SHOULDER

DYSTOCIA
DR AMTUL MATEEN
POST GRADUATE RESIDENT MTH
 DEFINITION
Vaginal cephalic delivery
that requires additional
obstetric manoeuvers to
deliver the fetus after the
head has delivered and
gentle traction has failed.
An objective diagnosis of
prolongation of head-to-
body delivery time > 60
seconds has also been
proposed.
INCIDENCE

 SHOULDER DYSTOCIA:
0.58 & O.7% ( RCOG )
 MATERNAL MORBIDITY  NEONATAL MORBIDITY &
MORTALITY
 PPH ( 11%)  BPI ( 2.3-16%)
 THIRD & FOURTH DEGREE  FRACTURES OF
PERINEAL TEARS (3.8) HUMERUS
 VAGINAL LACERATIONS  CLAVICLE
 CERVICAL TEARS  PNEUMOTHORACES
 BLADDER RUPTURE  HYPOXIC BRAIN
 UTERINE RUPTURE
DAMAGE
 SYMPHYSEAL SEPERATION
 SACROILIAC JOINT
DISLOCATION
 LATERAL FEMORAL
CUTANEOUS NEUROPATHY
FACTORS ASSOCIATED

PRE-LABOUR INTRAPARTUM
 PREVIOUS SHOULLDER
 Prolonged 1st stage of labour
DYSTOCIA  Secondary arrest
 MACROSOMIA > 4.5 KG  Prolonged 2nd stage of
 DIABETES MELLITUS labouroxytocin augmentation
 MATERNAL BMI > 30
 Assisted vaginal delivery
KG/M2
 Induction of labour
PREDICTION
 CLINICIANS SHOULD BE AWARE OF EXISTING RISK FACTORS IN
LABORING WOMEN & MUST ALWAYS BE ALERT TO THE
POSSIBILITY OF SHOULDER DYSTOCIA.
 RISK ASSESSMENTS FOR THE PREDICTION OF SHOULDER
DYSTOCIA ARE INSUFFICIENTLY PREDICTIVE TO ALLOW
PREVENTION OF LARGE MAJORITY OF CASES
 Low positive predictive value
 Conventional risk factors predicted only 16% of
shoulder dystocia that resulted in infant morbidity
 There is a relationship b/w fetal size & shoulder
dystocia
 It is not a good predictor
 Fetal size estimation is difficult
 3rd trimester scan has 10% margin of error
 Sensitivity of 60% for macrosomia> 4500grams
 Majority infants weighing > 4.5 kg will not develop
 48% of births complicated by shoulder dystocia
occur in infants who weigh <4 kg
PREVENTION
 Induction of labour at term can reduce the incidence of shoulder
dystocia in women with gestational diabetes
 Elective caesarean section should be considered to reduce the
potential morbidity for pregnancies complicated by pre-existing or
gestational diabetes mellitus, regardless of treatment, with an
estimated fetal weight >4.5 kg.
 Infants of diabetic mothers have a 2 -4 fold increased risk of
shoulder dystocia compared with infants of same birth weight born
to non-diabetic mothers.
PATHOPHYSIOLOGY
 ANTEROPOSTERIOR DIAMETER OF PELVIC
INLET IS NARROWER THAN OBLIQUE OR
TRANSVERSE DIAMETER.
 SHOULDER DYSTOCIA OCCURS WHEN THE
DIAMETER OF THE MATERNAL PELVIS
THROUGH WHICH FETAL SHOULDERS
ATTEMPT TO PASS IS LESS THAn the
bisacromial diameter of the fetus, commonly when
the fetal shoulders do not rotate to the wider oblique
pelvic diameter.
 Bisacromial diameter : distance between outermost
parts of the fetal shoulders
RECOGNITION OF SHOULDER
DYSTOCIA
 DIFFICULTY WITH DELIVERY OF FACE AND CHIN
 HEADREMAINING TIGHTLY APPLIED TO VULVA
OR EVEN RETRACTING “TURTLE SIGN” or “CHIN
RETRACTION
 FAILURE OF RESTITUITION OF FETAL HEAD
 FAILURE OF SHOULDERS TO DESCEND
 MANAGEMENT
 Call for help
 Problem should be clearly
stated that
 “This Is Shoulder
Dystocia” to the arriving
team.
 FUNDAL PRESSURE
SHOULD NOT BE USED
RELIEF
 McRoberts’
Manoeuvre
 success rate 90%
 Women should be laid
flat
 With one assistant on
either side legs should be
hyperflexed against her
abdomen
1. It straightens
lumbosacral angle
2. Rotates the maternal
pelvis toward maternal
head & increases
relative antero-posterior
diameter of pelvis inlet.
 Suprapubic pressure
Applied superior to
maternal symphysis in
downward & lateral
direction from side of
fetal back
1.To reduces fetal
bisacromial diameter.
2.To rotate the fetal
shoulders into wider oblique
angle of maternal pelvis
Consider EPISIOTOMY if
it will make internal
manoeuvers easier.
IT IS NOT NECESSARY IN
ALL CASES
INTERNAL MANOEUVERS
Delivery Of Posterior Arm
 Reduce diameter of fetal shoulder by
width of the arm
 Whole hand should be entered
posteriorly into sacral hollow , fetal
wrist should be grasped and posterior
arm should be gently withdrawn from
the vagina in a straight line .
 Associated with humeral fracture 2%
and 12% .
INTERNAL ROTATIONAL
MANOUVERS
ROTATION CAN BE EASILY ACHIEVED
BY PRESSING ON THE ANTERIOR OR
POSTERIOR ASPECT OF THE POSTERIOR
SHOULDER .
IF PRESSURE ON POSTERIOR
SHOULDER IS UNSUCCESSFUL, AN
ATTEMPT SHOULD BE MADE TO APPLY
PRESSURE ON POSTERIOR ASPECT OF
ANTERIOR SHOULDER TO ROTATE
SHOULDERS INTO OBLIQUE DIAMETER.
ASSOCIATED WITH REDUCTIONS IN
BOTH BPI & HUMERAL FRACTURES
THE ALL FOURS
 It has 83% success rate in one
case series.
 It may dislodge the anterior
shoulder and facilitates access
to the posterior shoulder to
enable internal manoeuvers to
be performed.
 Gentle traction should be
applied to fetal head to
determine if the shoulders have
been released.
THIRD LINE MANOEUVERS

 Cleidotomy
 Surgical division or bending with fingers
 Symphysiotomy
 Zavanelli manoeuvre
 Appropriate for rare bilateral shoulder dystocia
 Vaginal replacement of head & delivery by caesarean section
documentation
documentation
REFERENCES
GREEN-TOP GUIDELINES NO. 42 2ND
EDITION 2012
HIGH RISK PREGNANCY
DEWHURTS
ANY
QUESTIONS