What should be done first after delivering an infant with shoulder dystocia?

Management After Successful Delivery of an Infant with Shoulder Dystocia

Following successful delivery of an infant with shoulder dystocia, cord clamping should be deferred as per initial steps of NRP to allow for optimal placental transfusion and improved neonatal outcomes.

Rationale for Delayed Cord Clamping

Delayed cord clamping provides significant benefits for infants delivered after shoulder dystocia:

• Infants with shoulder dystocia may experience hypovolemic shock due to compression of umbilical vessels during the dystocia event 1
• Delayed cord clamping allows for fetoplacental transfusion of oxygenated venous blood, which can:
  • Buffer existing acidosis
  • Enhance blood volume by up to 20%
  • Improve hemoglobin concentrations
  • Reduce the need for blood transfusions 2

Recommended Protocol

1. Delay cord clamping for at least 60 seconds, ideally 3 minutes

   • Position the infant between the mother's legs or on the mother's abdomen 3
   • This allows for optimal placental transfusion regardless of fetal weight

2. Administer oxytocin to the mother immediately after delivery

   • This reduces maternal blood loss while allowing for delayed cord clamping 3

3. Assess the infant's condition during delayed cord clamping

   • If resuscitation is needed, it can be initiated with the cord intact 3, 2
   • Even compromised infants benefit from delayed cord clamping 2

Special Considerations for Shoulder Dystocia Cases

Infants delivered after shoulder dystocia are at particular risk for:

• Hypovolemic shock due to compression of umbilical vessels 1
• Hypoxic injury correlating with the duration of dystocia 4
• Brachial plexus injuries or clavicle fractures 5

In these cases, delayed cord clamping is even more crucial as it may:

• Allow autotransfusion from the placenta to restore blood volume 1
• Improve pulmonary perfusion to compensate for existing hypoxemia 2
• Enhance circulation by maintaining preload to the left ventricle 2

Common Pitfalls to Avoid

1. Immediate cord clamping before adequate ventilation

   • This can worsen the condition of an already compromised newborn 2
   • May reduce preload to the left ventricle and hinder establishment of circulation 2

2. Delaying volume resuscitation if needed

   • If signs of hypovolemic shock persist despite delayed cord clamping, volume resuscitation should be initiated promptly 1

3. Focusing solely on brachial plexus injury assessment

   • While important, the immediate priority is cardiorespiratory stabilization

By deferring cord clamping as per initial steps of NRP following delivery of an infant with shoulder dystocia, you provide the best opportunity for optimal placental transfusion and improved neonatal outcomes, particularly for these vulnerable infants who may have experienced compression-related hypovolemia and hypoxia.