GUIDED BY HOD AND PROFF. DR.

RATNA
THAKUR

PRESENTED BY DR. SNEHALATA

DR.TRINA
DR.SONAL
Introduction
Shoulder dystocia has emerged as one of the
most important clinical and medico legal
complication of vaginal delivery.

When shoulder dystocia is anticipated the

obstetrician should mentally rehearse the sequence
of steps necessary to treat this problem and be ready
to act in a logical , step by step fashion.

 The reported incidencevaries from 0.2 to 1.7% in

cephalic vaginal deliveries.
Certain patterns increases the
likelihood of shoulder dystocia
 1. a protracted or arrested active phase of first stage of
labour is associated with an increased incidence of
shoulder dystocia
 2. Protracted or arrested descent in the second stage of
labour is anothermarker.
 3. Assisted mid pelvic delivery carries a higher risk of
shoulder dystocia but it does not occur in 95% of such
deliveries.
Defination
 Shoulder dystocia is defined when the fetal head has
delivered but the shoulder do not deliver
spontaneously or with normal amount of gentle
downward traction.
 Clinical diagnosis is confirmed when the head delivers
but external rotation does not occur and the head
recoils tightly against theperineum. ( TURTLE SIGN )
 When the head to completion of delivery interval of
more than 60 secs or need to use additional
manoeuvres to deliver theshoulder.
 Shoulder dystocia is of twotypes
 Unilateral shoulder dystocia – when anterior or
posterior shoulder isimpacted.
 Bilateral shoulder dystocia – when bilateralshoulders
lie above the pelvicbrim.
Prediction
 Following predisposing factors have been identified but, in
general, lack specificity.
 Antepartum risk factors
 1. Macrosomia
 2. Diabetes- this is due to greater shoulder/head
circumference ratio because of the insulinsenstive
nature of the tissues that contribute to shoulder
girth , compared to brain growth which is not
affected by hupoglycaemia and hyperinsulinism.
 3. Obesity- chances are 0.6% in women less than
90kgs to 5% in women more than 113kgs.
 4. Post term pregnancy- incidence of macrosomia is 12%
at 40 weeks and 21% at 42 weeks. In later weeks of
pregnancy the fetal chest and shoulders continue to grow
steadily, whereas the biparietal diameter growth slows ,
increasing the likelihood of an unfavourableshoulder/head
circumference ratio.
 5. Previous shoulderdystocia
 Because macrosomia is the commonest association
with shoulder dystocia and neonatal injury, it has
been proposed that elective cs of fetus estimated to
weigh more than 4500gm and even 4000gm shouldbe
persued.
 6.Abnormal pelvic anatomy
 7.Short stature (less than 5feettall)
 8.Previous large infant (>4000gms)
 9.Anencephaly
 10.Multiparity
 11.Fetal ascites
Intrapartum risk factors
 Operative vaginal delivery
 Arrest in the late firststage of labour
 Arrest of descent in second stageof labour
 Precipitous delivery
ACOG guidelines on shoulder
dystocia
 Shoulder dystocia cannot be predicted or prevented
because accurate methods for doing so do not exist.
 Elective induction orcaesarean delivery for all womenwith
a suspected macrosomic fetus is notappropriate.
 When evaluating the risks and benefits of caesarean and
vaginal delivery in patients with a history of shoulder
dystocia , the obstetrician shouldconsider.
estimated weight
gestational age
maternal glycemic status
previous history of shoulderdystocia.
Complications
 Fetal – 1. Asphyxia fetus is not hypoxic before
shoulder dystocia occurs there should be 4 to 5
mins before the possibility of permanenthypoxic
damage.
 2.Brachial plexus injury is the most common and
serious complication.
 occurs in 5-15% of neonates .
 Most common type is Erb-Duchenne involving C5 and
C6 nerve roots . The range of permanent palsy in those
infants with brachial plexus is4-32%.
 3.Fractures occuring in 15% . Majority of theseare
clavicular,
with fracture of humerus account for less than 1%.
Maternal complication
 1.Genital tract lacerations more common dueto the
tight feto pelvicrelationship.
additional room needed for manoeuver
extension of episiotomy and 3rd and 4th degree tears
are more common.
 Post partum haemorrahage due to combination of -
uterine atony,
prolonged labour,
large infant
increased blood loss from lacerations and
extensive episiotomy.
Managing shoulder dystocia
 For managing shoulderdystocia we use term
HELPERR
 H – call for help
 E – evaluate forepisiotomy
 L – legs ( MC ROBERTS maneuver )
Mc Roberts Maneuver -symphysis rotates
superiorly which lifts the fetus and flexes the fetal spine toward the
anterior shoulder.
P – Suprapubic pressure
E- Enter maneuvers ( Internal
rotation ) – manipulates the fetus to rotate the anterior shoulder
into an oblique plane and under maternal symphysis.
R-Rubin 2 maneuver
 Placing two fingers behind posterior aspect of anterior
shoulder toward the fetal chest . This will adduct fetal
shoulder girdle, reducing itsdiameter.
Wood screw maneuver
 Two fingers on the anterior aspect of the fetal posterior
shoulder, applying gentle upward pressure 180degrees
,thus the posterior shoulder which is below the level of
pelvic brim is screwed around under the level of pubic
arch and then it is delivered from anterior position.
Deliver the posterior arm
 Flex the elbow and sweep the forearm across the chest.
Grasping of the upper arm should be avoided as there
is risk of fracture of humerus.
R- Roll the patient ( Gaskin or all
four maneuver ) increases the flexibility of sacroiliac
-
joint and gravity push the posterior shoulder anteriorly.
Maneuvers of last resort
 Zavanelli maneuver : Cephalic replacement followed
by cs.
 Cliedotomy
 Abdominal rescue
 Symphysiotomy
ZAVANELLI MANEUVER/cephalic
replacement
Summary
 Shoulder dystocia cannot be reliably predicted in the
antenatal period .
 Clinical estimation of macrosomia is as as accurate as
ultrasound.
 Elective cs is not recommended solely on the grounds
of suspected macrosomia.
 No consistent patterns of labour and/or delivery
reliably predict shoulderdystocia.
 Cs for cumulative risk factors in the antenatal and/or
intrapartum period may be reasonable on a selective
basis.
 All personnels involved with the care of the women in
labour should be familiar with a logical sequence of
manoeuvers to manage shoulderdystocia.
 No evidence is available that any one standard manoeuver
to deal with shoulderdystocia is superior to another.
However rotating the shoulders to the oblique diameter
and mc roberts manoeuver are easily
performed,logical,often successful , and associated with
minimal fetal trauma.

 Strong downward traction on the fetal head and neck

should be avoided as it is associated with high rate of
brachial plexus injury.
For patience hearing