SHOULDER DYSTOCIA

NCM 109 RLE

• Shoulder dystocia is the impaction of the anterior shoulder
against the symphysis pubis after the head has been delivered.
• Shoulder dystocia is a difficulty in the delivery of the shoulder
after the head is born.
• Macrosomia can lead to shoulder dystocia.
• Shoulder dystocia occurs when either the anterior or the posterior
(rare) fetal shoulder impacts the maternal symphysis or on the
sacral promontory respectively.
• Risk factors
• D = Maternal Diabetes
• O = Maternal Obesity/Fetal Obesity
(Macrosomia)
• P = Post-term pregnancy
• A = Anencephaly
Diagnosis
• Shoulder dystocia is
diagnosed if there is a delay
of 1 min in delivery of
shoulder after delivery of the
head.
• Turtle sign: Sudden recoil of
fetal head back towards the
mother’s perineum after it
emerges from the vagina.
 Complications
• Fetal:
• Asphyxia • Maternal:
• Brachial plexus injury (plexopathy) • PPH (11%)
due to stretch
• Humerus fracture • Cervical laceration,
• The clavicle or sternomastoid • Vaginal tear, perineal tear
hematoma during delivery. (3rd and 4th degree)
• Perinatal morbidity and mortality • Rupture of uterus, bladder
are high
• Sacroiliac joint dislocation
• Morbidity.
 Shoulder Dystocia Drill: 1st line maneuvers:

•Call for help

•Give episiotomy
•Avoid fundal pressure
•Give suprapubic pressure-
only one assistant needed
for this step.
 Mnemonic “HELPERR” as a guide for treating shoulder
dystocia:

• “H” stands for help    

• “E” stands for evaluating for the episiotomy.
• “L” stands for legs(pull your legs toward your stomach
McRoberts maneuver)
• “P” stands for suprapubic pressure
• “E” stands for entering maneuvers(internal rotation of baby’s
shoulders)
• “R” stands for remove the posterior arm from the birth canal.
• “R” stands for roll the patient. 
 McRoberts maneuver:
• Abduct the maternal thighs and
sharply hyperflex them onto her
abdomen.
• This straightens the lumbosacral
angle, rotates the maternal pelvis
upward and increases the
anterior-posterior diameter of the
pelvis.
• Suprapubic pressure may be used
together.
• Involves Lateral cutaneous nerve
of the thigh.
 Wood’s / Woodscrew maneuver:
• Under GA
• The posterior shoulder is rotated to an anterior position (180°) by a corkscrew
movement by inserting two fingers in the posterior vagina.
• Simultaneous suprapubic pressure is applied.
• This helps easy entry of the bisacromial diameter into the pelvic inlet.
Jacquemier’s maneuver (also called Barnum’s maneuver)
Extraction of the posterior arm:

• The operator’s hand is introduced into the vagina along the fetal
posterior humerus in the sacral hollow.
• The arm is then swept across the chest and thereafter delivered by
gentle traction.
• This procedure may cause either fracture clavicle or humerus or
both.
If all procedures fail…….
• Symphysiotomy – cutting the symphysis pubis to allow
delivery of the anterior shoulder.
• Clavicular fracture (@cleidotomy) – allows further
adduction of the fetal shoulder, reducing the diameter of
the shoulders, thus allowing delivery
• Zavanelli maneuvre – push the baby’s head back into
the uterus and proceed with emergency caesarean