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MRCOG PART 2 SBAs and EMQs

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Essay 243 - Macrosomia

Posted by Mohammad H.
A healthy 32 year old primigravida has been referred to the antenatal clinic at 38 weeks

gestation because the fetus has an abdominal circumference above the 97th centile on growth

scan. (a) Evaluate critically the options for safe delivery [10 marks]. She presents in

spontaneous labour at 39 weeks gestation. Delivery is complicated by shoulder dystocia.

Logically outline your interventions to achieve safe delivery [10 marks].
The patient has two options each has its advantages and disadvantages.
The first is planned caesarean section (CS)that has the advantages of avoiding difficult

vaginal delivery (VD)and shoulder dystocia which can be associated with fetal distress

,increased fetal morbidity and mortality.CS also has the advantage of avoiding perineal

,vaginal and cervical tears with their subsequent long term sequalae.However ,CS is

associated anaethetic compliocations (either epidural or general).Infections (wound and

endometritis )are more common with CS. There is increased risk of venous

thromboembolism(VTE) .As the fetus is macrosomic there is a risk of difficult cs with more

risk of extending the uterine incision with more risk of mahaemorrhage and ureteric injury.

Maternal mortality is higher with cs .Longer stay in hospital and more need for antibiotics

with cs as compared to vd.There is increased risk ofrecurrent cs,placenta previa and

placenta accreta in subsequent pregnancies.
The other option is vaginal delivery (VD)that is associated with less risk of VTE,and

endometritis.It avoids the abdominal and uterine scars.Itis associatedwith less maternal

mortality.Epidural analgesia can be used with vd nd iy has cpmlications that should be

discussed with the patient.Disadvantages of vd include shoulder dystocia that should be

expected during the delivery of macrosomic babayand may lead to Erb or Klumpke\'s

palsies.Perineal tears including third and fourth degree tearsare more expected and may

lead to long term sphincteric problems and needfor surgical repair.Fetal distress,fetal

loss and obstructed labor can occur with VD.Opeartive VD may be needed withits maternal and

fetal compliactions.CS may be neede at any time during VD for fetal distress or obstructed

labor.
Both options should be discussed with the patient and information leaflets should be

provided to help the patient to take a decision.


For shoulder dystocia ,call of help from senior obstetrician ,anaesthetist neonatologistis of great importance.Mild suprapubic pressure may help the anterior shoulder to enter the pelvis.
Mc-Robert manouvre in which hyperflexion and abduction of hips and flexion of the knees will help the anterior shoulder to enter the pelvis in more than 90% of cases.episiotomy may be neede . Fundal pressure has no role and should be avoided.
Posterior arm can be delivered through the sacral concavity then the anterior shoulder rotated posteriorly to be deliverde as the posterior one.
Symphisiotomy can be tried if all of the above manouvre s fail to deliver the shoulders.
Zaveneelli manouvre in which head is replaced in the abdomen and cs is performed is very difficult and rarely to be done.
Keep the patient always aware by every step and recors every step in an incident form.
Posted by Natalie P C.
A
3 options are spontaneous labour and vaginal delivery, induction of labour and vaginal delivery and elective caesarean section.
Elective caesarean section is only offered where there is another indication like diabetes which also increases the risk of shoulder dystocia. Macrosomia is associated with an increased risk of shoulder dystocia and caesarean will eliminate that risk but it will increase her risk of other complications like anaesthetic (GA-aspiration, spinal-dural leak), bleeding and transfusion, infection example in the wound, visceral injury, venous thromboembolism and long term risks of adhesions, delivery in the next pregnancy and risk of still birth at term. There is the fetal risk of transient tachypnea of the newborn. The NNT is very high to prevent one shoulder dystocia or one stillbirth or neonatal death.

There is no evidence that induction of labour reduces the risk of shoulder dystocia and with induction, there is a risk of failed induction and caesarean section. Spontaneous labour is generally recommended as it has the best chance of a normal delivery. Shoulder dystocia should be anticipated. Labour dystocia and slow progress in 1st or 2nd stage may predict shoulder dystocia. Instrumental delivery is associated with a further increase so staff with the appropriate expertise should be aware and on hand to assist (experienced registrar or consultant).

B
My first step would be to call for help by pulling the emergency buzzer and asking them to put out an emergency 2222 bleep informing that we have a shoulder dystocia and the location. This will call the registrars, consultant if on site, paediatrician and anaesthetist. I would appoint a scribe while I start the manoeuvres. I would then flatten the head of the bed, and consider if I have enough room to put my hands in the vagina for the manoeuvres and evaluate for an episiotomy. I would elevate her leg?s into Mc Robert?s position (hyperflex the hips with abduction and flex the knees). I would try to deliver for 30 seconds with each manoeuvre.

I would then ask an assistant to give suprapubic pressure behind the anterior shoulder, first constant then with a rocking motion. I would then try the internal manoeuvres. First pushing the anterior shoulder from behind. I would then add pushing the posterior shoulder from in front. I could then reverse it t do the reverse Woodscrew. I would then try for the posterior arm, pressing in the antecubital fossa to flex the elbow and grasp the arm and sweep it across the chest. I would then consider rolling the patient onto all foors and re-attempting the internal manoeuvres. I would then consider fracturing the clavicle to allow delivery of the shoulders if I had the expertise. Another option is a symphysiotomy or the Zavanelli which requires reverse manoeuvres and getting the head back in the pelvis and delivering by Caesarean section ( if the baby is still alive). I would fill out an incident form after this whatever the outcome and inform my consultant if he/she had not been present.



