SHOULDER DYSTOCIA

DEFINITION :
A delivery that requires additional
obstetric manoeuvres to release the
shoulders after gentle downward
traction has failed.
Occurs when either the anterior or
posterior fetal shoulder impacts on the
maternal symphysis or sacral
promonotory.
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INCIDENCE ;
In unselected USA and UK populations = 0.6%
Increased perinatal mortality and morbidity even
when managed appropriately
Maternal morbidity is increased with PPH (11%), 4th
degree tears (3.8%)
BPP is associated with 4-16% of cases of shoulder
dystocia (only 10% of these are permanent)
In UK incidence of BPP = 1/ 2,300 livebirths
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MANAGEMENT
Intrapartum
Pre-emptive preparation may help
Delivery
Routine traction in an axial direction may help diagnose
shoulder dystocia
Routinely observe for –
Difficulty in delivering face and chin
Turtle sign
Failure of restitution of fetal head
Failure of shoulders to descend
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Shoulder dystocia should be managed

systematically
47% of babies died within 5 minutes of the head
being delivered
1.Call for help
discourage maternal pushing and bring buttocks to
end of bed and drop end of bed
2. Fundal pressure should NOT be used
3. Episiotomy can be selectively used
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4.McRoberts’ manoeuvre
90% success rates reported
5. Suprapubic pressure
Apply with above in downward and lateral direction for
30 seconds
? continuous or rocking movement
6. Advanced manoeuvres if above fail
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6. Advanced Manoeuvres : Second Line
(1). All fours v internal manipulations
- If patient slim, mobile, no epidural and only a single
attendant can try all fours – deliver posterior shoulder with
gentle downward traction.
(2). Delivery of posterior arm v internal rotation
manipulations --- no clear advantage
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(2a) Delivery of posterior arm:

. follow posterior arm down to the elbow (usually
anterior to fetal chest)
. Flex arm at the elbow
. Sweep forearm across fetal chest
(grasping hand directly and pulling outward may lead to
unnecessary fractures – but even if well done might
expect 12% humeral fracture rate)
. Episiotomy would seem desirable
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(2b) Internal Rotation Manipulations
i Rubin Manoeuvre
. approach anterior shoulder from behind.
. exert pressure on scapula to adduct the most accessible
shoulder and rotate to the oblique position.
.continue McRoberts manoeuvre
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ii Woods Screw Manoeuvre

. approach posterior fetal shoulder from the front
. gently rotate shoulder towards symphysis
. combine with Rubin manoeuvre – birth attendant has
one hand on each shoulder rotating them together
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iii Reverse Woods Screw Manoeuvre

. approach posterior shoulder from behind
. Rotate fetus in opposite direction from Rubin and Woods
Screw manoeuvres
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6. Advanced Manoeuvres – Third Line

Cleidotomy, symphysiotomy, Zavanelli manoeuvre,

muscle relaxation with abdominal surgery
with hysterotomy to disimpact shoulders

7. Post delivery :
Be alert for PPH and third and fourth degree tears
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RISK MANAGEMENT
1. Rehearsal
H --- call for help
E --- evaluate for episiotomy
L --- legs (McRoberts)
P --- suprapubic pressure
E --- enter manoeuvres (internal rotation)
R --- remove posterior arm
R --- roll the patient
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2. Documentation
Record: . Time of delivery of head
. Direction of head after restitution
. Manoeuvres performed
. Time of delivery of body
. Staff in attendance&response time
. Condition of baby – Apgar
. Cord blood gases
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3. Auditable Standards
. Critical analysis of manoeuvres used
. Documentation
. Incidence of BPP
. Staff attendance at dystocia drills
4. Support