NEGLECTED SHOULDER PRESENTATION
(A Study of 61 Cases)
by
BIMAN CHAKRAVARTY, M.B.B.S., D.G.O. (Cal.), M.R.C.O.G. (Eng.)
Neglected shoulder presentation is
a rare condition in more developed
parts of the world. That it is not un-
common in the less developed coun-
tries is indicated by the fact that 61
cases were collected in a period of
only two years. All the cases were
delivered in a district hospital. The
hospital serves a wide area and is the
only hospital with specialist service
in about forty square miles. The po-
pulation is a mixed one with various
types of religious dogma and with a
big percentage of illiterate people.
Many of them have yet to learn the
importance of antenatal care. They
shun the hospital unless they are
forced to attend it.
This paper does not deal with all
the cases of transverse lie that attend-
ed the hospital, but only those that
came in very late in labour. As the
name suggests the cases were in such
a condition on admission that they
required immediate interference; in
all of them the m embranes had rup-
tured for over four hours and in
most cases one hand was prolapsed
with or without prolapsed cord. Foe-
tal heart was not heard in more than
75 per cent cases on admission; in the
rest foetal heart was feeble, either
Department of Obstetrics and Gynaeco-
logy, Rao J. N. Roy Hospital, Berhampore,
We st Bengal, India.
t
very rapid or slow, showing signs of
foetal distress. The maternal condi-
tion of almost all was one of exhaus-
tion, partly from persistent uterine
contractions; in many of them the ute-
rus was tonically contracted with no
relaxation in beween the contractions.
A number of them had rise of tem-
perature from superimposed infec-
tion.
Incidence
Garner et al. reported 65 cases in
15 years in 27,249 deliveries-one in
419 deliveries, Hall et al. gave an in-
cidence of 1 in 217. The present
series was collected from 8000 deli-
veries-an incidence of 7.5 per thou-
sand.
Age
Average age of the patients was 26
years, though there were patients in
all age groups, the youngest being 15
years and the oldest 40.
TABLE I
Up to 20 years 14 cases
21 years to 25 years 19 cases
26 years to 30 years 19 cases
31 years to 35 years 5 cases
36 years to 40 years 4 cases
As shown in the above table the
cases are mostly in the 20 to 35 years
group.
 NEGLECTED SHOULDER PRESENTATION
Parity
The average parity of the patients
was 4.9. More than 75 % of the cases
were grande multiparae i.e. they had
5 or more pregnancies; there were
two cases who were eleventh parae,
,. Seven of the cases were primigravi-
dae, giving an incidence of 11 % . Hall
et al. report 8 % primigravidae in
their series.
TABLE II
1st 2nd / 4th 5th/7th
8 23 19
I . Terminations
To help analysis, the cases have
been grouped in two different years.
·The number of cases during the
year 1962 was 23, in 1963 the num-
ber was 38. The author had the op-
portunity to look after the cases who
were admitted from the period of
October 1962 to December, 1963.
During the period qf 1962 the 23
cases terminated in the way as shown
in the following table (table III).
Spontaneous
Version
deliver y
1962 1 1
1963 9 12
In 1962, in 4 cases of classical
caesarean section ligation of fallopian
tubes was done. In one case of des-
tructive operation rupture of the ute-
rus was detected following decapita-
tion, for which hysterectomy was
performed. In this particular case
both hands were prolapsed and deca-
753
pitation was particularly difficult.
The other case where hysterectomy
was done, was an eighth gravida, 40
years old, for whom caesarean sec-
tion was decided, but on laparatomy
uterine rupture through the lower
segment was detected. Subtotal hys-
terectomy was performed along the
rupture and the patient made an un-
eventful recovery. In one case of
twin pregnancy, whe;re the first baby
had shoulder presentation with hand
8th/11th
prolapsed, caesarean section was per-
formed. Both the babies were born
11 alive; the second baby was present-
ing as vertex. Of the six destructive
operations five had decapitation and
one had evisceration. In 1963 in two
cases of classical section rupture of
uterus was detected on laparotomy,
and so the section was followed by
hysterectomy. One of them was a
ninth gravida, 38 years old, the other
was 23 years old and had two child-
ren. In one case twin pregnancy re-
mained undiagnosed until the first
baby, who had a prolapsed hand, was
delivered by internal version. Intra-
venous ergometrine was injected with
TABLE ill
Caesar ean sect ion
Destructive
Hysterectomy
operations
Classical Lower
6 10 5 2
7 9 1 2
delivery of the baby. The presence
of the second baby was diagnosed
only after the first was delivered. The
second baby was presenting by ver-
tex, with the head above the pelvic
brim. As soon as this misadventure
was detected the second baby was de-
livered as breech by internal version.
