CASE REPORT SESION

SHOULDER DYSTOCIA
IN
INTRAUTERINE FETAL DEATH
(IUFD)
Muhammad Ris Suangkupon Lubis
(12100115032)
Supervisor :
dr. Hesty Duhita Permata, Sp.OG

Program Pendidikan dan Profesi Dokter Fakultas

Kedokteran Unisba
Bagian Obstetri dan Ginekologi RSUD Syamsudin, SH
 SECTION I
INTRODUCTION
 Introduction

The infant mortality rate and maternal mortality rates

are two sensitive indicators to assess the degree of
public health

Maternal mortality associated with childbirth may be

caused by macrosomia because postpartum
hemorrhage can occur
Macrosomia infant mortality due to complications
caused by the adverse perinatal output as a low apgar
scores, asphyxia, and shoulder dystocia.
 Introduction
What is IUFD, Macrosomia, and Dystocia Shoulder ?

Fetus died in utero with a weight of 500 grams

or more or the death of a fetus in utero at 20
weeks or more
Heavy birth weight 4000 g

Deliveries require additional obstetric maneuvers

following failure on the baby's head for delivery of
the shoulders
 SECTION II
CASE PRESENTATION
 Patients Identity

Patient Husband
Name Mrs. L Mr. A
Date of Birth/ 38 years old 40 years old
Age
Nationality Indonesian Indonesian
Address Kp Lio Rt. 004/ Rw 002, Kp Lio Rt. 004/ Rw 002,
Sagaranten, Sukabumi Sagaranten, Sukabumi
Graduate Elementary School Elementary School
from
Marital Married Married
Status
Occupation Housewife Employe
Religion Islam Islam
th
 Chief Complaint

Fetal movement is not perceived since 3 days ago

 History Taking
Chronic Illness Disease & Family Illness : denied

Menstruation History
Menarche : (-)
Menstrual cycles : regularly, duration 5-7 days,
dysmenorrhea (+)
First day of last menstrual period : February 6th 2015
Estimated day of labor : November 13th 2015

Contraception History
She never using any contraception

Marriage History
Married once, status is still married

Antenatal Care
8 times to Posyandu every month
 Gestational History
Gestational Labour Birth
No Year Sex Info
Age History Weight
Spontaneous
1 2005 Aterm Vaginal Male 4000 gr Live
Delivery
Spontaneous
2 2012 Aterm Vaginal Male 3000 gr Live
Delivery

3 2014 Abortus

This
4 Pregnanc
y
 Physical Examination

A. General Status
Weight : 88 kg
Height : 160 cm
BMI : 34,375 kg/m2 Obesse

B. General Exam
- Breast : hyperpigmentation
areola
- Abdomen : striae gravidarum
- Lower extremities : edema -/-
 Obstetric Examination
EXTERNAL EXAMINATION
Leopold
o Leopold I : soft, movable round
o Leopold II : small part (right), hard and
longitudinal (left)
o Leopold III : hard, movable
o Leopold IV : convergent
Impression : head presentation
Fundal Height : 36 cm
Waist circumference : not examined
HIS : (-)
FHR : (-)
INTERNAL EXAMINATION
Vulva/ vagina : not found any abnomalities
Portio : thick, soft
Cervical dilation : 1cm
Fetal membrane : (+)
 Other Examination

Lab Exam
November 25th 2015
Hemoglobin : 9,1 gr/dl
Leukocytes : 22.700/L
Trombocyte : 277.000/L

USG
November 23th 2015, 18.30,
result :
Single fetus died.
The fetal heart rate does not
exist
Gestational age : 41-42 weeks
 Admission Diagnosis

G4P2A1, 38 years old,

ravida 41-42 weeks with Intrauterine Fetal Deat
 Follow Up

Novemb Novembe
er 23th November
r 24th
2015 25th 2015
2015

17.00 10.00 22.00 07.00

S : Fetal movement Patient move to S : Same S : Same
does not exist VK O : Cervical dilatation 5- O : Cervical dilatation
O : BP : 150/90 S : Same 6cm complete
VT : O : BP : 140/90 P : Drip Oxytocin P : Vaginal delivery plan
V/V no abnormality P : Misoprostol
Portio palpable 08.00
Cervical dilation 1cm
16.00 Patients led vaginal birth
Fetal membrane (+)
S : Same
P : infuse RL,
O : BP : 140/90
Observation GC, VS,
HIS P : Misoprostol
 Vaginal Delivery

Time : 08.00 08.30

Duration : Half an hour

After the baby's head is born, occurs shoulder

dystocia
After that taken :
1.Episiotomy (mediolateral)
2.Maneuver McRoberts, but failed
3.Maneuver Rubin
.Baby was born with weight : 5959 gram, and long
: 60 cm
Follow Up After Vaginal Delivery
November 26 2015
S : (-)
O:
GC : Good
Conciousness : compos mentis
BP 120/80, HR 80x, R 20x,T afebris
Breast feeding : (-)/(-)
Abdomen:
Tenderness (-)
Bowel sound (+)
Defecation (+); Flatus (+); Urination (+)

A : P3A1, 38 years old, Partus aterm with IUFD + Shoulder Dystocia

P : Go Home
 SECTION III
DISCUSSION
How to diagnose these patients ?
Why IUFD and Shoulder Dystocia occur in these
patients ?
How to manage this case ?
How the next pregnancy ?
 Case Analysis
How to Diagnosed These Patients?

