Management of shoulder dystocia.

OBJECTIVE: We sought to determine the management of shoulder dystocia currently practiced by physicians in the Middle Tennessee region and the frequency of use of the all-fours (Gaskin) maneuver in clinical practice. METHODS: A questionnaire was developed and sent to physicians in the Middle Tennessee area, asking how they would manage shoulder dystocia in specific practice scenarios. RESULTS: The methods most commonly used to manage shoulder dystocia are episiotomy, the McRoberts maneuver, and suprapubic pressure. Twenty-four percent of practitioners listed more than four options for the management of shoulder dystocia. Only 8% of those surveyed claimed knowledge of and use of the all-fours maneuver. CONCLUSION: Educational programs should be developed to inform practitioners of additional options for the management of shoulder dystocia.

All-fours maneuver for reducing shoulder dystocia during labor.

OBJECTIVE: To report on a large amount of clinical experience with shoulder dystocia managed primarily with the all-fours maneuver. STUDY DESIGN: The all-fours maneuver consists of moving the laboring patient to her hands and knees. Eighty-two consecutive cases of shoulder dystocia managed with this technique were reported to a registry through January 1996. RESULTS: The incidence of shoulder dystocia was 1.8%, and half of the newborns weighed > or = 4,000 g. Sixty-eight women (83%) delivered without the need for any additional maneuvers. The mean diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes (range, 1-6). No maternal or perinatal mortality occurred. Morbidity was noted in only four deliveries: a single case of postpartum hemorrhage that did not require transfusion (maternal morbidity, 1.2%), one infant with a fractured humerus and three with low Apgar scores (neonatal morbidity, 4.9%). All morbidity occurred in cases with a birth weight > 4,500 g (P = .0009). CONCLUSION: The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.

Cardiac disease in pregnancy: intrapartum considerations.

Impressive changes in the maternal cardiovascular system occur in response to pregnancy. The patient with normal cardiac function complies with these physiologic changes without difficulty. The patient with cardiac disease, however, may be at significant risk for morbidity and mortality when faced with these changes. Knowledge of the disease process is essential, because caring for the pregnancy patient with known cardiac disease presents a unique challenge to the critical care nurse.

Disseminated intravascular coagulation.

In normal hemostasis, a balance exists between coagulation and fibrinolysis. Disseminated intravascular coagulation (DIC) is a condition characterized by the excessive formation of fibrin clots; it involves all aspects of the coagulation system. In view of its potential for major morbidity and mortality, an understanding of the disorder is essential. Management of DIC in pregnancy should include removal of the triggering mechanism and aggressive blood and fluid replacement.