SHOULDER 
DYSTOCIA
 

By
Dr.Lubna Gulnaz
MD Obgyn
 

SHOULDER DYSTOCIA
 

Definition
Defined as impaction of anterior 
shoulder of fetus against the
maternal symphysis pubis or (less
commonly) the posterior shoulder 

 behind the sacral promontory

after delivery of fetal head.
 

Incidence
 0.5% in 11,000 deliveries
 

Birth weight   Incidence

3-3.5kg 0.3%
3.5-4kg 1.0%
4.0-4.5kg 5.4%
>5kg 19%
 

AIM….

To recognize risk factors


Timely management to reduce both maternal
and fetal mortality and morbidity.


Correct application of needful maneuvers.
 

RISK FACTORS
MATERNAL FETAL
• Obesity
•

• Gest.Diabetes
Previous h\o Shoulder  Macrosomia
• dystocia
 Large for gestational age.
• Multiparity (A baby may be LGA without
• Post term pregnancy  being macrosomic)
•
Short stature
• Abn.pelvic anatomy
 
 

Pathophysiology
 A “mismatch” between fetal size and maternal
 pelvic capacity


Positional variationsof–shoulders
oblique orientation vertical rather than
 Increased diameter of shoulder girdle
 Subcutaneous fat dep osition may be increased in
deposition
infant of diabetic mother – espec ially with sub-
especially
optimal glucose control
 

Sign
Signss Helping you to diagnose

• Turtle sign
• Unable to deliver anterior shoulder even after 
gentle traction.
 

turtle sign
 

Management..

  HELPERR  mnemonic- a clinical tool

that provides a structured framework for 
clinician to deal with shoulder dystocia.
 

Objective
 To reduce time consumed from delivery of head until delivery
of body of fetus for survival of the fetus 
TO BE REMEMBERED

Shoulder dystocia is never predicted priorly.

dystocia
 None
None of the maneuver is superior to aanother
nother to release the impacted shoulder  
Each maneuver should take place from 30-60 second, baby should be
delivered by max 5-6 min.

EPISIOTOMY is given to provide additional space for manipulation not for 

delivery of impacted shoulder..

 
 

Management contd….
 

Clinical Management
 Step One: Recognize the presence of a
shoulder dystocia


Step Two: Be sure enough help is present

  Nursing

 Obstetrics
 Pediatrics
 Anesthesiology
 

Clinical Management

Step Three: Apply primary maneuvers

Mc Roberts maneuver 

Oblique suprapubic pressure

Step Four: Apply secondary maneuvers; no
 prescribed order 

Rubin; Woods screw; Reverse woods screw; All-
fours; Clavicular fracture
 

Step Three – Primary Maneuvers


McRoberts maneuver 

Patient positioned with hips at edge of the broken-

down birthing bed

 Both hips are sharply flexed with knees
k nees remaining
flexed (“knees to shoulders”)
 

McRoberts Maneuver
 

Contd……
 

McRoberts Maneuver

This maneuver assists delivery by:

Straightening maternal lumbar lordosis

Rotates symphysis superiorly and anteriorly
 Improving angle between pelvic inlet and direction
of maximal expulsive force

Elevates anterior shoulder allowing posterior 
shoulder to descend
 

Woods screw maneuver

 Apply pressure on the clavicle to effect rotation of the
shoulders out of the vertical orientation


As fetus rotates, anterior shoulder should pass under 

symphysis
 May be a good choice for a right-handed operator 
when the fetal occiput is oriented to the maternal
right
 

Woods screw maneuver

 

Rubin’s maneuver
 Apply pressure to the fetal scapula to effect
rotation of the shoulders out of the vertical
orientation
 As fetus rotates, anterior shoulder should pass
under symphysis

May be a good first choice for a right-handed
operator when the fetal occiput is directed to
the maternal left
 

Delivery of Posterior Arm


The operator inserts a hand into the vagina and
locates the posterior arm.

The operator applies pressure in the
antecubital fossa to flex the elbow across the
chest

The operator grasps the forearm or hand and
 pulls it out of the vagina
 

Delivery of Posterior Arm


The anterior shoulder should pass under the
symphysis

Rotation maneuvers (Woods or Rubin’s) can
 be applied if needed
 This maneuver will tend to be more difficult
with one’s non-dominant hand
 

Delivery of Posterior Arm

 

Delivery of Posterior Arm


Potential complications

Fracture of humerus

Fracture of clavicle
 

Gaskin All Fours Maneuver


Attributed to midwife Ina May Gaskin
 An option for a patient without anesthesia

Traction is applied in the opposite direction
(still toward the floor, but now directed
towards delivery of the posterior shoulder 
first)
 

Still not out?!

What now???
 

Step Six – Final Steps


Zavanelli maneuver (cephalic replacement)

Rotate head back to OA (“reverse restitution”)

Flex neck 
 Upward pressure
 Cesarean section
 

Step Six – Final Steps


Symphysiotomy

 Not commonly done when cesarean is available

Insert Foley catheter 
 Use vaginal hand to laterally displace urethra to avoid
injury
 Incise symphysis through mons pubis
 

Do not:
 Panic

Apply any more lateral traction than would be applied

in an uncomplicated delivery
 Apply fundal pressure – may worsen the shoulder 
impaction or even rupture the uterus

Cut a nuchal cord until after the shoulders are
released
 

Do:
 Remain calm

Communicate well

Call for help

Document clearly and legibly
 Send cord gases


Review with the family exactly what happened and
answer questions
answer the
 Follow questions
baby’s course in the nursery

 Notify Risk Management
 

Complications
Maternal
Hemorrhage- 11%
injury-4%
Soft tissue injury-4%
Anal sphincter injury
Rectovaginal fistula
Symphyseal diathesis
Rupture Uterus.
 

Complications contd….
FETAL
 Brachial plexus injury(transient,permanent)
Or ERB’S palsy4-15%

Fracture of clavicle.


Fracture of humerus.
 Fetal hypoxia.

Fetal death.
 

IMPORTANT FACTS

Occurs with equal frequency in both primipara
and multigravida.

Recurrence rate 14%

Perinatal mortality ranging from
21\1000.morbidity 16-48%

Mc Robets maneuver with suprapubic pressure
itself help >50% in shoulder dystocia.
 

Take home message


Early identification of risk factors and
attaining appropriate means of delivery

Call for seniors help.

Always a team work.
 Pre inform pediatrician.
 

References
 www.medescape.com
 Obs –gyn Emergency by Danyl jamison Macon
county.
 www.aafp.org
 www.lifepassager.net


ALSO
 Willams obstetrics.
 

WE ALL THANK U