754 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
The baby was alive and had no in-
tracranial injury. The first baby was
found macerated on delivery. In an- .
other case of internal version in a
fifth gravida, aged 35, the foetal heart
was heard on admission and cervix
was fully dilated. The membranes
were ruptured about 6 hours before
she came in. It was decided to do an
internal version in the operation
theatre, with the patient prepared
for caesarean section, if version fail-
. ed. The version was performed with-
out much difficulty, but a contraction
ring developed at the region of inter-
nal os and obstructed the delivery of
the aftercoming head. Anaesthesia
was deepened with increased con-
centration of ether but the contrac-
tion ring persisted. It was only after
injecting adrenalin, one in thousand
solution 1 c.c., intravenously tliat
the ring relaxed and the baby could
be delivered, but this long delay in
delivery of the aftercoming head led
to foetal death. The baby weighed 7
lbs. and had irreversible asphyxia. In
another case during internal version
type II placenta praevia was detected.
The foetus was already dead and ver-
sion was completed without causing
any vaginal bleeding. Of the 7 cases
of destructive operations performed
in 1963, 4 had decapitation and in
three evisceration was performed.
Foetal Salvage
Of the 23 cases in 1962 there were
24 babies including one pair of twins.
Of these 24, eight were live-born.
One of the twins died in the neonatal
period from infection. All the eight
living babies were delivered by cae-
sarean section.
Of the 38 cases in 1963, there were
39 babies including a pair of twins.
Of these only five living babies could
be delivered. Three of the live-born
babies were delivered by internal
podalic version and two by caesarean
section. It was only in six cases that
foetal heart was present on ,adrn'is-
sion. Only one of the six babies was
lost, the one which after-verson could
·.
not be delivered easily due to con-
traction ring.
Thirteen live-born babies out of 63
gives a percentage of 20 living-babies
and 80 % foetal mortality, Garber et
al report foetal mortality of more
than 94 % when labour has be2n pro-
longed for more than 24 hours.
Hospital Stay
This district hospital is so much
overcrowded that the normal deli-
very cases are · discharged 48 hours ...
after delivery.
TABLE IV
Hospital Stay
Spontaneous delivery 3 days
Intunal podalic version 4.3
Destructive operations 5.5
Caesarean section 21.5
The cases of transverse lie that
delivered spontaneously had a hos-
pital stay of only 3 days. Those
with internal version required hos-
pitalization on the average for 4.3
days. The cases who had destructive
operations had an average stay of 5.5
days. The patients who had a caesa-
rean section, on the other hand, re-
quired an average stay of 21.5 days.
One case had to stay as long as 57
days before being discharged cured.
Four cases had to stay more than a
 NEGLECTED SHOULDER PRESENTATION
month after caesarean section. The
main postoperative complication was
infection. It is interesting to note
that patients who required hysterec-
tomy had a smooth postoperative
period, and they were discharged
within a fortnight after operation.
Discussion
In the Chapter on "Results of neg-
lected shoulder presentation" in the
British Obstetric and Gynaecological
Practice, MacLenan, Wrigley and Per-
cival write that spontaneous deli-
very is possible, though extremely
rare, when the lie is uncorn'!cted. In
this series of 61 cases, there have
been 10 cases who delivered them-
selves, the spontaneous delivery rate
is, therefore, more than 16(; .
In all these 10 cases the baby was
dead. In all but one case the baby
was over six pounds in weight. Only
four babies were macerated. One
case was premature, of 32 weeks'
pregnancy. Most of the cases of spon-
t:meous delivery ended by spontane-
ous expulsion i.e. the entire foetus
doubled up and was expelled, back
foremost, the head and feet appearing
last. Two patients were delivered by
spontaneous evolution, in which the
breech was driven down first and the
baby was finally delivered as breech.