Posted by Parveen  Q.
The aim for safe deivery is to reduce maternal and foetal morbidity and mortality. First of all, thrid trimester USS is associated with 10%error for actual birth weight and sensitivity of just over 60%for macrosomia. There are other factors associated with shoulder dystocia like increase BMI of over 30 in the mother, induction of labour and assisted vaginal delivery. The options available are spontaneous vaginal delivery, induction of labour , elective or emergency caesarean section. all the options have their own risk and benefits. Early induction of labour in asuspected case of macrosomia does not improve the maternal or foetal outcome. However in normal cases, it is associated with less time for delivery, reduced rate of PPH, and less need for operative delivery. Elective C.S for suspected case of macrosomia, in a non diabectic(healthy woman here) is not recommended. It has been estimated that an additional 2000 more cases need to be done to prevent 1 permanent injury from shoulder dystocia. caesarean section is associated with increase hospital stay, increase risk of thromboembolism, and an carries around 15 additional risk of either blood transfusion or endometritis. There is increase risk of transient tachypnoea of newborn. spontaneous vaginal delivery carries the risk of still birth, shoulder dystocia, PPH,third and fourth degree perineal tear, and may end in operative delivery. I will ensure to involve her in the decision making process and provide her with information leaflets.

I will call for help, involving senior obstetrician, midwife, anasthetist, and neonatal team. I will ask her to remain calm and defer from pushing, as pushing may cause impaction of shoulders. I will ensure that her buttocks were brought to the edge of the table. I will ensure that fundal pressure is not being used. I will evalute the need for episitomy, as it is not necessary in all cases. It is of value only in enter manoeuvres. McRobert\'s manoeuvre will be done first whereby the maternal thighs were positioned on her abdomen, causing flexion and abduction of maternal hips. The sucess rate is 90% and has a low rate of complications. It may be used along with suprapubic pressure where the pressure is applied downwards and laterally. If this fails, i will employ either all 4position or enter manoeuvres depending on the clinical situation. If the patient is thin,without epidural anaesthesia, and only midwife is available , all 4position will be employed and success rate of 83% has been reported. In the secondary manoeuvres, first iw ill give episiotomy as it make the manoeuvres easy and either delivery of posterir arm or internal rotation manoeuvres done . If above measures fail to impact shoulders, i will inform consultant obstetrician, anasthetisit and consider all 4 position or repeat all manoeuvres. Thrid line manoeuvres are division of clavicle, symphysiotomy, or (cephalic replacement and delivery by caesarean section)zavanelli manoeuvre, these are rarely required . There is a risk of PPH and thrid and fourth degree perineal tear. Active management of thrid stage of labour will be undertaken to avoid PPH and patient will be examined with good lighting and analgesia, suturing done. Accurate documentation of the events, about the time of delivery, time of delivery of body, condition of the baby and umblical cord PH. It is essential to document the position of foetal head at delivery as damage to the brachial plexus of posterior shoulder is considered not due to the action of accoucher.
Posted by Radhika A.
A healthy 32 year old primigravida has been referred to the antenatal clinic at 38 weeks gestation because the fetus has an abdominal circumference above the 97th centile on growth scan. (a) Evaluate critically the options for safe delivery [10 marks]. She presents in spontaneous labour at 39 weeks gestation. Delivery is complicated by shoulder dystocia. Logically outline your interventions to achieve safe delivery [10 marks].
The options for consideration are vaginal delivery either at spontaneous onset of labour or induction and delivery by elective cesarean section. Vaginal delivery option is only to be considered if the pelvis is not abnormal (contracted, malformed).The outcome is most favourable following vaginal delivery following spontneous labour onset since evidence shows that the incidence of shoulder dystocia is the least then.Maternal obesity is an important indicator of possible complications. There is no evidence that the induction of labour reduces the incidence of shoulder dystocia. The problems with vaginal delivery are higher chances perineal tears (due to the need for interventions following shoulder dystocia), post partum hemorrhage and maybe a need for an emegency cesarean section. Also there are chances of stretch on the neck of the baby causing brachial plexus and spinal injuries.Elective cesarean section on the other hand would prevent only 1 shoulder for 2000 such procedures. The advantage is that the baby is relatively safely delivered but the problems are those of anesthesia and the operative procedure itself that is pain in the spinal site, spinal site leak, extension of uterine incision , TTN, higher chances of blood tranfusion, endometritis and VTE. I would like to discuss the options with the patient and also hand her infornation leaflets to help her arrive at a decision.
b) I would immediately call for help of a senior obstetrician, paediatrician and anethetist and I would also ask a midwife to start the timer. I would like to try out each procedure for about 30 seconds and I would like deliver her within 8 min.I would reassure the mother and tell her relax and also help me deliver the baby by following my instructions. I would ensure that the bladder is empty ,ask her to shift to the edge of the table and flex her legs at the thigh and knee along with abduction at the hip joint to draw the legs to the abdomen (McRobert\'s manoevre). I will ask the assistant to apply suprapubic pressure
