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Obstetric Emergency – Shoulder Dystocia

- Impaction of anterior shoulder against the maternal symphysis pubis after the fetal head
has been delivered
- Occurs when the bisacromial diameter (breadth of shoulders) exceed diameter of pelvic
inlet
- Head to body time interval >60 secs
Risk factors – 50% of shoulder dystocia have no antecedent factors
Prenatal
- Fetal macrosomia
- GDM
- Post-dates pregnancy
- Maternal obesity
- Short statue
- Abnormal pelvic anatomy
- Advanced maternal age
- Previous large infant
- Prior shoulder dystocia
Intrapartum
- Protracted active phase of first stage of labour
- Prolonged second stage
- Instrumental delivery – vacuum/forceps
Morbidity and mortality
Maternal
- Soft tissue injury
- Third/fourth degree perineal tear
- PPH
Fetal
- Brachial plexus injuries
o Erbs (C5-6)
o Klumpke palsy (C8-T1)
- Fractures – clavicle humerus
- Hypoxia – permanent neurological damage
- Death
*Once fetal head has been delivered, fetal pH will drop by 0.04 per minute

Management
• Anticipate problems through known risk factors
• „Turtle sign“- fetal head retracts against the perineum
• Maneuvers should
– Increase the functional size of the bony pelvis
– Decrease the bisacromial diameter
– Change the relationship of the bisacromial diameter within the bony pelvis
• Each maneuver: 30-60 secs
• Episiotomy
• McRoberts Maneuver
• 40-50% of dystocias deliver
• Suprapubic pressure
– Pressure over anterior shoulder
– „CPR“ style
• Internal maneuvers
– Rubin I+II
– Woods screw
• Delivery of the posterior arm
• Roll patient on all fours (Gaskin maneuver)
• Methods of last resort
• Deliberte clavicle fracture
• Zavanelli maneuver
• Symphysiotomy

RCOG – 2012 – Shoulder Dystocia


 Definition: a vaginal cephalic delivery that requires additional obstetric manoevres to deliver
the fetus after the head has delivered and gentle traction has failed
 Perinatal morbidity and mortality associated with condition
 Maternal morbidity: PPH, third and fourth degree perineal tear
 Fetal complication: Brachial plexus injury

Prediction
- Should be aware of existing risk factors in laboring women and must always be alert to the
possibility of shoulder dystocia
Factors associated with shoulder dystocia
Pre-labour
- Previous shoulder dystocia
- Macrosomia >4.5kg
- Diabetes mellitus
- Maternal BMI >30kg/m2
- Induction of labour
Intrapartum
- Prolonged first stage of labour
- Secondary arrest
- Prolonged second stage labour
- Oxytocin augmentation
- Assisted vaginal delivery

Management of suspected fetal macrosomia


- Induction of labour does not prevent shoulder dystocia in non-diabetic women with a
suspected macrosomic fetus
- Induction of labour at term can reduce the incidence of shoulder dystocia in women with
GDM
- Elective C-section should be considered to reduce potential morbidity for pregnancies
complicated by pre-existing or gestational diabetes, regardless of treatment with an EFW of
greater than 4.5kg
- Either C-section or VD can be appropriate after a previous shoulder dystocia – decision
should be made jointly by the woman and her carers
- What measures shold be taken when shoulder dystocia is anticipated – all birth attendants
should be aware of the methods for diagnosing shoulder dystocia and the techniques
required to facilitate delivery
Diagnosis of shoulder dystocia
- Birth attendants should routinely look for the signs of shoulder dystocia
o Difficulty with delivery of the face and chin
o The head remaining tightly applied to vulva or even retracting (turtle-neck sign)
o Failure of restitution of the fetal head
o Failure of shoulders to descend
- Routine traction in an axial direction can be used to diagnose shoulder dystocia but any
other traction should be avoided
Management
- Systematic management
- Immediately after recognition of shoulder dystocia, additional help should be called
- Problem should be stated clearly as “this is shoulder dystocia” to arriving team
- Fundal pressure should be used
- McRoberts’ manoeuvre – simple, rapid and effective intervention and should be performed
first
- Anteriorly - Suprapubic pressure should be used to improve effectiveness of McRoberts’
manoeuvre
- An episiotomy is not always necessary
- Maternal pushing discouraged – may exacerbate impaction of shoulders
- Mc Roberts’ manoeuvre – flexion and abduction of maternal hips, positioning her thighs on
her abdomen – straightens the lumbosacral angle, rotates pelvis towards head and
increases the relative AP diameter of pelvis
- Woman laid flat and any pillows removed from under her back, legs hyperflexed
- Suprapubic pressure employed with McRoberts to increase success rates
- Internal manoeuvres or “all fours” position should be used if McRoberts and suprapubic
pressure fail
- Gaining access to vagina for internal manoeuvres – gained posteriorly into sacral hollow
- Whole hand should be entered posteriorly to perform internal rotation or delivery of
posterior arm
- Internal rotational – press on anterior or posterior aspect of posterior shoulder and reducing
shoulder diameter by adducting shoulders
- Deliver posterior arm reduces diameter of fetal shoulder by width of the arm
- Fetal wrist grasped and posterior arm gently withdrawn from vagina in a straight line
- Third line manoeuvres should be considered very carefully to avoid unnecessary maternal
morbidity and mortality
- Document head – right or left occipioposterior – document arm affected
- Risk of brachial plexus injury
Maternal complications
- PPH
- Episiotomy
- Perineal trauma

Management of woman and baby after shoulder dystocia


- Birth attendants should be alert to possibility of PPH and severe perineal tears
- Baby should be examined for injury by a neonatal clinician
- An explanation of delivery should be given to parents
- Documentation should be accurate and comprehensive
It is important to record within the birth record the:

- time of delivery of the head and time of delivery of the body


- anterior shoulder at the time of the dystocia 

- manoeuvres performed, their timing and sequence
- maternal perineal and vaginal examination
- estimated blood loss
- staff in attendance and the time they arrived
- general condition of the baby (Apgar score)
- umbilical cord blood acid-base measurements
- neonatal assessment of the baby.104,106
- It is particularly important to document the position of the fetal head at delivery as this
facilitates identification of the anterior and posterior shoulder during the delivery.
McRoberts’ manoeuvre

Suprapubic pressure

Delivery of posterior arm