It seems that if sufficient time is al-
lowed in labour these cases will either
expel the foetus themselves or have
rupture of the uterus. Due to trans-
port difficulties many of the patients
arrived in the hospital late in labour,
and perhaps that explains the high
rate of spontaneous delivery in this
series. The parity of the mother did
not influence this method of deli-
very. That the babies were all dead
•
755
on admission was significant. The
softening of the foetal bones perhaps
helped in the process of expulsion in-
stead of causing rupture of uterus,
thougli most of the babies were not
macerated.
The author would not like to con-
clude that spontaneous delivery in
neglected shoulder presentation is to
be expected in all cases but this series
just shows that this type of termina-
tion is not as rare as it is thought.
Internal Version
It is interesting to note that in the
year 1962 there was only one case of
internal version, whereas in 1963,
there were 12 cases which were ter-
minated by internal podalic version.
In these 12 cases there was not a sin-
gle case of ruptured ut2rus. The
author feels that if internal version
is carefully done, the risk of rupture
can be minimised. The decision can
only be made after the patient is
anaesthetised. If the uterus relaxes
and there is no contraction ring, in-
ternal version can be attempted.
Gentle manoeuvre is the secret. In
some cases it was possible to pull
down the legs, the lie being corrected,
the foetus was left to be delivered
spontaneously. This increased num-
ber of versions has minimised the
number of caesarean sections. When
the foetal heart is present the author
would advise caesarean section even
if the cervix is fully dilated. In cases
of neglected shoulder presentation
the babies are moribund, if not al-
ready dead, and so it is advisable to
deliver them with minimum foetal
manipulation which is possible only
by caesarean section. Failure to fol-
low this rule cost the life of a 7 lb .
756 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
baby whose aftercoming head . was
obstructed by a contraction ring, as
has been described before. · · But the
cases where the foetus was already
dead, internal version gave a much
better postoperative period than in
the caesarean section cases. These
cases usually are infected and give a
stormy postoperative period . after a
major operation like caesarean sec-
tion; they are mostly anaemic and
stand blood loss adversely. In many
the uterus is so much retracted that
only a classical section can deliver the
baby. Classical section in a dehydrat-
ed, anaemic, infected patient, is never
very safe. Fortunately, in this group
we did not lose any patient, but one
case of caesarean section had to stay
in hospital as long as 57 days. The
lack of free availability of blood adds
to the danger of section.
Destructive Operations
Both eviscerations and decapita-
tions are difficult operative proce-
dures and the cases should be care-
fully chosen. This should always be
undertaken by people who have suffi-
cient experience in these types of ope-
rations. The type of destructive ope-
ration will depend upon the most
approachable presenting part. As a
rule decapitation is a cleaner op2ra-
tion than evisceration and should be
preferred if the neck of the foetus is
easy to approach. Both these opera-
tions are meant for babies who are
already dead. If carefully performed
there is very little risk of maternal in-
jury and a smooth postoperative
period is expected. In the present
series decapitation knife was used in
the usual way. The author had no
opportunity to use Blond-Heidler de-
capitation thimble and wire saw. In
all cases after decapitation, explora-
tion of the uterus was performed to '"'
exclude rupture of uterus. Some-
times the uterus that has ruptured
before coming into the hospital is
only diagnosed by exploration after
removing the baby. In one of the
cases of this series, rupture was de-
tected after decapitation. In this case
decapitation was specially difficult
because both the hands were prolaps-
ed, and it is possible that manipula-
tions caused the rupture. The patient -
required hysterectomy after decapita-
tion and had an uneventful postopera-
tave period. In no case of this series
was there any vesico-vaginal or
recto-vaginal fistula, but in cases
where there is risk of operative in-
jury, bladder should be continuous-
ly drained for at least a week. All
these cases had prophylactic antibio- "
tics. The cases of destructive opera-
tion required hospitalization on the ·
average for only 5.5 days as against
21.5 days after caesarean section. In
a busy district hospital like this it
makes a difference in the burd2n on
hospital beds. The author makes a
plea that in cases of neglected shoul-
der presentation where the baby is
dead, destructive operation gives .
equally good results as caesarean sec- .,. ~
tion, if not better, in relation to ma-
ternal morbidity and mortality.