downwards and medially to help the shoulders descend down. I will assess the need for an episiotomy and apply it in case the vaginal space is less for manipulations inside.I would insert my hand posteriorly and try to bring down the posterior arm by gentle movement of the arm over the baby\'s chest and bring dwon the arm - this in itself may help to release the shoulders.
In case the delivery of posterior arm is not possible, I would try to rotate the posterior shoulder anteriorly or after the delivery of the posterior arm, rotate it anteriorly to make the other shoulder come into the sacral hollow (Wood\' cockscrew manoevre). If this too doesnot succeed, I would ask the patient to kneel on all fours and repeat the procure again. If this too fails, there is option of cesarean section in case the baby is alive or cleidotomy in a dead baby.
Posted by Saad A.
The cause of macrosomia foetus could be obesity, uncontrolled diabetes mellitus or due to idiopathic macrosomic syndrome or could be constitutional..The associated maternal risks are shoulder dystocia, increased risk of c-section and instrumental delivery, risk of PPH and perineal trauma. The foetal risks are birth asphyxia, erb?s paralysis, and fracture of clavicle/humerus, hypoglycaemia, and jaundice,polycythemia. There is a need to prevent above-mentioned risks. So history will be obtained from the patient including her LMP to ascertain gestational age, exclude diabetes mellitus its severity and treatment taken if present. Family history of diabetes mellitus, obstetric history including birth weight of babies, history of gestational diabetes in the previous pregnancies and MOD and about shoulder dystocia in previous pregnancies. Her current pregnancy notes are reviewed to identify any risk factor like obesity ,dibetes mellitus,any treatment taken during pregnancy. Biochemical screening is reviewed, dating scan is checked to ascertain gestational age, and identify any anomalies in foetus. Her examination including BP, BMI is checked. Abdominal examination is carried out to assess the size of the foetus, presentation and asses foetal status by CTG. Ultrasound will be needed to confirm presentation, estimated foetal weight, liquor volume, placenta localization. Blood sugar will be checked and if raised then dietary advises is given. If there is need of insulin then multidisciplinary care including dibetologist, diabetic nurse will be required for dose adjustment to control blood sugar. She will be advised that MOD will be c-section as vaginal delivery is associated with maternal/foetal complications .Her wishes will be obtained .The management plan will be documented on the notes. Written information and hospital contact details will be provided.
b. Call for help from senior obstetrician, midwife, neonatologist and anaesthetist. Note time of request and arrival and condition of the patient and foetus on arrival. Patient is placed in lithotomy/left lateral position and given extended episiotomies given and traction applied on the foetus (downward and backward). Supra pubic pressure is applied to dislodge the anterior shoulder to reduce the bis acromial diameter. Mc-Robert manouver is needed which is hyperflexion and abduction of maternal hip and judicious traction is applied on foetal head. Rotation of foetal shoulder is done in oblique diameter of the pelvic brim to facilitate the delivery of posterior arm. Cork screw method in which rotating through 180 rotates the posterior shoulder to anterior shoulder is another method. The same for anterior shoulder is done. If above manoeuvre fail sliding the hand into vagina behind the posterior shoulder does delivery of posterior arm and posterior arm of foetus is sweeped across the chest with the elbow flexed. Then grasp the hand and pull it along the foetal head to deliver the posterior arm. Other methods are cleidotomy, symphisiotomy .Zavanelli(pushing back the fetal head) and c-section is required ,the operation is associated with increased maternal mortality. Senior operator undertakes destructive procedures. Outcome depends on experience of the operator. Unit protocols must be followed. The events will be documented in notes. Risk incident form is filled. Letter will be sent to GP.and recommendations for future pregnancy should be included.

Posted by Valerie T.
A healthy 32 year old primigravida has been referred to the antenatal clinic at 38 weeks gestation because the fetus has an abdominal circumference above the 97th centile on growth scan. (a) Evaluate critically the options for safe delivery [10 marks]. She presents in spontaneous labour at 39 weeks gestation. Delivery is complicated by shoulder dystocia. Logically outline your interventions to achieve safe delivery [10 marks].

a) This baby is macrosomic. The first option is to await spontaneous labour and aim for a vaginal delivery. This reduces the risks of induction such as fetal distress and caesarean section. In labour, electronic fetal monitoring should be done. It is beneficial since it identifies fetal distress. In the second stage of labour, a senior obstetrician and senior midwives should be present because there is a risk of shoulder dystocia and postpartum haemorrhage. The third stage of labour should be managed actively to minimize blood loss.
The second option is induction of labour. Although this may result in a successful vaginal delivery, it is not advisable to perform an induction of labour. The reason for this, is that induction of labour is associated with a risk of fetal distress, instrumental delivery and caesarean section. Although the scan suggests macrosomia, there may be some discrepancy in these findings. It would not be worthwhile inducing her, if the baby is actually smaller than the scan suggests.
The third option is an elective cesarean section. This option may result in a successful vaginal delivery. However, it is not indicated in a healthy woman with macrosomia. Caesarean section has increased risk of bladder injury, bowel injury, and haemorrhage. Theew will be a longer hospital stay.

