You are on page 1of 20

SHOULDER DYSTOCIA

Prepared by:
Dr. Gehanath Baral
MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
2nd April,2007

1
Definition

 Shoulder dystocia is defined as a delivery that requires


additional obstetric manoeuvres to release the shoulders
after gentle downward traction has failed.

2
Shoulder dystocia will still the
obstetric nightmare

3
Background

 Shoulder dystocia occurs when either the


anterior or,less commonly, the posterior
fetal shoulder impacts on the maternal
symphysis or sacral promontory.
 Unpredictable and unpreventable event
 Incidence= 0.5-1%

4
Complication
 High perinatal mortality  High maternal
High perinatal morbidity
morbidity

Fetal asphyxia
Brachial plexus injuries,  High operative del.
Fractures of the humerus
Fractures of the clavicle  30 degree perineal
Sternomastoid hematoma
tears
 PPH

5
Fetal Complications
Brachial plexus injuries

6
Diagnosis

1. Shoulder delivery delayed over a minute


2. Difficulty with delivery of the face and chin
3. The head remaining tightly applied to the vulva or
even retracting
4. Failure of restitution of the fetal head
5. Failure of the shoulders to descend

7
Predisposing factor
1. Fetal macrosomia=>4kg

2. Postmaturity  Unpredictable and


unpreventable
Anencephaly
event
3.

4. Fetal ascites/abd.mass

5. Multiparity

8
Fetal Macrosomia

9
Factors associated with shoulder dystocia

10
Previous shoulder dystocia

Advise elective caesarean section for:

1. Severe previous neonatal or maternal injury


2. Macrosomia associated with maternal
diabetes mellitus
3. Maternal choice

11
Management: General principles
 Do not become panicky  Maternal pushing should be
discouraged
 Ask for help:
 Assistance  Give episiotomy
 Obstetrician
 Pediatric  Do not give traction on
resuscitation team fetal head
 Anesthetist
 Try to dislodge shoulder
 Bring the buttocks to the
edge of the bed  Do not give fundal
pressure

12
The McRoberts' manoeuvre

13
McRoberts’ manoeuvre

Flexion and abduction of the maternal hips


Positioning the maternal thighs on her abdomen

Straightens the lumbo-sacral angle


Rotates the maternal pelvis cephalad
Increases in uterine pressure
Increases amplitude of contractions

14
McRoberts manoeuvre: X ray pelvimetry study

1. No increase in pelvic dimensions


2. Decrease in the angle of pelvic inclination
3. Straightening of the sacrum
4. Tends to free the impacted anterior shoulder
15
McRoberts’ manoeuvre
+
Suprapubic pressure

Suprapubic pressure:
1. Reduces the bisacromial
diameter
2. Rotates the anterior shoulder
into the oblique pelvic diameter
3. Downward and lateral direction
to push the posterior aspect of
the anterior shoulder towards
the fetal chest
4. For 30 seconds

. 16
If Mc Roberts failed:

Woods manoeuvre:
1. The hand is placed
behind the posterior
shoulder of the
fetus.
2. The shoulder is
rotated progressively
1800 in a corkscrew
manner.
3. Impacted anterior
shoulder is released.
17
Delivery of the posterior arm.
By inserting a
hand into the
posterior vagina
and ventrally
rotating the arm at
the shoulder

Delivery
over the
perineum

18
Third-line methods

1. Cleidotomy (bending the clavicle with a


finger or surgical division)
2. Symphysiotomy (dividing the symphyseal
ligament)
3. Zavanelli manoeuvre

19
Zavanelli manoeuvre

 Cephalic replacement of the head and


delivery by caesarean section
 Most appropriate for:
 Bilateral shoulder dystocia
 Where both the shoulders impact on the pelvic
inlet
 Anteriorly above the pubic symphysis
 Posteriorly on the sacral promontory

20