SHOULDER DYSTOCIA

DEFINITIONS

• Obstetric emergency
• vaginal cephalic delivery that requires additional
obstetric maneuvers to deliver the fetus after the
head has delivered and gentle traction has failed
• occurs when either the anterior, or less commonly
the posterior fetal shoulder impacts on the
maternal symphysis, or sacral promontory,
respectively

Source : RCOG Guidelines

DEFINITIONS

• Impaction of fetal shoulders at the pelvic outlet

after the delivery of the head

Source: Handbook of Obstetrics & Gynaecologic Emergencies

• Difficulty in delivery of the fetal shoulders

Source: Obstetrics by Ten Teachers

MECHANISM OF LABOUR
Process of delivery during labor normally passes
through these steps:
Engagement  Descend  Flexion  Internal rotation 
Extension  Restitution  External rotation  Delivery of the
body

In shoulder dystocia:
Engagement  Descend  Flexion  Internal rotation 
Extension  Restitution  External rotation  /// /// ///
/// /// ///  Delivery of the body
Unilateral Shoulder
Dystocia
Bilateral shoulder
dystocia
RISK FACTORS – Pre-labour

• Previous shoulder dystocia

• Induction of labour
• Infants of diabetic mothers
• Fetal macrosomia >4.5kg
- excessive weight gain during pregnancy
- maternal obesity (BMI>30)
- asymmetric accelerated fetal growth in non-diabetic
patients
- post-term pregnancy
- parity
RISK FACTORS – Intrapartum

• Prolonged first stage of labour

• Secondary arrest
• Prolonged second stage of labour
• Oxytocin augmentation
• Assisted vaginal delivery
 PREVENTION

The risk factor assessment and progress of labour may help in

prediction of it but they are insufficient.

But trials include:

A. Management of suspected fetal macrosomia

B. History of previous shoulder dystocia and its sequelae

C.Partograph may signal you the delay of the stages and any
fetal distress
 Management of
suspected fetal macrosomia
• Early induction of labour
- Doesn’t prevent SD in non-diabetic woman with
suspected macrosomic fetus
- Reduce incidence of SD at term for GDM
mothers
• Elective LSCS
- Should be considered if pregnancies complicated
by pre-existing or gestational DM, regardless of
treatment, with an estimated fetal weight of
greater than 4.5 kg.
History

Approach
Examination

Investigation:
early

Monitoring
and
Partograph

Delivery of
the head
of the
baby

Delivery of
shoulders +
Body

After delivery
 Preparation for labour

All birth attendants should be aware of the

methods for diagnosing shoulder dystocia
and the techniques required to facilitate delivery.

Birth attendants should routinely look for the signs of

shoulder dystocia.

Timely management of shoulder dystocia requires

prompt recognition.
 DIAGNOSIS

• Difficulty with delivery of the face and chin

• The head remaining tightly applied to the vulva or
even retracting (turtle-neck sign)
• Failure of restitution of the fetal head
• Failure of the shoulders to descend
Turtle-neck
sign
Fetal head emerges and
retracts against the
perineum
Routine traction in an axial direction can be used to
diagnose shoulder dystocia but any other traction
should be avoided.
Routine traction is defined as ‘that traction required
for delivery of the shoulders in a normal vaginal
delivery where there is no difficulty with the
shoulders’.
Axial traction is traction in line with the fetal spine
i.e. without lateral deviation.
Management

First-line
Maneuvers

Second-line

Maneuvers
 Call for Help, initiate RED ALERT!

• State clearly
• Experienced obstetrician, midwife, nurses,
neonatologist, anesthetist
• Secure IV line
• Lithotomy position, legs in stirrup with buttocks at edge
of bed
• Empty/catheterise the bladder
Time window for brain hypoxia is 5 minutes.
* Fundal pressure should not be used.
* Encourage the mother not to push.
Episiotomy

• To create more space for greater access to the

pelvis
• An episiotomy is not always necessary.
Legs: McRoberts’ Maneuver
External Pressure - suprapubic pressure
Enter pelvis: rotational maneuvers

Rubin II +
Woodscrew’
s Maneuver

Reverse
Woodscrew’
s Maneuver
Remove the posterior arm
Roll the patient to her hands & knees

Gaskin maneuver
Third-line
maneuvers
* The baby most likely in hypoxic-acidotic state…

 Cleidotomy

 Zavanelli maneuver (mostly for bilateral dystocia)

Symphysiotomy

Future: Posterior axillary sling

Cleidotomy
• Anterior clavicle is pressed against the ramis of the
pubis.

• Avoid puncturing the lung by angling the fracture

anteriorly.

• Theoretically, a fracture of the clavicle is less

serious than a brachial nerve injury and often heals
rapidly.
 Zavanelli maneuver

Consists of cephalic replacement

+ caesarean delivery.
• Relax uterus with terbutaline
• Rotate head back to OA
(“reverse restitution”)
• Flex neck
• Upward pressure
• To Operation Theatre
Symphysiotomy

• Insert Foley catheter

• Use vaginal hand to
laterally displace
urethra to avoid
injury
• Incise symphysis
through mons pubis
AFTER DELIVERY
MATERNAL COMPLICATIONS

• Postpartum hemorrhage – 11%

• Vaginal lacerations

• Cervical lacerations

• Third and fourth degree tears – 3.8%

• Puerperal infection
FETAL COMPLICATIONS

• Brachial plexus injury

• Fetal fractures - humerus or
clavicle
• Erb’s palsy
• Perinatal asphyxia
• HIE
• Neonatal death
Brachial Plexus Injury
• Most cases resolve
without permanent
disability
• Larger infants at higher
risk
• Due to excess traction,
maternal propulsive
force
• Damage to the
posterior shoulder
plexus is unlikely
due
to healthcare
professional
Future pregnancy

• Mode of delivery – LSCS or vaginal delivery

• Important to discuss with patient and her husband
THANK
YOU