LECTURE 10 :

SHOULDER DYSTOCIA
Endang Sri Widiyanti
OBGYN Team

Objective
1. Define shoulder dystocia
2. Review appropriate fetal/maternal assessment
3. Discuss the risk factors of shoulder dystocia
4. Discuss the complications of shoulder dystocia
5. Discuss appropriate management of shoulder dystocia

Shoulder dystocia is one of emergency problems during delivery. Following

the delivery of the head, there is impaction of the anterior shoulder on the symphysis
pubis in the AP diameter, in such a way that the remainder of the body cannot be
delivered in the usual manner. More than 50% of cases shoulder dystocia occur in the
absence of any identified risk factor. The student will discuss the assessment of
shoulder dystocia, the complication for fetus and mother, identification of risk factor,
diagnosis and management

Definition
After the birth of the head, external rotation will take place which causes axis of the
head to be on the normal axis to the spine. Generally shoulder will be on the oblique
axis under the pubic ramus. Pushing of the mother will cause the anterior shoulder
become under the pubis. If the shoulder fails to hold a rotation of adjusting to the axis
of tilted pelvis and remain in the anteroposterior position, the baby will most collision
front shoulder to the symphysis.

Shoulder dystocia is mainly caused by deformities of the pelvis, the failure of the
shoulder to "folded" into the pelvis (eg on macrosomia) caused by active phase and
short second stage of labor in multiparas so the descence of the head is too quickly,
causing the shoulder does not fold through the birth canal or head has through the
middle pelvis after a prolong of the second stage of labor before the shoulder
successfully folded into the pelvis.

Incidence
• 1 - 2 in 1000 Birth
• 16 in 1000 baby weight > 4000 g

Complication :
• Baby
- Death
- Asphysxia and its complications
- Fracture of Clavicula, humerus
- Brachial Plexus Injury
• Mother
- Postpartum haemorrhage
 - Uterine Rupture

Risk Factors :
• Post date pregnancy
• Maternal Obesity
• Macrosomia baby
• History of prior shoulder dystocia
• Operative vaginal delivery
• Prolong second stage of labour
• Uncontrolled Maternal Diabetes

Diagnosis
• Turtle’ sign
• Prolonged second stage of labour
• Fail to deliver the baby with maximal effort and proper management

Management

Requirement :
 Maternal vital condition is sufficient to work together to completing deliveries
 The mother has the ability to pushing
 The passage and the pelvic outlet are adequate for the baby's body
accommodation
 The baby is still alive or are expected to survive
 Not monstrum or congenital abnormality that prevents the delivery of baby

The management : "ALARMER"

1. Principles : Do not 4 “P” :
 Panic
 Pulling (the head of the baby)
 Pushing (the fundal of uterine)
 Pivoting (the head of the baby with coccygeus as fulcrums
2. Ask For Help :
 The mother of patient
 Husband
 Midwife
 Physician in charge or other paramedic
3. Lift the buttock- McRobert’s Maneuver
 Figure 1. McRobert's Maneuver

4. Anterior Disimpaction -
4.1. Suprapubic Pressure (Manuver Massanti )
• Suprapubic pressure on the baby's anterior shoulder toward the chest of
the baby.

Figure 2. Suprapubic Pressure

4.2. Rubin Manouver

• vaginal approach
• adduction anterior shoulder by pressing the posterior shoulder towards
the chest
• Consider episiotomy
 Figure 3. Rubin Manouver

5. Rotate the posterior shoulder- Corkscrew/ Wood Maneuver

Figure 4. Wood Maneuver

6. Manual removal of posterior arm / Schwartz and Dixon Maneuver

 Pressure on antecubital fosa to flexi the forearm
 move the forearm anteriorly.
 Reach the forearm or the fingers
  Deliver the posterior shoulder

Figure 5. Schwart and Dixon Maneuver

7. Episiotomy-consider
 Help Wood Manouver or giving more space to deliver the posterior arm,
rotate the chest and ease reaching the posterior shoulder

8. Roll over

9. Last Efforts :
 Break the clavicle
 Cephalic replacement (Zavenelli Manouver)
 Symphisiotomy

10. After procedure :

• Post partum haemorrhage anticipation
• Exploration of lasceration and tear
• Examination of the baby
• Explain to the patient
• Record the procedure

Reference
1. Cunningham FG, Leveno KJ, Bloom SL, Spong, CY, Dashe JS, Hoffman BL,
Casey BM, Sheffield JS. 2014. William Obstetrics, 24 edition. Mc Graw Hill.
2. Buku Acuan Modul PONEK. 2008. JNPK-KR.
3. ALARM International Course