Topic 42: Shoulder Dystocia

Shoulder dystocia: when the fetal head has delivered but the shoulders fail to deliver spontaneously or with
the normal amount of downward traction.

- The head recoils against the mother’s perineum to form the so-called ‘turtle sign’.
- If delivery is delayed the baby may become asphyxiated and, unless care is exercised when
assisting the birth, may suffer brachial plexus palsy or limb fractures from over-vigorous
manipulations.
- Shoulder dystocia is associated with the birth of macrosomic infants (> 4500 g) especially if the
mother has diabetes.
- Other predisposing factors are prolonged second stage of labour and assisted vaginal
delivery.
- Unfortunately, shoulder dystocia is unpredictable; only a minority of macrosomic infants will
experience shoulder dystocia and the majority of cases will occur in normal labours with infants
weighing less than 4000 g.
- For this reason, all birth attendants should be skilled in the recognition and the specific steps in the
management of this potentially serious emergency.
- Normally, delivery of the anterior shoulder is achieved with gentle downward traction and
then followed by upward traction to deliver the posterior shoulder.
- If this is not successful, the recommended first-line treatment for shoulder dystocia is
McRobert’s manoeuvre.
- The woman is placed in the recumbent position with the hips slightly abducted and
acutely flexed with the knees bent up towards the chest.
- At the same time, an assistant applies directed suprapubic pressure to help dislodge
the anterior shoulder and for it to be in the oblique diameter of the pelvic inlet.
- A generous episiotomy is also performed.
- McRobert’s manoeuvre is successful in the majority of cases of shoulder dystocia.
- Other more complex manoeuvres are described such as rotation of the fetal shoulders to one or
other oblique pelvic diameter, manual delivery of the posterior arm and Wood’s ‘screw’ manoeuvre.

McRobert’s manoeuvre
- It involves hyperflexing the mother's legs tightly to her abdomen.
- It is effective due to the increased mobility at the sacroiliac joint during pregnancy, allowing
rotation of the pelvis and facilitating the release of the fetal shoulder.
- If this manoeuvre does not succeed, an assistant applies pressure on the lower abdomen
(suprapubic pressure). current guidelines strongly recommend never pulling on the infants head,
as this could lead to brachial plexus injury. Instead, support while keeping the neck straight is
indicated.
- The technique is effective in about 42% of cases