Intrauterine Fetal Death

Theory Patient
History Taking History Taking

No feel fetal movement. Patients say no feel fetal

Abdomen not enlarged,
maybe even smaller
Abdomen hardened, pain as
want to labor
Decrease the body weight
movement
Patients has the abdomen
often becomes hard and felt
like a labor
 Case Analysis
Theory
Physical Examination
Inspection
Fundus uterus reduced or lower
than gestational age
No fetal movement can usually
be seen
Palpation
Decrease uterine tone
No palpable fetal movement
Auskultation
The ultrasonic Doppler examination
is not audible fetal heart rate
Patient
Physical Examination
Inspection
At the time of inspection no fetal
movement can be seen
Palpation
On palpation of the uterus is not
palpable fetal movement
Auskultation
On auscultation did not hear the
fetal heart rate
 Case Analysis

Theory Patient
Ultrasonography (USG) Ultrasonography (USG)
Appear Spaldings Sign
Appear Naujokess Sign Single fetus, gestational age
Appear Gerhards Sign 40 weeks, estimated birth
Appear Robertss Sign weight : 3476 gr-5235gr, no
Appear femur length that do fetal heart rate
not comply with gestational
age
Looks are not visible fetal
heart rate
 Case Analysis

. Shoulder Dystocia
Theory Patient
History Taking History Taking

Macrosomia/history births >4 Patients has a history of having

kg big baby weight/macrosomia
Obesity
Over increase body weight
Small pelvic
Diabetes maternal
Prolonged second stage
History dystocia shoulder
 Case Analysis

Theory Patient
Physical Examination Physical Examination

The baby's head is born, but the The baby's head is born but the
shoulder restrained and can not shoulder restained
be born Do traction on the head is not
Chin interested in and pressing successful delivery of the
the perineum shoulders.
Ttraction on the head of the
unsuccessful delivery of the
shoulders which remain in the
cranial symphysis
 Case Analysis
Why IUFD and Shoulder Dystocia occur in these
patients ?

- Seen from the age, patients has one of factor occur shoulder dystocia
and IUFD, because event of shoulder dystocia and IUFD can occur in > 35
years old
- Seen from body mass index in patients has one of risk factor occur
shoulder dystocia, because shoulder dystocia is related with obesity
- Maybe patients has diabetes mellitus or diabetes gestational (must check
screening)
- Preeklampsi
- Patients has history labor big baby weight (macrosomia),
 Case Analysis
How to manage this case ?

Intrauterine Fetal Death

Theory Patient
Active Active
If the seviks mature, induction labor with the 1. Giving misoprostol 2 times pervaginal, are
oxcitocin expected to:
Dont perfome amniotomy - Cervical Ripening
Secio sesarea is the alternative solution - Increase opening of the cervix

If spontaneous labor does not occur within 2 2. Giving oxytocin, expected progress of labor
weeks, decreased platelets, and the cervix have
not matured, cervical ripening with misoprostol:

Give 50 mcg intravaginal misoprostol, which

can be repeated one time after 6 hours after
the first administration
Administration of oxytocin drops 5 UI in
dextrose 5% from 20 drops per minute up to a
 Case Analysis

B. Shoulder Dystocia
Theory Patient
The management of patients with shoulder In this patients the management is done:
dystocia according to Advanced Life Support - Episiotomy (performesd mediolateral
in Obstetrics Provider (ALSO) 2004, episiotomy)
HELPERR. - McRoberts Maneuver
Help - Rubin maneuver
Evaluate for episiotomy
Legs (Manuver McRoberts)
Pressure on suprapubic (suprapubic
pressure/manuver Rubin )
Enter (internal rotation maneuver: Rubin
and Woods Corckscrew)
Remove posterior arm (manuver
Jacquemier)
Roll the patients to the all four position
 Case Analysis
How the next pregnancy ?

For the next pregnancy are advised to :

Screening (history illness of diabetes mellitus, hypertension, and other)
If pregnant again, see the baby big or not using ultrasonography. If large then it could
be advisable to do section cesarean, do not vaginal birth, because the woman has a
history of large babies and shoulder dystocia.
Do the ANC regularly, so that the development of the baby and the mother's health can
be monitored.
TERIMA KASIH