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7/21/2014

Shoulder Dystocia

Objectives
Recognize risk factors for shoulder dystocia
Utilise a systematic approach to managing
shoulder dystocia
Demonstrate appropriate manoeuvres to
reduce a shoulder dystocia using the
HELPERR mnemonic

Background
Impaction of the anterior shoulder against
the symphysis after birth of the fetal head
Incidence - varies by birthweight
0.3% in infants weighing 2500-4000 grams
5-7% in infants weighing 4000-4500 grams
>50% occur in normal weight infants

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Impacted
Shoulder

Axial traction
Lateral flexion

Risk Factors
Antenatal Labour and birth
Prior birth with a shoulder Assisted vaginal delivery with
dystocia vacuum or forceps
Gestational or pre-existing Labour dystocia/arrest disorders
diabetes Prolonged second stage
Macrosomia
Male gender
Maternal obesity
Post-dates pregnancy
Abnormal pelvic anatomy
Short maternal stature (< 1.5m)

Complications
Maternal Neonatal
soft-tissue injuries brachial plexus palsy
anal sphincter damage clavicular fracture
post-partum humeral fracture
haemorrhage fetal acidosis
uterine rupture hypoxic brain injury
symphyseal separation

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Prevention
Elective caesarean section or labour induction
NOT indicated
Glycaemic control
Weight control
Pre-conceptual and during pregnancy

Give birth in non-supine position or McRoberts

Prevention of Injury
Lateral flexion should not be used. Traction
should only be applied along the long axis of the
fetal neck.
Careful, considered use of manoeuvres reduces
fetal and maternal trauma

Recognition

Fetal head retracts against perineum


(turtle sign)
Gentle traction does not effect birth
Proceed to HELPERR

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H = Help
Activate institutional guideline
Appropriate notification
Additional staff
Additional back-up
neonatal resuscitation personnel
obstetric / surgical backup
anaesthesia

E = Evaluate for Episiotomy


Shoulder dystocia is not a soft-tissue
dystocia
Consider when additional room needed
for advanced manoeuvres
Decision based on clinical judgement
and response to initial manoeuvres

L = Legs
McRoberts Manoeuvre:
Flex maternal hips so that thighs are on
abdomen
Effects:
Straightens the lumbosacral lordosis
Increases AP diameter of pelvis
Flexes the fetal spine
Reduces >40% of shoulder dystocias

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P = Pressure
Supra-pubic pressure by assistant (Rubin I):
CPR-style hand position
Force should act to adduct anterior shoulder
Initially continuous, but can involve a rocking
motion
Attempt for at least 30 seconds
With McRoberts manoeuvre will reduce 50% of
shoulder dystocias

E = Enter
Rubin II
Approach anterior fetal shoulder from
behind
Exert pressure on scapula to adduct most
accessible shoulder and rotate to oblique
position
Continue McRoberts manoeuvre

E = Enter (II)
Woods Screw Manoeuvre
Approach posterior fetal shoulder from
the front
Birth attendant has one hand on each
shoulder, rotating together
Gently rotate shoulder toward
symphysis

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E = Enter (III)
Reverse Woods Screw manoeuvre:
Approach posterior shoulder from
behind
Rotate fetus in opposite direction from
previous manoeuvres

R = Remove the Posterior Arm


Follow posterior arm down to elbow
usually anterior to fetal chest

Flex arm at the elbow


Sweep forearm across fetal chest

R = Roll the Woman


Roll woman to McRoberts all-fours
position
Increases pelvic diameters
Movement and gravity may also
contribute to dislodging the impaction
Deliver posterior shoulder with gentle
downward traction
May attempt all Enter manoeuvres in
this position

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HELPERR
Remember the manoeuvres aim to:
increase the functional size of the bony
pelvis
decrease the bisacromial diameter
change the relationship of the bisacromial
diameter with the bony pelvis

Manoeuvres of Last Resort


Posterior axillary traction
Deliberate clavicle fracture
Zavanelli manoeuvre
Muscle relaxation
Abdominal surgery with hysterotomy
Symphysiotomy

Summary
Shoulder dystocia is a common and life-threatening
emergency
Risk factors helpful, but difficult to predict
Anticipation and preparation are keys to successful
management
Institutional protocol is recommended
HELPERR provides a structured approach