From the Guidelines
Shoulder dystocia is an obstetric emergency that requires immediate attention to prevent serious complications, including clavicular fracture and brachial plexus injury, which are approximately 10-fold and 18-to 21-fold more likely in macrosomic infants with birth weight over 4,500 g, as reported by 1. When managing shoulder dystocia, it is essential to follow a systematic approach to minimize the risk of fetal injury. The HELPERR mnemonic is a useful tool to guide the management of shoulder dystocia: call for Help, evaluate for Episiotomy, Legs (McRoberts maneuver), suprapubic Pressure, Enter maneuvers (internal rotational maneuvers like Woods' screw or Rubin's), Remove the posterior arm, and Roll the patient onto hands and knees (Gaskin maneuver) 1. Some key points to consider in the management of shoulder dystocia include:
- Recognizing the condition promptly to initiate appropriate management
- Avoiding excessive traction, which can lead to clavicular fracture or brachial plexus injury
- Using internal rotational maneuvers to facilitate delivery
- Considering the use of instrumental delivery or cesarean section if necessary In the event of a clavicular fracture, management is typically conservative, with immobilization using a figure-of-eight bandage or simple sling for comfort, as reported by 1. It is crucial to inform parents about the injury, reassure them about the excellent prognosis, and instruct them to handle the infant carefully to avoid pain during the healing process. Most neonatal clavicular fractures heal completely within 7-10 days with excellent remodeling and no long-term sequelae 1.
From the Research
Shoulder Dystocia and Clavicular Neonatal Fracture
- Shoulder dystocia is an obstetric emergency that can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder, anal sphincter, and rectum, and postpartum hemorrhage 2.
- The condition can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality 3.
- In rare cases, intentional clavicle fracture may be considered as a management option for shoulder dystocia when other maneuvers are unsuccessful 2, 4.
- Clavicular fracture is a potential complication of shoulder dystocia, and it is essential to weigh the risks and benefits of this intervention 4.
- The management of shoulder dystocia involves a preplanned sequence of maneuvers, including the McRoberts maneuver, suprapubic pressure, internal rotation, and removal of the posterior arm, to relieve the impacted shoulder and allow for spontaneous delivery of the infant 2, 4, 5.
- The primary goal of these maneuvers is to reduce maternal and neonatal morbidity and mortality by minimizing the risk of fetal and maternal injury 6, 3.