Intrauterine fetal death followed by shoulder dystocia and birth by modified posterior axillary sling method: a case report

Abstract

Background Various manoeuvres such as McRoberts position, suprapubic pressure, rotational methods, posterior arm extraction and all-four position (HELPERR) have been proposed for relieving shoulder dystocia with variable success. Posterior axillary sling method using a rubber catheter was proposed in 2009 but has not been widely used. We modified this method using ribbon gauzes and a long right-angle forceps and report a successful case. Case presentation A 44 years old parity one Chinese woman with a history of a caesarean delivery and poorly controlled type 2 diabetes mellitus was admitted to the Accident and Emergency Department for advanced stage of labour at term. Upon arrival, intrauterine fetal demise was diagnosed with severe asynclitism causing obstruction at the perineum. Episiotomy resulted in birth of the fetal head. The fetal posterior right shoulder, however, remained very high up in the pelvis and HELPERR methods failed to extract the shoulders. We then tied two long ribbon gauzes together, and guided its knot to the anterior aspect of the posterior axilla. By using a long right-angle forceps (24 cm long) to grasp the knot on the posterior side of the axilla and pulling it through, a sling was formed. Traction was then applied through the sling to simultaneously pull and rotate the posterior shoulder. A stillbirth of 3488 g was finally extracted. Conclusions We modified the sling method by using two ribbon gauzes, tied together and a right-angle forceps with several advantages. Compared to a rubber catheter, ribbon gauze with a knot can be easily held between the fingers for easy guidance past the fetal axilla. It is also thin, non-elastic and stiff enough to ensure a good grip for traction. The long and slim design of the right-angle forceps makes it easy to pass through a narrow space and reach the axilla high up in the pelvis. We emphasize simultaneous traction and rotation, so that the shoulders are delivered through the wider oblique pelvic outlet dimension.

Neonatal mortality in singleton pregnancies: a 20-year retrospective study from a tertiary perinatal unit in Hong Kong

“…37,38 We also proposed a modified posterior axillary sling technique to relieve severe shoulder dystocia. 39…”

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong

“…The situation was resolved by our modified posterior axillary sling traction technique, which involved using a ribbon gauze to form a sling, in combination with long and slim right-angle forceps to facilitate sling placement. 23 In our report as well as in our recent review, we emphasised that the sling primarily functions by facilitating shoulder rotation to enable delivery through the wider diagonal diameter of the outlet of the birth canal. 10…”

Asynclitism and Its Ultrasonographic Rediscovery in Labor Room to Date: A Systematic Review

“…Moreover, Hinkson et al, in an observational study, referred to a case of neonatal cephalhematoma after rotational forceps delivery, which resolved spontaneously, without neurological complications [ 27 ]. Lastly, Kwan et al reported a case of severe asynclitism, which led to obstruction and shoulder dystocia ending up with fetal death during delivery [ 33 ]. Malvasi et al described the mechanism of subaponeurotic hemorrhages caused by asynclitism and operative delivery.…”

“…Nevertheless, these groups of researchers have invented and described several technique and signs over the years, which has led to the current consolidation of asynclitism and ultrasound. The fil rouge among the several papers reported is that the more accurate the ultrasound diagnostic tools are for asynclitism, the more diversified the labor and delivery management options become [ 33 ]. However, the scientific evidence on asynclitism is limited, making it impossible to have standardized diagnostic signs and respective cutoffs or ranges of reference values.…”