Operation: Shoulder Dystocia

Date: _______________
Obstetrician: _______________
Assistant(s): _______________
Anesthesia: epidural / pudendal nerve block / local lidocaine
Anesthesiologist: _______________
PreOp Dx: Shoulder Dystotica
PostOp Dx: Same + live male/female infant
Procedure: McRoberts, Suprapubic pressure, Ruben II, Wood's screw, delivery of the posterior shoulder, etc
Operative Findings: macrosomic infant, etc

Clinical Note: Ms. _______________ is a 25 year old G1 who presented to L&D on (date) in spontaneous labour at 39 weeks. At her most recent clinic visit, she was measuring large for gestational age. A 3rd trimester US at 38.4 weeks suggested an EFW of 4100 grams. The patient had oxytocin augmentation due to an arrest in the 1st stage of labour. At (time), she was 5cm dilatation, abd an AROM was performed with no complications. She became fully dilated at (time). She began pushing and second stage was X hours/minutes long. Her fetal heart rate strip was reviewed and assessed as reassuring throughout her labour.

After delivery of the fetal head at (time) we were unable to deliver the anterior shoulder by applying moderate downward motion. Help was called for a shoulder Dystocia. McRoberts, suprapubic pressure and anterior shoulder disimpaction were all immediately attempted but unsuccessful in delivering the shoulders. The Woodscrew maneuver was then attempted and the posterior shoulder was delivered. The remainder of the infant was delivered at (time).

The shoulder dystocia took a total of (time) to deliver the infant and on delivery the infant appeared flat and unresponsive to standard stimulation. As such, the cord was clamped twice and cut immediately and the infant was handed over to the awaiting pediatric staff.

Cord gases were then obtained. The placenta was then delivered (spontaneously/with assistance/manually). The placenta appeared intact and had a 3-vessel cord. There was a 1st/2nd/3rd/4th degree laceration that was repaired in layers with 2-0 vicryl in the usual fashion. (Mention labial lacerations, if any). Estimated blood loss was less than 300 cc. There were no complications beyond the shoulder dystocia. At the end of the procedure, all sponge, instruments, and sharps were counted and correct. Both mom and baby were stable and transferred to 4C for routine postpartum care.

The (fe/male) baby weighed (3535) grams, and Apgars were (4) and (8) at 1 and 5 minutes respectively. Arterial and venous cord gases were (7.35 with a base deficiet of -5 and 7.32 with a base deficent of -2) respectively.