Despite starting the recommended therapy, the patient's 2-hour postprandial blood glucose levels remain 140 mg/dL. At 37 weeks gestation, ultrasound examination reveals an estimated fetal weight of 4 kg (8 lb 13 oz). At 38 weeks gestation, the patient comes to the hospital in spontaneous labor and has a protracted labor course, pushing for 3 hours. Following delivery of the fetal head, the anterior shoulder cannot be delivered. A tight nuchal cord is palpated. She is instructed not to push. Which of the following is the best next step in management of this patient?

Question

Despite starting the recommended therapy, the patient's 2-hour postprandial blood glucose levels remain >140 mg/dL.  At 37 weeks gestation, ultrasound examination reveals an estimated fetal weight of 4 kg (8 lb 13 oz).  At 38 weeks gestation, the patient comes to the hospital in spontaneous labor and has a protracted labor course, pushing for 3 hours.  Following delivery of the fetal head, the anterior shoulder cannot be delivered.  A tight nuchal cord is palpated.  She is instructed not to push.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da84_dd43_bc81_f1d293bb51ce_MD0003_00 This patient is experiencing shoulder dystocia, or impaction of the fetal anterior shoulder behind the maternal pubic symphysis that impairs delivery of the shoulders with routine gentle traction. Risk factors include gestational diabetes mellitus (as in this patient) and associated fetal macrosomia (ie, birth weight ≥4.5 kg [9 lb 14 oz]). Shoulder dystocia is an obstetric emergency that can lead to both fetal and maternal complications. Fetal complications include brachial plexus injuries, clavicular or humeral fractures, and hypoxic encephalopathy. Maternal complications include fourth-degree (ie, rectal mucosa) perineal lacerations and postpartum hemorrhage. brachial plexus injuries perineal lacerations Management of shoulder dystocia requires maneuvers to dislodge the anterior shoulder or reorient the fetus to deliver through the widest diameter of the bony pelvis. The initial step in relieving shoulder dystocia is the McRoberts maneuver-flexing the patient's hips back against her abdomen-and applying suprapubic pressure. The McRoberts maneuver flattens the sacral promontory and decreases obstruction through the bony pelvis. Suprapubic pressure may then dislodge the anterior shoulder to allow delivery. The combination of these maneuvers relieves shoulder dystocia in nearly half of cases without further intervention. McRoberts maneuver (Choice A) Forceps are applied to guide the fetal head under the pubic symphysis to expedite the second stage of labor. After delivery of the head, forceps are removed, and the shoulders are delivered with maternal expulsive efforts. Forceps are not indicated in the management of shoulder dystocia. In addition, increased traction on the fetal head increases the risk of brachial plexus injury. (Choice B) The impediment to this patient's delivery is the impacted fetal shoulder, not the tight nuchal cord (umbilical cord that is looped around the neck and can be manually reduced). During shoulder dystocia, clamping and cutting the umbilical cord (even a nuchal cord) is absolutely contraindicated because it would sever the only source of oxygen to the fetus, resulting in fetal hypoxia, hypoxic encephalopathy, and fetal death. tight nuchal cord (Choices D and E) Replacement of the fetal head into the maternal pelvis (ie, Zavanelli maneuver) is performed if all other maneuvers fail and an emergency cesarean delivery must be performed. Educational objective: Shoulder dystocia, an obstetric emergency, is impaction of the fetal anterior shoulder behind the maternal pubic symphysis that results in the inability to deliver the shoulders with routine gentle traction. Initial management is the McRoberts maneuver (ie, flexion of the patient's hips back against her abdomen) and application of suprapubic pressure. References: A comparison of obstetric maneuvers for the acute management of shoulder dystocia. (http://www.ncbi.nlm.nih.gov/pubmed/21555962)

Despite Starting the Recommended Therapy, the Patient's 2-Hour Postprandial Blood