Circumferential shoulder laceration after posterior axilla s
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A 33-year-old woman (gravida 5, para 0) at 35 weeks, 1 day gestation underwent induction of labor for poorly controlled type 2 diabetes mellitus. Delivery of the large-for-gestational-age infant (4,060 g) was complicated by intractable shoulder dystocia, relieved at 3 minutes with PAST, resulting in a deep, circumferential laceration of the fetal posterior shoulder and contralateral phrenic nerve palsy.

PAST provides a potentially lifesaving option during intractable shoulder dystocia. Simulation or education about the technique facilitates its use when standard maneuvers fail. It is important to disseminate information about potential complications associated with these novel maneuvers.

The fetal shoulders had traversed the pelvic inlet in the anteroposterior position at the diagnosis of shoulder dystocia. Initial maneuvers, including suprapubic pressure and McRoberts positioning, were unsuccessful at releasing the anterior shoulder. A right mediolateral episiotomy was cut to create space, followed by attempted delivery of the posterior arm. Rotational techniques were then used, with the Rubin maneuver followed by the Wood corkscrew, resulting in clockwise rotation of the fetus to a 60° oblique angle. The Gaskin maneuver was not attempted because of dense neuraxial analgesia. Replacement of the fetal head with emergent cesarean delivery (Zavanelli maneuver), abdominal rescue, and symphysiotomy were not rapidly feasible with the maternal body habitus.

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