In cases where the uterus is toni-
cally contracted, any uterine mani-
pulation, including decapitation, is
liable to fail and prove practically
dangerous, and in these cases caesa-
rean section is preferred. In Hall's
series of 85 cases there were three
maternal deaths. All the deaths were ...
in the first ten years of 1924 to 1958 .
. '
 NEGLECTED SHOULDER PRESENTATION
There were no deaths in the later
years. In the present series, of 61
cases there were no maternal deaths
though in 60 % cases vaginal delivery
was undertaken. Antibiotics and ex-
pert anaesthesia have ~a~e vagi:r:al
delivery safer. In India, m the dis-
tricts blood is not yet freely available
for tr'ansfusion and cannot be readily
organised in case of emergen~y. ~n
view of this, caesarean sectwn m
neglected shoulder presentation
should be carefully considered and
under the present conditions in this
country should be avoided if possible.
Ceval Babumea of Istanbul seems to
have worked in similar circumstances
as in India, and he has also ad-
vocated destructive operations when
the baby is dead. He reports 26 case~
without a maternal death. He had
two cases of ruptured uterus, one was
_ treated conservatively and the other
had hysterectomy. He quotes support
from Eastman, Kurtz, Etal, and Ried.
Discussing on Garber et al's paper
Holmes commented that internal ver-
sion was an ideal operation in its ap-
propriate field and it would be wise
to realize that· caesarean section was
not a panacea for all obstetric compli-
cation, and other obstetric operations
still had a definite place as a means
of delivery. The author's experience
in this series is in complete agree-
ment with Holmes's view.
Aetiology
In this present series no cause for the manuscript for me.
transverse presentation could be de-
tected in 58 cases. In one there was References
pJacenta praevia and there were two
cases of twins. No uterine abnorma-
, lity was detected in any case; 28 cas~s
were grand multiparae , but this
29
757
condition was also found in seven
primigravidae. In none of these pri-
migravidae was any gross pelvic con-
traction detected. Hall and O'Brien
found no cause in 79 7o of their series.
Conclusion
Neglected shoulder presentation is
an avoidable condition. It can only
be found in countries where antenatal
care is far from satisfactory. It is al-
ways associated with a very high foe-
tal mortality and maternal morbidity
and mortality. The author has col-
lected 61 cases during a period of two
years in a district hospital and has
analysed the results of the various
methods of treatment. Where the
baby is alive caesarean section is the
method of choice, but if the baby is
already dead internal podalic version
or decapitation should be carefully
considered as possible alternative~.
Spontaneous expulsion may occur in
some cases but should not be awaited
for.
I am grateful to Dr. (Miss) Bose,
the lady medical officer of the Unit,
for her help in collecting the cases. I
would like to thank Dr. Bhattacharya
for allowing me to collect the cases
that were under his care. My thanks
are due to Dr. Roy Choudhury, the
Chief Medical Officer, and Dr.
Chakravarty, the Superintendent of
the hospital, for allowing me to pub-
lish th2 hospital cases. I am grateful
to Mr. Mukherjee for kindly typing
1 . Babuna, Ceval: Am. J. Obst. &
Gynec. 87, 1963.
2 . Eastman, N. J.: Obstetrics, ed. 10,
758 JOURNAL OF OBSTE'l'lUCS AND OYNAECOLOGY OF. IN:OIA

New York, 1950, Applaton Century Obstetrics and Gynaecological

Crofts, Inc.
3. Garber, E. C. (Jr.), Fayetteville,
N. C., Hudnall Wave, H. (Jr.)"
Richmond, V. A.: Am . .J. Obst. &
Gynec. 61: 62, 1951.
4. Hall Stanley C., O'Brien, Francis,
B.: Am. J. Obst. & Gynec. 82: 1180,
1961.
5. Holland E. and Bourne, A.: British
-Practice, ed., London, 1955, Heine-
mana, p. 631.
~. Kurtz, G. R., Stall, W. A., and Sat-
tenspiel, E. and Bull E.: Margaret
Hagne Maternity Hospital 3: 18,
1950.
7. Reid, D. E.: A Text-book of Obs-
tetrics, Philadelphia, 1962, W. B.
Saunders Company.

.,.,