b) Shoulder dystocia is an obstetric emergency. The first step is to call for help. We would need a senior obstetrician, senior midwives and an anaesthesist. Mc Roberts manuoever is the first intervention to be performed. The legs and hips should be fully flexed to increase pelvic diameters and allow delivery of the shoulders. Traction should be applied without much force, to minimize chances of brachial plexus injury. The next step is to give suprapubic pressure. This pressure is given to try to disimpact the shoulder. If unsuccessful, the next step is to deliver the posterior arm. If unsuccessful, the next step is to try to rotate the shoulders internally placing the biacromial diameters in the oblique position. If unsucessful, third line interventions must be attempted. Cleidiotomy is the division of the clavicle to reduce the biacromial diameter. Symphysiotomy is division of the symphysis ligament to increase the pelvic diameters. Zavenelli manuoever is replacing the head in the abdomen and following with a caesarean section.
Post delivery, consider an active third stage, in view of risk of postpartum haemorrhage
Posted by Idris O.
a) I would inform the woman this is probably a constitutionally big baby. I would assess her BMI as BMI>30 may be associated with big baby. I would perform a clinical estimation of fetal weight and review her scan result .A USS fetal weight estimation > 97th centilie for GA in the presence of normal liquor volume would confirm a constituttionally big baby. I would inform the woman there is up 10-20% error margin in fetal weight estimation by USS. The options for safe delivery would include expectant management. This allows spontaneous onset of labour. It is associated with reduced need for analgesia in labour and reduced risk of fetal distress in labour. There is however a 5-10%chance of pregnancy going beyond term with an increased risk of macrosomia. There is also an increased risk of perinatal mortality after 41weeks of pregnancy . Maternal obesity is associated with and increased risk of primary and secondary dysfunctional labour due to poor uterine contraction. The second option is induction of labour because of fetal macrosomia. The benefit is that it may prevent further increase in the fetal growth. There is however an increased need for pain relief in labour .Secondly, there is the risk of shoulder dystocia during delivery and an increased risk of instrumental vaginal delivery with the risk of 3rd and 4th degree perineal tear and post partum hemorrhage. Induction of labour in women without diabetes has not been shown to reduce maternal or neonatal morbidity. The third option would be an elective caesarean section. This would be offered if the estimated fetal weight is above 5kg. This is to prevent the risk of permanent brachial plexus injury following shoulder dystocia in large infants.
Caesarean section if her BMI is high is associated with anaesthetic complication due to difficulty in siting a spinal block and GA is associated with increased risk of aspiration , pneumonitis and chest complications.
The operative risk would include abdominal scar, bleeding
during the operation, injury to bladder and bowel and thromboembolic complication. There is also increased risk of wound infection, wound dehiscence and prolonged hospital stay.There is the risk of scar dehiscence and uterine rupture in subsequent pregnancy
I would provide information leaflet on macrosomia for her to make an informed choice.

b) I would inform the patient about the problem and need to perform some manipulations with her cooperation to be able to reduce the morbidity and mortality to the fetus. I would call for help from senior obstetrician, anaesthetist, registrar neonatologist and midwife. The most senior obstetrician would take over and I would ask the midwife to note the time spent on each of the manoeuvre. I would evaluate for an episiotomy and if necessary perform one as it may facilitate the internal manipulations. The first manoeuvre I would employ is the McRoberts manoeuvre which is an exaggerated flexion of the maternal hips. This releases the anterior shoulder by causing cephalad rotation of the symphysis pubis. This is successful in about 90% of patients and associated with the lowest rate of complication. If this is unsuccessful, the next step to improve the success rate is suprapubic pressure together with McRobert\'s
manouvre. The suprapubic pressure reduces the bisacromial diameter and rotates the anterior shoulder into the oblique pelvic diameter. Second line manouvres by the Wood\'s cockscrew involve using two fingers in front of the posterior shoulder and rotating it through 180 degrees. This brings the the lower posterior shoulder anteriorly underneath the pubic symphysis
from where it can be hooked out. A reversed Woodscrew is attempted if still unsucccessful. The next step is the delivery of the posterior arm . I would slid a hand in the vagina behind the posterior shoulder and sweep the posterior arm of the fetus across the chest by keeping the arm flexed at the elbow. The trunk of the baby usually follows spontaneously but associated with disk of humeral and brachial plexus injury. In a mobile woman without epidural analgesia she can positioned in all fours and this is successful in about 80% of patients. Third line manouvres include cleidotomy( bending the clavicle with a finger or surgical division), symphysiotomy ( dividind the symphyseal ligament) and Zavanelli monouvre( cephalic replacement of the head back into the pelvis and caesarean section) . The third line manoeuvres are rarely required and associated with maternal morbidity and mortality. Accurate documentation of the manouvres would be made in the note and an incident form would be filled.
Posted by Dr Mamta D.
a) As there is evidence of fetal macrosomia, the options for safe delivery in this woman include either an elective cesarean section or vaginal delivery, which may be spontaneous or induced. However there is no evidence that induction of labour for fetal macrosomia result in decreased incidence of shoulder dystocia and perinatal morbidity. Both an elective cesarean section and vaginal delivery has its advantages and disadvantages.

