Shoulder Dystocia

Definition
– A delivery that requires additional
manoeuvres to release the shoulders after
gentle downward traction has failed.
Shoulder dystocia occurs when either the
anterior or, less commonly, the posterior
fetal shoulder impacts against the maternal
symphysis or sacral promontory.

– Incidence :-Is approximately 0.6% in UK

 Risk factors
• Antenatal • Intrapartum
Maternal – Prolonged second stage
– Diabetes – Prolonged active phase
– Short Stature of first stage
– Previous shoulder – Instrumental birth
dystocia – Induction of labour
– Obesity
– Augmantation by
– Pelvic anomalies oxytocin
Fetal
– Fetal macrosomia
– Post term

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 RISK FACTORS FOR SHOULDER
DYSTOCIA
Although fetal macrosomia is the main risk
factor 50% of shoulder dystocias occur in
infants of normal Wt
 Complications of Shoulder
Dystocia*
• Maternal • Fetal
– Postpartum – Brachial plexus palsy
hemorrhage
– Clavicle fracture
– 3rd or 4th degree
perineal tears – Fracture of the
humerus
– Rectovaginal fistula
– Fetal hypoxia
– Symphyseal • With or without
separation permanent
neurologic damage
– Uterine rupture
– Fetal death
 Shoulder
dystocia
will still the
obstetric
nightmare
 -Clinical Manifestations
• Turtle neck sign following birth of the
baby’s head. The baby’s head will retract
back against the perineum
• Routine manoeuvres for delivery of
shoulders during next contraction after
delivery of the head fails.
Shoulder Dystocia
The turtle sign
 Management
• Manoeuvres aim to
– Increase the functional size of the pelvis
(McRoberts)
– Decrease the biacromial diameter
(Suprapubic Pressure Rubins I)
– Change the relationship of the biacromial
diameter with the bony pelvis (Rubins II ,
Woodscrew)

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 HELPERR pneumonic
• H – Help
– Call for assistance,anaesthetis,paediatrition
• E – Evaluate for episotomy
• L – Legs (McRobert’s Maneuver)
• P – Pressure (suprapubic)
• E – Enter the vagina
• R – Remove the posterior arm
• R – Roll the patient
– To hands and knees
 McRoberts’ manoeuvre
• The McRoberts’ manoeuvre is flexion and
abduction of the maternal legs at hip,
positioning the maternal thighs on her
abdomen.
• It flattens the lumbo-sacral spine, rotates
the maternal pelvis cephalad so the pubis
will slip overe the shoulder.
Shoulder Dystocia Management
 HELPERR ©

• Pressure – suprapubic(Rubins I)
– Continuous pressure downward over the
posterior aspect of anterior shoulder to
facilitate adduction of the fetal shoulders and
reduce the biacromial diameter.
– After 30 seconds a rocking motion of the
hands can be tried to achieve the same
outcome.

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McRoberts / Suprapubic pressure
Enter vagina(internal maneuvers)

• Rotate anterior shoulder(Rubin II):Apply pressure

to posterior aspect of anterior shoulder to adduct
the shoulders then push them into the diagonal

• Wood’s screw maneuver: Apply pressure to the

anterior aspect of the posterior shoulder while
continuing to rotate the anterior shoulder also.

• Reverse Wood’s screw maneuver: an attempt to

rotate the baby in opposite direction.
17
18
Woods screw

19
Reverse Woods screw

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 Shoulder dystocia
• Remove posterior arm:passing ahand
in front of the post.shoulder&deliver
the post arm by swinging it infront of
fetal chest.
Delivery of the posterior arm.

delivery
over the
perineum
 Shoulder dystocia
• Roll pt on to all fours:to increase the
anterio-posterior diameter of the inlet.

Last resort measures

– Fracture clavicle
– Zavanelli maneuver
– Symphysiotomy
 All- Fours Manoeuver
It consists of placing the patient onto
her hands and knees
2.Flexion of the head, Returning it to
the vagina with upward constant
firm pressure, followed by CS