive rescue maneuvers (which are rarely used today):

Fracture of the child's clavicle or humerus may become necessary as part of the Jacquemier maneuver .
Zavanelli maneuver : pushing the child's head back into the birth canal in the opposite direction to the mechanics of the birth and subsequent caesarean section . This maneuver is only used when all other options have been exhausted, as it is associated with a high risk for both the mother and the child.

Symphysiotomy : The birth canal is enlarged by separating the connective tissue between the two pubic branches.

literature

Ch. Mändle, S. Opitz-Kreuter, A. Wehling: The midwifery textbook of practical obstetrics. Schattauer, Stuttgart 1997, ISBN 3-7945-1765-2 .
Gerhard Martius : Midwifery Textbook. Georg Thieme Verlag, Stuttgart 1971.
EG Baxley, RW Gobbo: Shoulder dystocia . In: Am Fam Physician. 2004 Apr 1; 69 (7), pp. 1707-1714. PMID 15086043
F. Kainer: Specialist in obstetrics. Urban & Fischer, Munich 2006, ISBN 3-437-23750-0 .

Individual evidence

^ R. Schäfers: Gestational diabetes - an overview of the current state of knowledge. In: The midwife. 2, 2008.
^ Karen Kish, Joseph V. Collea, Lauren Nathan: Current Obstetric & Gynecologic Diagnosis & Treatment . Ed .: Alan H. DeCherney. 9th edition. Lange / McGraw-Hill, 2003, ISBN 0-07-118207-1 , Malpresentation & Cord Prolapse (Chapter 21), pp. 382 .

[1] R. Schäfers: Gestational diabetes - an overview of the current state of knowledge. In: The midwife. 2, 2008.

[2] Karen Kish, Joseph V. Collea, Lauren Nathan: Current Obstetric & Gynecologic Diagnosis & Treatment . Ed .: Alan H. DeCherney. 9th edition. Lange / McGraw-Hill, 2003, ISBN 0-07-118207-1 , Malpresentation & Cord Prolapse (Chapter 21), pp. 382 .