An elective cesarean section should be done if estimated fetal weight is more than 4.5 kg but a third trimester ultrasound has 10% error in giving accurate estimation of birth weight by abdominal circumference, exact calculation of fetal weight may be difficult. The advantage of elective cesarean section is the avoidance of shoulder dystocia and decreased perinatal mortality and morbidity. In this 32 year old primigravida (not diabetic not obese),the maternal risks associated with cesarean section include increased incidence of febrile morbidity, blood transfusion, endometritis, extension of uterine incision as it is big baby, atonic PPH due to big baby and VTE risk.The fetal complications include increased risk of TTN and RDS.
There is increased perinatal morbidity and mortality during vaginal delivery which is due to shoulder dystocia, fetal trauma, resulting in Erb?s palsy due to brachial plexus injury, fracture humerous and clavicle and hypoxic ischemic encephalopathy. The maternal complications during vaginal delivery are due to increased risk of difficult labour and delivery resulting in genital tract injuries, PPH (both tramautic and atonic), third and fourth degree perineal trauma.
Advance planning is required for safe delivery. It should be planned in theatre or in labour room under consultant supervision with labour room staff fully experienced in management of shoulder dystocia. An epidural should be sited. As it is a high risk pregnancy, fetal monitoring includes continues CTG monitoring during labour, partogram should be charted and regular assessment by per vaginal examination to identify secondary arrest in which case an emergency cesarean section should be done.

b) An early diagnosis and prompt interventions are required to achieve safe delivery in shoulder dystocia. First of all, I will call for help, which includes a senior obstetrician, anesthetist, pediatrician, midwives and other labour staff. Simultaneously I will bring the patients buttuck to the edge of table, her thighs and knees are completely flexed against the abdomen and hips are abducted so as to facilitate the delivery of arrested shoulder (Mac Robert?s manoeuvre). I would assess the need of giving an episiotomy if it is not given before. I would tell my assistant to give suprapubic pressure downwards and laterlly on the posterior aspect of anterior shoulder. post,. Mac Robert?s manoeuvre is successful in 90% cases, if it fails, then without wasting any time, I would perform other advanced manoeuvres in which shoulder is rotated into oblique diameter of pelvis and is moved against chest so as to decrease the dimensions of shoulders which may facilitate delivery. Another manoeuvres is Wood?s cockscrew which is performed if posterior shoulder is below sacral promontory by rotating it through 180 degree so that posterior shoulder becomes anterior and delivery may occur.
If above manoeuvres fail or both shoulders are above pelvic inlet, I would deliver the posterior arm by sweeping across the fetal chest. If time permits and epidural is not sited then the patient may be put in all four positions to facilitate the delivery. An alternative choice is deliberately fracture the clavicle but it is not practiced. Symphisiotomy may be performed as last resort and if expertise is there but it is not considered safe. Zavenelli manoeuvre, in which head is placed back in the pelvis and patient is prepared for operative delivery, may be considered in the end but fetus may not be alive by this time.
I would fill the risk management form with detailed documentation of events ,including the manoeuvres performed, time between delivery of head and body and cord blood pH value. Debriefing of the patient should be done by senior obstetrician or consultant.

