SHOULDER DYSTOCIA

Risk Factors
1. Fetal macrosomia
2. Maternal DM
3. Others:
- Antepartum: Obesity, Multiparity,
Post-term gestations, Short
stature, Previous hx of
macrosomia, Previous hx of
shoulder dystocia
- Intrapartum: Labor induction,
epidural analgesia, Prolonged
labor, Operative vaginal delivery

Def: Difficult
delivery of the
shoulder.
Arrest of normal
labor after the
delivery of the head
by the impaction of
anterior shoulder
against symphysis
pubis.
Posterior shoulder
may also be
obstructed by
sacral promontory.
Complications
Fetal risks
- Asphyxia
- Birth trauma: Brachial
plexus injuries (Erbs &
Klumpkes), Frx humerus &
clavicle
- Death

Maternal risks
Genital tract
trauma
risk of PPH
Uterine rupture

Clinical Manifestations
Fetal shoulder fails to deliver
after delivery of fetal head
despite routine maneuvers.
Impaction of fetal shoulder
behind pubic symphysis.
Turtle sign: Retraction of
fetal head into perineum
after its delivery and before
the shoulders can be
delivered.

Pregnancies at Risk
Cannot accurately predict (50%
without risk factors)
ACOG recommends CS for EFW 5kg in
nonDM mothers and 4.5kg in DM
mothers.

HELPER
H: Call for Help.
E: Evaluate for Episiotomy
Midline episiotomy.
F(x): Facilitates delivery of posterior
shoulder.
L: Legs @ McRoberts Maneuvre
Hyperflexion, abduction & external rotation of maternal legs.
F(x): Straightens maternal lordosis, remove sacral promontory as
obstr, open pelvis to max dimension, pelvic inlet into plane
perpendicular to max expulsive force.
P: Suprapubic Pressure @ Mazzanti Technique
Direct suprapubic pressure against fetal anterior
shoulder to dislodge from under symphysis pubis.
E: Enter @ Rubin & Wood-Corkscrew Maneuvres
Rubin: Digital pressure to the posterior aspect of anterior shoulder, pushing towards
fetal chest.
Woods: Digital pressure applied to anterior aspect of posterior shoulder, pushing
towards fetal back.
R: Release of posterior shoulder @ Jacquemier Maneuvre
Hand inserted into vagina, and the posterior arm is grasped and pulled
resulting delivery in posterior shoulder & displacement of anterior
shoulder.
Gaskin All-Fours
Put patient on all fours (knee-chest position) and repeat
maneuvers.
Last Resorts:
Zavanelli Maneuvre: Replace head back into pelvis &
deliver CS.
Deliberate fracture of clavicle.
Symphysiotomy