Dystocie of the shoulders

Because it is rare (1 per 1000 births) and almost always unforeseeable (90% of the cases), the dystocie of the shoulders does not belong to the experiment of any obstetrician.

Definition

severe Dystocie suitable for the Childbirth of the large fetus, being characterized by the absence of engagement of the shoulders after expulsion of the head. The increase in the diameter biacromial (> to 13 cm) or sometimes its abnormal orientation in the antéro-posterior diameter causes the thrust of the projections acromio-claviculaires on curbstone of the higher strait.
This dystocie is to be differentiated from the difficulty to the shoulders which corresponds to a blocking of the posterior shoulder in the excavation.

Causes of the dystocie of the shoulders

The engagement of the shoulders is done at the time of the release of the head. When there is dystocie shoulders, there is immobilization of the diameter Bi-acromial attracting the head towards the basin. This one sticks to the vulva without movement restitution possible or difficult, cyanosite, becomes purplished, the child gaspe. It is an impressive situation which can encourage with operation of traction which can result in the death of the fetus.

Action to be taken

Not to create a dystocie shoulders

inappropriate Operation by drawing the head in a plan parallel on the ground or by blocking the former shoulder behind the pubic symphyse

Operate to make

not to be only (if possible, to benefit from an analgesia péridurale)
To remain calm
systematic Épisiotomie, broadest possible

Initially if the posterior shoulder is in the pelvic excavation

There is a shoulder with the touch Vagin
Manœuvre of Mac Roberts

Extreme inflection of the thighs in abduction: Reduction of lumbar lordosis and slip of the pubic symphyse on the former shoulder Simultaneous pressure on the line of centers with the top of the pubic symphise involving a reduction in the diameter biacromial

Operation To bend

Introduction of two fingers under the pubic symphyse to the former elbow of the fetus, releasing the former arm by lowering of the arm under the symphyse. One obtains the opening-up of the posterior shoulder thus. Compression suspubienne of the former shoulder allowing its orientation in an oblique diameter. The operation To bend is not possible that if the former shoulder left, therefore not of dystocie of the shoulders… the dystocie of the shoulders is characterized by impossibilitée of exit of the shoulders. the head, only, is outside. To carry out the operation To bend, one needs an engagement of the former shoulder.

Operation of Wood

Double axial rotation of the fetus allowing the transformation of the posterior shoulder into former shoulder to allow the release of it. It is necessary to turn the shoulders and not the head of the fetus if not there exist risks important of fracture or elongation of the plexus brachial. One introduces the fingers on the posterior face of the posterior shoulder.

Operation of Hibbard

Allows the engagement of the former shoulder then the evolution of the whole of the shoulders thanks to a simple lowering of the helped fetal head of a soft uterine expression.

Truth dystocie of the shoulders: Fixing of the shoulders at the edge of the maternal osseous basin (higher Strait)

Operation of Jacquemier

Reduction of the diameter biacromial in a acromio-thoracic diameter is a reduction of three centimetres: The hand used is that of the presentation; this one goes up until the sacro-iliaque sine corresponding to the posterior shoulder (thus opposed to the fetal back) which butts against the headland. The posterior hand of the fetus is seized by the wrist, lowered in the genital ways according to an axis ombilico-coccygien in the ventral plan, the humérus being protected by the fingers of the operator placed in splint. One obtains a reduction in the diameter biacromial, extraction of the member, one carries out a rotation of 180°, the former shoulder become posterior, is then lowered. One can remake this operation after rotation of 180° if the first attempt fails.

Operation of Letellier

To slip the hand behind (right hand for the left shoulder). Naked hand, soaped. To locate the shoulder with the higher strait, To pass the index in hook in the armpit, of back ahead. The inch can be brought out of grip thénar the articulations of its finger and its wrist, the front armlever works because the arm of lever of the operator is long. When the shoulder is put moving, to seek to engage, therefore to push forwards and downwards in gimlet. The gesture becomes easy, natural. To bring the shoulder to the pubic warhead where it is released in a traditional way, fingers in splint on the humérus The way of the shoulder is initially in the plan of the higher strait, then in spiral in the excavation to the pubic warhead The clavicle transmits the tractive effort, with the sternum. The thorax accompanies rotation. The shoulder “is gradually raised”. The acromio-thoracic diameter was reduced without any traction on the neck.

Operation of Zavanelli

Rehabilitation of the fetal head in the genital ways followed by an extraction by Cesarean

Historical operations

fracture deliberated on the clavicle of the fetus, even its section with the scissors of Dubois (cleidotomy).
partial symphysiotomy according to the method of Zarate (1924).
Operations on dead fetus : operate of RibemontDessaignes (1893): successive release of the two arms by fracturing them to be able to lower them. Embryotomies: either bilateral cleidotomy with the scissors of Dubois, or amputation of the shoulder, or thoracotomy with evisceration, or cervical embryotomy followed by an operation for the trunk (not of a Cesarean!)

Prevention of the dystocie of the shoulders

The prevention of the dystocie of the shoulders is difficult , almost impossible because the accident is generally unforeseeable.

the ponderal estimate at the end of the pregnancy is not very reliable even by echography carried out with the approach of the term.
the attempts at correlation between the diameter biachromial and the existence of a dystocie of the shoulders could not be highlighted.
50% of the dystocies of the shoulders does not occur at fetuses macrosomes.
the Diabète gestationnel explains only 20% of macrosomias and an assumption of responsibility adapted of the diabetes gestationnel eliminates only partially this risk

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