Posted by Sabahat S.
a) The sonological findings suggest fetal macrosomia, but fetal ascites, abdominal tumors should be ruled out. Waiting for onset of spontaneous labour is quite safe, as majority of large babies deliver uneventfully. The patient should be informed of the high risk of prolonged labour, emergency CS with all its attendant risks, shoulder dystocia, birth trauma & third & fourth degree perineal trauma, in case of a vaginal delivery. If she opts for elective CS, the risk of haemorrhage, BT, DVT, infective morbidity & the implications for next child birth, should be considered. Patient should make an informed decision after considering the benefits & risks of both modes of delivery.
Sonological estimate of the expected birth weight (EBW) should be obtained (+ / - 20 % margin of error ), which if more than 4.5 kg, elective CS could be more beneficial although the number needed to treat will be high. If the EBW is less than 4.5 kg, spontaneous onset of labour should be awaited. Induced & augmented labour, more often end up in arrested progress of labour, emergency CS or shoulder dystocia. A lower threshold for emergency CS should be applied. Instrumental delivery should be avoided ? as failure or delay in descent of the head indicates a high risk of shoulder dystocia There is no evidence of benefit from IOL at 38 ? 39 wks. Elective CS at 39 wks avoids the above risks. But there is the increased risk of BT, infection, anaesthetic risks, thromboembolic risks & the risk of scar dehisence in the subsequent vaginal deliveries ( .2 - .7 % ). In CS the baby also have an increased risk of respiratory morbidity.
b) The most senior obstetrician anaethetist, mid wife should be informed immediately .The time of delivery of head shoulder be noted. The patient should be requested not to push. The buttocks of the mother are brought to the edge of the bed & Mc Roberts maneuver along with gentle suprapubic pressure delivers 80 ? 90 % of the shoulder dystocias.
If the shoulder is still undelivered, woods cork- screw maneuver is done next. A generous episiotomy helps in the vaginal manipulations. If the anterior shoulder is above the symphysis pubis & posterior shoulder is in the sacral hollow, pressure is applied on the anterior aspect of posterior shoulder, vaginally, while simultaneously the abdominal hand applies the pressure on posterior aspect of anterior shoulder, to enable rotation of the baby & the delivery of anterior shoulder. If both the shoulders are above the pelvic brim, deliver fetal arm by introducing the hand vaginally to flex the forearm & pull the hand of the baby sliding it across the chest & face of the baby. The baby?s hand is used to apply traction to rotate & deliver the fetus. Or else the fetal clavicle can be fractured, to reduce the biacromial diameter & facilitate delivery. In case all this fails & the baby is still alive, zavanelli maneuver & abdominal delivery by crash CS may be tried ? although by this time fetal & maternal morbidity will be high. Symphysiotomy may be tried in desperate situations, although its place in modern obstetric practice is limited, with high maternal morbidity.
A careful & accurate documentation of the time of delivery of head, the maneuvers tried, their time & sequence, the help requested should be documented. Incident report should be filled for risk management. The patient & her family should be given an adequate explanation of the happenings.
Posted by Natalia  N.
A. There are three options for delivery in a case of fetal macrosomia, e.g. spontaneous vaginal delivery, induction of labour, and Caesarean section. Abdominal circumference above 97th centile is suggestive of fetal macrosomia. However, the 3rd trimester ultrasound has a margin error of at least 10% for estimation of fetal weight, and sensitivity of 60% for detection of macrosomia. The risk factors of shoulder dystocia should be reviewed before desicion is made, e.g. (previous shoulder dystocia and DM irrelevant in this healthy primagravida, obesity BMI > 30). The risk of shoulder dystocia is higher if BPD is significantly smaller than abdominal circumference, for instance if BPD < 50 centile.
In healthy primigravida with no risk factors for shoulder dystocia spontaneous vaginal delivery is the safest option associated with less maternal and fetal morbidity in comparison with induction of labour and Casarean section. Vaginal delivery will avoid risks of surgery (infection, bleeing, injury to internal organs, placenta previa & accreta, hysterectomy, scarred uterus). It will also avoid complicaitons of induction of labour (more pain, increased risk of hyperstimulation, fetal distress, assisted delivery, and, therefore, increased risk of maternal and fetal morbidity). SIgns suggestive of shoulder dystocia should be watched for during labour, e.g. proplonged 1st and 2nd stage of labour, secondary arrest, oxytocin augmentation, assisted vaginal delivery. Although risk factors of shoulder dystocia have poor predictive value, e.g. they predict only 16% of shoulder dystocia resulting in infant morbidity. Experienced obstetrician, midwife, and peadiatrician should be present during delivery. Woman should have intravenous access. In anticipation of shoulder dystocia she should be preferably deliver in lithotomy, local anaesthetic, urinary catheter, syringe, needles, scissors, scalpel should be made available in case complications arise.
Induction of labour and Caesarean section are not recommended in women at term without diabetes where fetus is thought to be macrosomic as the large majority of infants with a birth weight of >4.5 kg do not develop shoulder dystocia, and about 50% of shoulder dystocia occurs in infants with a birth weight less than 4kg.
B. I would immediately call for help - senior obstetrician, midwife, neonatologist, aneasthetist. I will discourage her from pushing as it may impact shoulders even more. I would transfer woman into lithotomy position. I will empty her bladder. I will assess if episiotomy is required (it is not recommended routinely). I would then proceed to McRoberts maneuvres flexing and abducting woman\'s legs and bringing her thighs onto abdomen. Suprapubic pressure (to disimpact anterior shoulder) could be applied simultanouesly with McROberts maneuvre and following it. I will at the same time apply axial traction of the baby\'s head. If these maneuvres were unsuccessful I will attempt to deliver posterior shoulder, and then proceed to internal rotation maneuvres (wood screw, and reverse wood screw). I willthen transfer woman into \"all fours\" position and repeat internal rotation maneuvres attempting to deliver posterior or anterior shoulders. If these actions were not successful fracturing clavicule might help in delivering shoulders. If baby is alive my next step will be symphisiotomy and attempt to deliver anterior shoulder. If baby has died I will proceed to Zavanelli procedure - replace head into uterus and perform Caesarean section.
All the above-mentioned actions should be prompt and effecient as about 50% of babies die within 5 minutes of delivering head. The operator should also careful not to cause injuries (brachial plexus, spinal cord, fractures of humerus).
Posted by Sangeetha S.
Safe delivery means good fetal and maternal outcome. With this patient considering her scan result the most important concern is macrosomia and associated shoulder dystocia there by causing increased maternal (11% PPH and 3.8% 3rd and 4th degree perineal tear) and fetal morbidity(4to16% risk of brchial plexus injury, hypoxia and clavicular and humoral fractures, still birth). The estimation of fetal weight by scan is unreliable as it has 10% marginal error and 60% sensitivity. The large majority of macrosomic infants do not experience shoulder dystocia. Shoulder dystocia is more common with infants of normal weight and is therefore a largely unpredictable and unpreventable event.
There is no evidence to support for induction at term in view of macrosomia as this does not reduce the risk shoulder dystocia in healthy woman instead is associated with increased risk failed induction and caesrean section and assosciated morbidity and mortality.
Elective caesarean section is not recommended as studies have shown that to prevent one birth injury because of shoulder dystocia, 2345 caesareans have to be performed which increases the cost involved and also increase the risks to mother associated with caesarean section.
Therefore the best ossible option of delivery is to await spontaneous labour until 41+3 weeks and anticipate and be preared for managing possible shoulder dystocia.

