Shoulder Dystocia

DEFINITION
Shoulder dystocia can be defined
as failure of the shoulders to
spontaneously traverse the pelvis
after delivery of the fetal head.

Next Slide
In practice, the diagnosis of
shoulder dystocia is subjective; it
is considered when the routine
practice of gentle, downward
traction of the fetal head fails to
accomplish delivery.
 Risk Factors
Maternal
– Abnormal pelvic anatomy

– Gestational diabetes

– Post-dated pregnancy

– Previous shoulder dystocia

– Short stature

Next Slide
Fetal

– Suspected macrosomia

– Male sex

Labor related

– Assisted vaginal delivery (forceps or

vacuum)

– Protracted active phase of first-stage labor

– Protracted second-stage labor

Numerous risk factors for development
of shoulder dystocia exist.

One of these risk factors is Fetal

Macrosomia.

Macrosomia has consistently been

shown to be one of the major risk
factors for shoulder dystocia.

Next Slide
Macrosomia is best defined as:
– An estimated fetal weight (EFW) or
birth weight >4000 grams

– or Birth weight >90th percentile for

gestational age.

– The overall prevalence of birth

weight over 4000 grams
Postterm pregnancy:
– A large proportion of deliveries
complicated by shoulder
dystocia occur in postterm
pregnancies.

– Fetal size was primarily

responsible for the increased
risk of shoulder dystocia Next Slide
Male fetal gender:
– The frequency of male gender is higher in
pregnancies complicated by shoulder
dystocia cases

– This is the result, in part, of the

relationship between fetal macrosomia and
gender. This was illustrated in a study that
found that 70 percent of newborns
weighing >4545 grams (10 pounds) were
male.
Next Slide
 PATHOPHYSIOLOGY
The fetal
bisacromial
diameter normally
enters the pelvis at
an oblique angle
with the posterior
shoulder ahead of
the anterior one. Next Slide
Rotating to the anterior-posterior
position at the pelvic outlet with
external rotation of the fetal
head.

The anterior shoulder can then

slide under the symphysis pubis
for delivery.
If the fetal shoulders remain in an
anterior-posterior position during
descent, then the anterior shoulder
can become impacted behind the
symphysis pubis and the posterior
shoulder may be obstructed by the
sacral promontory.
Advanced maternal age:
– Advanced maternal age has been
identified as a risk factor for
shoulder dystocia; however,
confounding variables such as
gestational diabetes and maternal
weight probably account for this
association.
Next Slide
 DIAGNOSIS

Once the head is delivered, it may

look as if it is trying to return into
the vagina, it is called shoulder
traction and is called “Turtle
Sign”.
 COMPLICATIONS

MATERNAL:
• Hemorrhage

• Maternal mortality and morbidity

• Uterine rupture
FETAL:
• Birth asphyxia

• Brachial plexus injury

• Neonatal death
 MANAGEMENT

The midwife should keep calm

and provide adequate explanation
to the mother to ensure her co-
operation for the maneuvers
needed to complete the delivery.
 PROCEDURES AND
HELPERR Mnemonic
McRoberts maneuver

Suprapubic pressure

Robins maneuver

Woods maneuver

Zavenellis maneuver
H- Call for help

E- Episiotomy

L- Legs

P- Pressure

E- Enter

R- Remove

R- Roll
H Call for Help:
– Activating the pre-arranged protocol

– Notifying the appropriate personnel

– Necessary equipment to be arranged

in the labor and delivery unit.

Next Slide
HELPERR Mnemonic

Click Diagram to Dismiss it

Episiotomy:
– Episiotomy should be
considered throughout the
management of shoulder
dystocia. Shoulder dystocia is a
bony impaction, so episiotomy
alone will not release the
shoulder.
Next Slide
Because most cases of
shoulder dystocia can be
relieved with the McRoberts
maneuver and suprapubic
pressure, many women can be
spared a surgical incision.
L Legs (McRoberts maneuver):
– This procedure involves flexing
and abducting the maternal
hips, positioning the maternal
thighs up onto the maternal
abdomen.

Next Slide
–This position flattens the
sacral promontory and
results in cephalad
rotation of the pubic
symphysis.
McRobert’s Maneuver

Click Diagram to Dismiss it

P Pressure (Suprapubic):
– The hand of an assistant should be
placed suprapubically over the fetal
anterior shoulder, applying pressure
in a cardiopulmonary resuscitation
style with a downward and lateral
motion on the posterior aspect of the
fetal shoulder.

Next Slide
– This maneuver should be attempted
while continuing downward traction.
Suprapubic Pressure

Click Diagram to Dismiss it

E Enter maneuvers (internal
rotation):
– These maneuvers attempt to
manipulate the fetus to rotate
the anterior shoulder into an
oblique plane and under the
maternal symphysis.

Next Slide
"Enter" Maneuvers
1. Rubin II
At vaginal examination
apply pressure. If
shoulders move into
the oblique diameter,
attempt delivery.

Next Slide
2. Rubin II + Woods corkscrew
maneuver
If unsuccessful, add the Woods
corkscrew maneuver and continue
rotation in the same direction. Use both
hands and apply pressure. If shoulders
now move into the oblique, attempt
delivery. If this is unsuccessful,
continue rotation 180 degrees and
deliver.
3. Reverse Woods corkscrew
maneuver
If the last maneuver is
unsuccessful, change to
reverse Woods
corkscrew maneuver.
Slide fingers down to
back of posterior
shoulder and attempt
180-degree rotation in
the opposite direction.
R Remove the posterior arm:

– Removing the posterior arm from

the birth canal also shortens the
bisacromial diameter, allowing
the fetus to drop into the sacral
hollow, freeing the impaction.

Next Slide
The elbow then should be flexed
and the forearm delivered in a
sweeping motion over the fetal
anterior chest wall.

Grasping and pulling directly on

the fetal arm may fracture the
humerus.
Removing Posterior Arm

Click Diagram to Dismiss it

R Roll the patient:
– The patient rolls from her existing
position to the all-fours position.

– Often, the shoulder will dislodge

during the act of turning, so that this
movement alone may be sufficient
to dislodge the impaction.

Next Slide
R Roll the patient:

Click Diagram to Dismiss it

– In addition, once the position change
is completed, gravitational forces
may aid in the disimpaction of the
fetal shoulders.
 Zavanelli manoeuvre

Reversal of the mechanisms of

delivery so far and reinsertion of
the fetal head into the vagina.
Delivery is then completed by
Cesarean section
 Prevention
Prophylactic cesarean delivery is not
recommended for preventing morbidity in
pregnancies in which fetal macrosomia is
suspected.

One of the preliminary intervention for

patient with risk factors involves
implementing the "head and shoulder
maneuver" to "deliver through" until the
anterior shoulder is visible. Next Slide
This step is accomplished by
continuing the momentum of the
fetal head delivery until the
shoulder is visible.

After controlled delivery of the

head, proceed with immediate
delivery of the anterior shoulder
without stopping to suction the
oropharynx.
Next Slide