If the above are initially unsuccessful, they may be repeated, and finally other methods may be elected. With an allours maneuver, also called the Gaskin maneuver, the parturient rolls onto her knees and hands. Here, downward traction against the head and neck attempts to free the posterior shoulder (Bruner, 1998). Challenges with this include immobility from regional analgesia and time lost in patient repositioning.
In some, the posterior arm is inaccessible for delivery. Cluver and Hofmeyr (2009) describedposterior axila sling traction to deliver the posterior arm. With this alternative method, a suction catheter is threaded under the axilla and both ends are brought together above the shoulder. Upward and outward traction on the catheter loop delivers the shoulder. In a small series of 19 cases, this maneuver was successful in 18 cases. However, neonatal injury included three cases of humeral fracture and one permanent and four transient cases ofErb palsy (Cluver, 2015).
FIGURE 27-6 Delivery of the posterior shoulder for relief of shoulder dystocia. A. The operator's hand is introduced into the vagina along the fetal posterior humerus. B.The arm is splinted and swept across the chest, keeping the arm flexed at the elbow. C. The fetal hand is grasped and the arm extended along the side of the face. The posterior arm is delivered from the vagina.
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FIGURE 27-7 Woods maneuver. The hand is placed behind the posterior shoulder of the fetus. The shoulder is then rotated in a corkscrew manner so that the impacted anterior shoulder is released.
FIGURE 27-8 The second Rubin maneuver. A. The bisacromial diameter is aligned vertically. B. The more easily accessible fetal shoulder (the anterior is shown here) is pushed toward the anterior chest wall of the fetus (arrow). Most often, this results in abduction of both shoulders, which reduces the bisacromial diameter and frees the impacted anterior shoulder.
Deliberate fracture of the anterior clavicle using the thumb to press it toward and against the pubic ramus can be attempted to free the shoulder impaction. In practice, however, deliberate fracture of a large neonate's clavicle is diicult. If successful, the fracture will heal rapidly and is usually trivial compared with brachial nerve injury, asphyxia, or death.
he Zavanelli maneuver involves replacement of the fetal head into the pelvis followed by cesarean delivery (Sandberg, 1985). Terbutaline, 0.25 mg, is given subcutaneously to produce uterine relaxation. he irst part of the maneuver consists of returning the head to an OA or OP position. The operator flexes the head and slowly pushes it back into the vagina. Cesarean delivery is then performed. Sandberg (1999) reviewed 103 reported cases. It was successful in 91 percent of cephalic cases and in all cases of breech head entrapments. Despite successful replacement, fetal injuries were common bur may have resulted from the multiple manipulations used before the Zavanelli maneuver (Sandberg, 2007).
Symphysiotomy, in which the intervening symphyseal cartilage and much of its ligamentous support is cut to widen the symphysis pubis, is described in Chapter 28 (p. 548). It has been used successfully for shoulder dystocia (Goodwin, 1997; Hartield, 1986). Maternal morbidity can be signiicant due to urinary tract injury. Cleidotomy consists of cutting the clavicle with scissors or other sharp instruments and is usually done for a dead fetus (Schramm, 1983).
Hernandez and Wendel (1990) suggest use of a shoulder dystocia drill to better organize emergency management: 1. Call for help-mobilize assistants and anesthesia and pediatric personnel. Initially, a gentle attempt at traction is made. Drain the bladder if it is distended.
2.