Answer for b: This is an Obstetric emergency.Aim to deliver the baby as effecive as possible as 47%of the babies died within 5 minutes of the head being delivered. I will call for help, extra midwives, anaesthetist, neonatologist. Discourage maternal pushing as it may cause further impaction of shoulder. Move
womans buttock to the edge of the table, lay down the head end of the table flat. Fundal pressure should not be given as this may cause more damage to mum and baby. Macroberts manouver should be perfomed first- maternal hip flexion and abduction which increase the pelvic inlet, straightens the lumbosacral angle, increases uterine pressure and amplitude of contractions. This is the most effective as has 90% success rate and low complication rate. If shoulders not dellivered by this the suprapubic pressure is needed in downward and lateral direction which pushes the posterior aspect of anterior shoulder there by reducing the bisacromial diameter, it should be done for 30 to 60 seconds.
Now need for episiotomy should be considered as might require inernal rotation and delivery of posterior arm.
Secondary manouvers should be used if above fails these include
inernal rotation or delivery of the posterior arm. Altrnatively the all four position may be used. If these fail the third line manouvers clavicular fracture, symysiotomy, cephalic replacent (Zavenellis), but these are rarely needed.
Risk of PPH and perineal lacerations should be considered.
In the end proper DOCUMENTAION, DEBRIEFING OF THE WOMAN,
INCIDENT REPORTING should be done

Posted by Malar R.
There are 3 available options.They include expectant management of pregnancy and induction of labour after 41 weeks,induction of labour at 39-40 weeks and elective caesarean section at 39 weeks.

Expectant management until 41 weeks may result in spontaneous onset of labour.This will reduce medical interventions and may result in better maternal satisfaction.Maternal morbidity and operative deliveries may also be reduced.Induction after 41 weeks is more likely to work than if induced earlier.

The disadvantage of this approach is that the baby will continue to grow during this time and there is a risk of shoulder dystocia.

The second option is to consider induction of labour from 39 -40 weeks.There is no evidence to show that this reduces the risk of shoulder dystocia.There is also a risk of failed induction of labour and increased operative delivery.Labour may also be prolonged and more analgesia may be needed.

The third option is to offer caesarean section at 39 weeks. This will eliminate the risk of shoulder dystocia. However it is associated with maternal morbidity of caesarean section and implications on future pregnancies and deliveries.There is no strong evidence to support routine caesarean section to prevent shoulder dystocia.

The mother should be involved in the decision and the options and their implications fully discussed with her. Also it is important to ensure there is no obvious cephalopelvic disproportion for example secondary to previous pelvic fractures as this could preclude trial of labour.She should also be informed of the risks of shoulder dystocia with the reassurance that senior staff will be available at delivery.


Help must be asked for, specifically asking for a senior midwife, senior obstetrician, neonatal team and anaesthetist.The woman and her partner must be informed of the urgency of the situation and hence the need for more support.
The patient\'s back must be flat and her hips and legs abducted and flexed to Mc Robert\'s position by 2 assistants.Assessment must be made to check if an episiotomy is needed for manoeuvres described later.Suprapubic pressure must be applied constantly for 30 seconds and delivery must be attempted. If unsuccessful, rocking suprapubic pressure must be applied and delivery attempted for 30 seconds.

Manoeuvres to enter the vagina with an attempt to disimpact the anterior shoulder from the suprapubic bone must be made (Reverse Woodscrew and Rubin\'s manoeuvres) and delivery tried for 30 seconds each.
If unsuccessful, an attempt should be made to remove the posterior arm and delivery attempted.

If all the above measures do not deliver the baby, then the patient should be rolled to lie on all fours so manoeuvres to dislodge the posterior shoulder (now anterior) can be repeated for 30 seconds each.

If still unsuccessful, procedures such as Zavanelli or symphysiotomy may be considered be a senior obstetrician.

It is important to have a person documenting the whole events with the times and procedures performed in then notes. The neonatologists must be present to resuscitate the baby.Also the parents must be fully debriefed after the events and follow up offered a few weeks after delivery to ensure they understood the events and to plan future deliveries.A risk management form must be filled in.The GP and community midwife must be informed in case of poor outcome.



Posted by Jancy V.

