Good afternoon, doctor. Are you enjoying your quiet Sunday afternoon shift with this snowstorm outside (just playing odds this year)? That's great. Well, I hate to break up the calm, but I have this patient out here in the waiting room? She says she's like a G8P5 or something, and she's 38 weeks, and she thinks she's in labor? She's in a lot of pain and it appears that her contractions are occurring every minute or so.
Maybe you have obstetrical capabilities at your hospital or maybe you don't. In this case it doesn't matter as there is no time. You get the patient into the stirrups and have her push. The head starts coming nicely and quickly, but then everything....stops...all...of...a...sudden. It would appear that this large child has become stuck on the pelvic brim, and is "turtling" back into the womb!
Deliveries in the ED are obviously a rare event, and dystocias are a rarity inside of this rarity (representing about 0.6% to 1.4% of deliveries), but they still happen, and you need to know what to do if you end up with the catcher's mitt.
First of all, you'll need help. A HELPERR to be exact!
This is a great mnemonic to run through the initial algorithm. (ALARMER is another good one). But seriously, first step--call for some help. You will need at least two additional pair of hands regardless of how Han Solo you like to be in your shop. On top of that, get someone else on the phone. If there's an obstetrician in house, call them. If there's a neonatologist in house, call them. If there's an anesthesiologist in house....you get the idea.
Tell your patient to stop pushing--her Valsalva'ing may potentially worsen the situation so you'll need to take over. Have a look at the perineum--will a quick episiotomy let the baby fall out? The answer is probably not, and it's controversial (some studies have shown that it increases risk for severe perineal trauma), but it's always good to have a look.
The money will likely be in the McRoberts maneuver. Studies have shown that this alone will solve the problem in almost half of cases, so do it right! You'll need an assistant on either side to get the patient's legs back in extreme, extreme, super lithotomy to rotate the pubic symphysis superiorly. Have them hyper-flex the hips with the knees pushed to the chest.
Supplement this with suprapubic (not fundal!) pressure directed inferiorly to hopefully push the anterior shoulder out. This is also known as the Mazzanti maneuver--dystocia is just crawling with eponyms.
If unsuccessful, try rotational maneuvers like the famous Woods' Screw, aka the Rubin Technique. Essentially you'll want to place a finger into the vagina, anterior to the infant's posterior shoulder. Then rotate 180 degrees, like a big old screw in the wall. The reverse Woods' is as expected, and involves the posterior aspect of the shoulder (and theoretically should be more effective).
Continuing on, you can try posterior arm delivery. This is accomplished by flexing the arm, gripping the humerus (gently and evenly of course) and then sweeping it across the chest and then out the vagina. No luck? We move on to the last "R" of HELPERR, which stands for"roll onto all fours." This refers to the Gaskin maneuver, which utilizes downward traction on the head to allow the posterior shoulder to descend and be delivered. You can also deliver the posterior arm in this position.
There are a number of remaining last resorts, like fracturing the fetal clavicle, or the ultimate Zavanelli, but they are so incredibly risky and controversial we won't take the chances of describing them in detail.
Here's a very calm (unlike the real thing) demonstration on a model:
So while you will unlikely be faced with this rarest of rare situation, as emergency physicians, you should always be prepared. Here is a quick rundown of the maneuvers we discussed:
- McRoberts maneuver: The least invasive and the most successful (achieves delivery in up to 40% of cases), this maneuver involves hyperflexing the mother's hips and knees such that her pelvic outlet is rotated anteriorly, freeing the impacted anterior fetal shoulder. This can be augmented by having an assistant place moderate suprapubic pressure (but not fundal - the idea is to push the fetus' shoulder below the pubic rami) while you provide gentle posterior traction on the head.
- Wood's screw: This is a second-line technique that involves sticking your fingers on the front of the fetus' posterior shoulder (i.e. the one against the mother's sacrum) and rotating the fetus' body such that the anterior shoulder is rotated out from under the pubic rami. Variations on this include the Reverse Wood's screw (fingers on the posterior scapula) and Rubin's maneuver (fingers on the anterior shoulder's scapula).
- Posterior arm delivery: This is one of the more complicated ones, and I don't really see myself doing it ever. In short, you stick your hand between the fetus and the sacrum until you find the fetus' elbow, then flex the elbow with posterior forearm pressure until you can grab the hand. Sweep the hand across the fetus' chest and out of the vaginal opening. Then rotate the shoulder girdle until you can deliver the anterior shoulder. This seems likely to produce brachial plexus injuries to us (and as it turns out, it is).
- Gaskin maneuver: Have mother move onto the all fours position with the back arched. This will help widen the pelvic outlet for delivery of the shoulder.
- Controlled destruction: If all else fails, you can always make things more flexible by carefully breaking the fetus' clavicle. But like we mentioned before, it's incredibly controversial--and you especially didn't hear about it from us!
- Zavanelli maneuver: If really all else fails, one can throw a Hail Mary by pushing the infant back into the birth canal and then rushing the patient to a crash C-Section. We think this sounds like a terrible idea, and if you think we're recommending it you've got another thing coming.
And don't forget the HELPERR mnemonic!
As always, these posts are for EDUCATIONAL PURPOSES ONLY. If you have to catch a baby and you're in trouble, call for help if it's available. Don't try to be a hero. Seriously.
- del Portal MD, D. A., MD, A. E. H., MD, G. M. V., MD, T. C. C., & MD, J. W. U. (2014). Technical Tips. Journal of Emergency Medicine, 46(3), 378–382. doi:10.1016/j.jemermed.2013.08.110
- Gherman, R. B., Goodwin, T. M., Souter, I., Neumann, K., Ouzounian, J. G., & Paul, R. H. (1997). The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it? American Journal of Obstetrics and Gynecology, 176(3), 656–661.
- Roberts and Hedges Clinical Procedures in Emergency Medicine, Sixth Edition. Chapter 56.