A 36-year-old woman, gravida 6 para 5, at 41 weeks gestation comes to the emergency department for spontaneous rupture of membranes and contractions every 3 minutes; she has had no vaginal bleeding. Fetal movement is normal. The patient's current pregnancy has been uncomplicated. A 1-hour glucose challenge test was 155 mg/dL at 28 weeks gestation; however, a 3-hour glucose tolerance test was normal. She has no chronic medical conditions and has had no previous surgery. Vital signs are normal. The fetal heart rate tracing is category 1. The tocometer shows contractions every 3 minutes. Fundal height is 42 cm. Pelvic examination confirms rupture of membranes and the cervix is 5 cm dilated. The patient is admitted and epidural analgesia is administered. Her labor progresses normally. After 15 minutes of pushing, the fetal head delivers and, immediately after it delivers, retracts into the perineum. The patient is instructed to push, gentle downward traction is applied to the fetal head, and the anterior fetal shoulder does not deliver. Which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old woman, gravida 6 para 5, at 41 weeks gestation comes to the emergency department for spontaneous rupture of membranes and contractions every 3 minutes; she has had no vaginal bleeding.  Fetal movement is normal.  The patient's current pregnancy has been uncomplicated.  A 1-hour glucose challenge test was 155 mg/dL at 28 weeks gestation; however, a 3-hour glucose tolerance test was normal.  She has no chronic medical conditions and has had no previous surgery.  Vital signs are normal.  The fetal heart rate tracing is category 1.  The tocometer shows contractions every 3 minutes.  Fundal height is 42 cm.  Pelvic examination confirms rupture of membranes and the cervix is 5 cm dilated.  The patient is admitted and epidural analgesia is administered.  Her labor progresses normally.  After 15 minutes of pushing, the fetal head delivers and, immediately after it delivers, retracts into the perineum.  The patient is instructed to push, gentle downward traction is applied to the fetal head, and the anterior fetal shoulder does not deliver.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c041_c934_8f63_47b5aaf5c143_MD0005_00 Shoulder dystocia occurs when the anterior fetal shoulder does not deliver with the usual obstetric maneuvers (eg, gentle downward traction). The typical presentation of shoulder dystocia is the retraction of the fetal head into the maternal perineum immediately after delivery ("turtle sign"). Shoulder dystocia is an obstetric emergency associated with fetal risk for brachial plexus injury, clavicular or humeral fracture, hypoxic encephalopathy, and death. Maternal complications of shoulder dystocia include pelvic injury (eg, fourth-degree perineal laceration) and postpartum hemorrhage. Risk factors for a shoulder dystocia include prior shoulder dystocia, diabetes mellitus, maternal obesity, fetal macrosomia, post-term pregnancy, and operative vaginal delivery. shoulder dystocia Shoulder dystocia is caused by impaction of the anterior fetal shoulder behind the maternal pubic symphysis. It is managed by the performance of maneuvers that work to disimpact the anterior shoulder. The first maneuver for shoulder dystocia is the McRoberts maneuver, during which the maternal hips are hyperflexed. This maneuver decreases obstruction through the bony pelvis by rotating the pubic symphysis cephalad and flattening the sacral promontory. The combination of McRoberts maneuver and suprapubic pressure frequently relieves the shoulder dystocia with no additional maneuvers required. McRoberts maneuver (Choice A) Excessive downward traction on the fetal head during delivery is avoided as it can overstretch the brachial plexus and cause a palsy. (Choices B and D) Delivery of the fetal posterior arm and application of rotational pressure to the posterior fetal shoulder (Woods screw or Rubin maneuver) are second-line maneuvers indicated if the McRoberts maneuver and suprapubic pressure fail. (Choice C) Pushing the fetal head back into the pelvis and performing an emergency cesarean delivery (eg, Zavanelli maneuver) are indicated when all other maneuvers fail. Educational objective: Shoulder dystocia, the failure of the usual obstetric maneuvers to deliver the fetal anterior shoulder, is an obstetric emergency. It typically presents with retraction of the fetal head into the perineum after the head delivers. Initial management includes the McRoberts maneuver and suprapubic pressure. References: Shoulder dystocia: risk factors, predictability, and preventability. (http://www.ncbi.nlm.nih.gov/pubmed/24863023) Shoulder dystocia: management and documentation. (http://www.ncbi.nlm.nih.gov/pubmed/24863024)

A 36-Year-Old Woman, Gravida 6 Para 5, at 41 Weeks