The growth scan indicates fetal macrosomia. Macrosomia is associated with diabetes has higher risk of intrapartum complications than non diabetics. The anticipated complication of macrosomia is shoulder dystocia at delivery which carries a high risk of neonatal mortality and morbidity, especially in the form of Erb?s palsy, 10% of which is permanent; fracture of clavicle/ humerus, soft tissue injury. There is also high risk of maternal morbidity due to perineal tears, extended episiotomy, post partum hemorrhage and psychological morbidity. Since the woman is not diabetic, early induction of labour is not beneficial in improving maternal and fetal outcome in cases of suspected macrosomia. Induction may be done in diabetic women on insulin , asit shows a slight reduction in shoulder dystocia incidence. If estimated weight is more than 4.5 kg, consideration for elective CS may be given. However it is not an absolute indication. In cases of suspected macrosomia, patient should be cared for in labour, especially in second stage by a senior obstetrician, knowledgeable of the maneuvers to tackle shoulder dystocia. The staff should be aware of the measures to manage shoulder dystocia and frequent training with drills should be done. In labour, anticipate shoulder dystocia in cases of delayed first and second stage and head receding between contractions .Avoid instrumental delivery. The incidence and risks of shoulder dystocia should be explained to the woman in antenatal period and informed choice should be encouraged and decision documented.

Once shoulder dystocia is identified, I will call for help of senior obstetrician, additional midwife and alert theatre, pediatrician and anesthetist. I will keep a person to record the events with time as 45% mortalities occur within 5 mts of delivery of head. I will quickly explain to the woman about the situation and ask her not to panic, to stop pushing and to co operate with me. I will bring her buttocks to the edge of the bed and evaluate if there is episiotomy or not, if not I will put an episiotomy as it will help in vaginal manipulations if needed. I will then ask the midwives to abduct and flex the woman?s thighs over her abdomen (Mc Robert?s maneuver) as it increases the anteroposterior diameter of the inlet by straightening the sacrum and cephalad rotation of symphysis pubis. This maneuver is adequate to release the shoulder in 90% of cases. If it fails I will ask the assistant to give suprapubic pressure while maintaining steady gentle traction on the head. This disimpacts the shoulder from the anteroposterior diameter to the longer oblique diameter. If it fails, I will insert my hand to the vagina and try to rotate the shoulder 180 degree (wood?s screw )so that the posterior shoulder which is lower becomes anterior and below the symphysis. If it fails I will try to deliver the posterior arm by sweeping it in front of the chest of the baby. If this fails I will attempt to keep the woman in all fours and deliver the baby, but it is difficult to get maternal co operation for this. I can resort to symphysiotomy and deliberate fracture of clavicle as last measures. If all this fails I will replace the head back into the birth canal and take her for emergency cesarean section (Zavanelli manouvre). However the results are poor as there would be considerable morbidity to the baby by this time. Once the baby is delivered, I would look for vaginal and perineal lacerations and do active management of third stage in view of chance of PPH. I would fill an incident form, document the events with time, maneuvers used and outcome of mother and baby. I will inform the mother about the events and measures taken
Posted by Shahla  K.
Referral due to large for date generate considerable anxiety, which can lead to early induction and request for caeserian section .
.Ultrasound measurements at third trimester is prone to error by 15%,
Before making any plane gestational age should be confirm with early scan to avoid prematurity.
Plan of delivery is to avoid fetal as well as maternal morbidities, most worrying is shoulder dystocia.
Plans should be individualize women\'s wishes respected.
If estimated fetal weight is less then 4.5 kg and she is non diabetic then waiting for spontaneous labour is one option,with plan to deliver in well prepared environment to deal with shoulder dystocia .
.
Other option is INDUCTION OF LABOUR ,with intention of minimizing more gain in weight by delivering earlier, unfortunately induction does not prevent shoulder dytocia ,there will be more failed induction which leads to emergency caeserian section.
ELECTIVE CAESERIAN Section is mostly requested by women .this associate with anaesthetic and operative risk in short term and in long term scared uterus ,repeated caeserian section increase chance of placenta praevia in her obstetric future. there are 3700 caeserian sections are done to avoid one permanent brachial palsy there fore number require to prevent is very high.
Shoulder dystocia is an emergency .Anticipation of shoulder dytocia ,with active planes and well rehearsed staff is essential.
Most senior obstetrician anaesthetist pediatrician should be called for,
Assessment for presence of posterior shoulder in sacral curve is made
Macrobert maneuver involve hyperflexion and abduction at hip joint, suprapubic pressure to bring anterior shoulder in oblique diameter and then under suprapubic arch, a mediolateral episiotomy should be cut for manupilation, gentle traction of fetal head for 30 second,this maneuver succed in 80% of cases.
If this fail delivering posierior shoulder will relief shoulder dystocia.
If this fail then wood screw maneuver tried which involve rotating fetus like screw ,some time it is impossible to do.

Bringing women to all four position increase anterior posterior diameter by few centimeter at pelvic inlet and then relief dystocia .
In the absence of posterior arm in sacral hollow made all these maneuver impossible.
Symphysiotomy and fractureing clavicle bone are more aggressive measure should only done when fetus is still alive.
Zavenelli maneuver involve pushing head back in to uterus and then deliver by caeserian section.this can complicate into annular detachment of uterus.
Neonate handed over to peadiatrician ,Risk of postpartum haemorrhage deal actively.
Documentation to record whole event it is important for medicolegal reason and plan for future pregnancy.
Women debriefing may help minimize inappropriate blame to herslf and to her care giver.