O&G CME HKT 18 July 2022

Shoulder Dystocia
Dr Wan Muhammad Farhan bin Wan Fauzi

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 Shoulder Dystocia

Situation
You are the second call in HKT. Your first call is still in HSI sending case.

Suddenly, one of the nurses informed you that they have a patient with prolonged second stage of labor.

Upon attending, the baby's head is already popping out but the shoulder is stuck. You called for help from ED MO but,
unfortunately there is only 1 MO available in ED and he was resuscitating an ill child.

Having remembered the HELPERR mnemonic, you attempted all possible maneuver... but still failed to deliver the child.

What's next?!
 Shoulder Dystocia

Did you
know?
Based on the National Health and Morbidity Survey 2019,
there are approximately

3.9 million
Malaysians living with diabetes, which equals to

and 1 in 2 adults are either

overweight or obese
based on the same study.
 Shoulder Dystocia

Content Overview
Risk factors

Clinical presentation
HELPERR

Additional maneuvers
Complications
 Shoulder Dystocia

Overview
Shoulder dystocia is when the baby's anterior shoulder become
impacted behind the maternal pubic symphysis, preventing delivery of
the fetal body.

Shoulder dystocia is a true obstetric emergency. During the dystocia,

the fetus is not getting any oxygen.

Any delivery requiring more than routine maneuver to accomplish

delivery is considered as a shoulder dystocia.
 Shoulder Dystocia

Risk factors Fetal macrosomia

Maternal diabetes mellitus

Previous shoulder dystocia

Maternal obesity

Prolonged 2nd stage of labor

 Shoulder Dystocia

2nd stage
of labor
 Shoulder Dystocia

Failure of shoulder delivery Turtle sign Prolonged 2nd stage

Failure of the fetal shoulders to deliver with Turtle sign: retraction of the fetal head Abnormal progression of 2nd stage of labor
gentle downward traction on the fetal head tightly against the maternal perineum

Clinical presentations
 Shoulder Dystocia

Call for help

Initial Never manage shoulder dystocia alone.

steps Keep calm

Being calm helps you make better judement and decision.

Have mother stop pushing

Pushing is only further forcing the shoulder into the pubic symphysis.
Relaxing allows room for manoeuvres to dislodge the shoulder.

Take note of the time

Important for documentation and expecting outcome.

 Shoulder Dystocia

HELPERR
Help
Call for help.

Episiotomy
Consider episiotomy to allow space for maneuvers.
This is a bone-on-bone obstruction, thus episiotomy will not
relieve shoulder dystocia.
 Shoulder Dystocia

HELPERR
Legs
Elevate the legs. (“Knees to armpits”) - McRoberts position
Abduction + hyperflexion of the maternal hips
Causes cephalad rotation of the pubic symphysis and flattens the
lumbar lordosis → maximizes the pelvic diameter

Pressure
Performed by the assisstant
Attempts to push the shoulder down and inward
Slightly rotates the fetus and dislodges the impacted shoulder
Avoid fundal pressure, which may make the dystocia worse
 Shoulder Dystocia

HELPERR
Enter
Enter the vagina for internal rotation.
Woodscrew: 2 fingers behind posterior shoulder and 2 finger in front
anterior shoulder - rotating the baby
Rubin: 2 fingers behind posterior shoulder to rotate the shoulder (folding
the shoulder in) to decrease diameters between the shoulders

Relieve
Remove the posterior arm to increase space in the sacral column.
There is an increased risk of clavicle fracture and humerus fracture.
 Shoulder Dystocia

HELPERR
Roll over
Rotate the patient to her hands and knees. (Gaskin maneuver)
 Shoulder Dystocia

Breaking the clavicles Zavanelli manoeuvre Symphysiotomy

Place your fingers underneath the clavicle and Go through the cardinal movement of labour in Cut the cartilage in between the pubic
pull out the clavicle. reverse and push the baby back into the uterus to symphysis using a scalpel.
perform Caesarean section.

Additional manoeuvres
 Shoulder Dystocia

Complications Brachial plexus injury

Clavicle fracture

Humerus fracture

Fetal asphyxia

Contusions and lacerations

 Shoulder Dystocia

Brachial
plexus injury
Erb's palsy (75%): C5-C6
Klumpke's palsy (2%): C8 -T1

Erb's Klumpke's
 Shoulder Dystocia

Situation
You are the second call in HKT. Your first call is still in HSI sending case.

Suddenly, one of the nurses informed you that they have a patient with prolonged second stage of labor.

Upon attending, the baby's head is already popping out but the shoulder is stuck. You called for help from ED MO but,
unfortunately there is only 1 MO available in ED and he was resuscitating an ill child.

Having remembered the HELPERR mnemonic, you attempted all possible maneuver... but still failed to deliver the child.

What's next?!
Shoulder Dystocia
 Shoulder Dystocia

Take home messages

Always be Repeat the Documentation

prepared. maneuvers. is important.
Any delivery has the Repeat the maneuvers a Document the events of the
potential to become few times before moving on delivery, maneuvers done,
shoulder dystocia. Take to the more risky additional and baby examination.
note of clinical maneuvers. Almost 90% of
presentation that alarming shoulder dystocia can be
you of shoulder dystocia. delivered by repeating the
steps in HELPERR.
O&G CME HKT 18 July 2022

Thank you!

The End