Shoulder

dystosia
Definition
Shoulder dystocia is inability to deliver the
shoulders after the fetal head has been
delivered despite the performance of routine
obstetric maneuvers.
It is an acute obstetric emergency requiring
prompt, skillful management to avoid significant
fetal damage and death.
INCIDENCE :
Varies depending on the criteria's used for the
diagnosis.
015 to 17 % of all vaginal deliveries .
Recurrence 10 %
Occurs with equal frequency in primigravid
& multigravid women, although it is more
common in infants born to women with
diabetes.
Risk assessment
Shoulder dystocia cannot be predicted.
Be prepared for shoulder dystocia at all deliveries,
especially if a large baby is anticipated.
Predisposing factors include:
Macrosomia
Diabetes mellitus: 2 to 10 fold
Women with previous hx of macrosomic babies
History of shoulder dystocia: recurrence 10%
Post term pregnancy: relative risk 13
Obesity & high weight gain.
Advanced maternal age.
Male fetal gender
Shoulder pelvis disproportion.
MECHANISM OF SHOULDER DYSTOCIA

Normal Mechanism Of Labor :

Biacromial diameter enters the pelvis at oblique
angle
Posterior shoulder ahead of anterior shoulder.
Sliding of anterior shoulder under symphysis
delivery.
In Case Of Shoulder Dystocia:
Fetal Shoulders remain in AP position or descend
simultaneously.
Impaction of Anterior Shoulder behind the
symphysis (common).
Impaction of the Posterior Shoulder on the sacral
promontory (rare).
 Complications
Birth asphyxia and metabolic acidosis, shock,
renal failure, seizure
Neurological damage, mental retardation, cerebral
palsy etc
Traumatic birth injuries: fracture of the humerus
and clavicle;
Injury to the brachial plexus (Erbs palsy)
Maternal complication of the cervix, vagina and
perineum that may lead:
Hemorrhage, Fourth degree lacerations, lower genital
tract lacerations, Uterine atony, Uterine rupture
 Diagnosis
The fetal head is delivered but remains tightly
applied to the vulva
The chin retracts and depresses the
perineum.
Traction on the head fails to deliver the
shoulder, which is caught behind the
symphysis pubis.
Suspected when fetal head retracts in to the
perineum (Turtle sign) after expulsion due to
reverse traction from shoulder being impacted
in the pelvic inlet.
 MANAGEMENT
The goal of mgt is to safely effect delivery of
the infant before asphyxia and cortical
injury occur, and without causing peripheral
neurologic injury or other trauma.
Options of management
Prophylactic cesarean delivery
Vaginal delivery
Prophylactic cesarean delivery
ACOG recommendation
as induction does not improve maternal or

fetal outcomes, suspected fetal

macrosomia is not an indication for
induction of labor
However, expectant management
beyond the estimated due date is
generally not recommended
C/S may be cosidered for EFW >5000 in
nondiabetic and >4500 in diabetic
 Prophylactic c/s cont
For patients with prior history of shoulder dystocia
The benefit of universal elective cesarean delivery is
questionable
Factors that may aid in the decision-making process
includes evaluation of
Present EFW compared with the prior pregnancy birth wt
Gestational age,
Presence of maternal glucose intolerance,
Severity of the prior neonatal injury, and
Discussion and review of the prior delivery events and
risks and benefits of cesarean delivery should be
undertaken with the patient
Strong consideration of c/s recommended when a
prolonged stage occur in association with macrosomia
 Intrapartum management
If the clinician is concerned about a
possible shoulder dystocia, certain
shoulder precautions can be employed;
ensuring the presence of an extra staff
emptying the patients bladder, secure IV
line
Patient position with her buttock flush with
the beds edge
Performing a generous episiotomy
 Make an adequate episiotomy to reduce soft tissue
obstruction and for manipulation.
In the lithotomy position, ask the woman to flex both
thighs, bringing her knees as far up as possible
towards her chest. Ask two assistants to push her
flexed knees firmly up onto her chest (McRoberts
maneuver).
After wearing high-level disinfected gloves undertake
the following maneuvers to deliver the shoulder:
Apply firm, continuous traction downwards on the
fetal head to move the shoulder that is anterior
under the symphysis pubis. Avoid excessive traction
on the head as this may result in brachial plexus injury.
 Have an assistant simultaneously apply suprapubic
pressure downwards to assist delivery of the shoulder
If the shoulder still is not delivered, insert a hand into the
vagina and apply pressure to the shoulder that is
anterior in the direction of the babys sternum to rotate the
shoulder and decrease the shoulder diameter. If needed,
apply pressure to the shoulder that is posterior in the
direction of the sternum.
If the shoulder still is not delivered despite the above
measures, insert a hand into the vagina; grasp the
humerus of the arm that is posterior; and, keeping the
arm flexed at the elbow, sweep the arm across the
chest. This will provide room for the shoulder that is
anterior to move under the symphysis pubis.
 If all of the above measures fail to deliver the shoulder, the
last options is to fracture the clavicle to decrease the width
of the shoulders and free the shoulder that is anterior;
apply traction with a hook in the axilla to extract the arm
that is posterior.

Steps recommended by
WHO clinical
experience
MacRoberts
Anterior shoulder
Posterior shoulder
Salvage

Symphysiotomy
Splitting the
symphesis pubis.
Prevention
Even though shoulder dystocia can not be predicted,
the complication of shoulder can minimized by:
Fetal weight estimation at term and, if the estimated
weight of the fetus is 4 or more Kg, elective cesarean
delivery is effected. Fetal weight estimation is especially
required among women with:
diabetes mellitus,

previous history of macrosomic babies,

obesity

big abdomen

Avoid mid-pelvic manipulation in the 2nd stage

Adequate training of providers
THANK YOU