SHOULDER

DYSTOCIA
By
Dr.Lubna Gulnaz
MD Obgyn
SHOULDER DYSTOCIA
 Definition
Defined as impaction of anterior
shoulder of fetus against the
maternal symphysis pubis or (less
commonly) the posterior shoulder
behind the sacral promontory
after delivery of fetal head.
 Incidence
 0.5% in 11,000 deliveries

Birth weight Incidence

3-3.5kg 0.3%
3.5-4kg 1.0%
4.0-4.5kg 5.4%
>5kg 19%
 AIM….
 To recognize risk factors

 Timely management to reduce both maternal

and fetal mortality and morbidity.

 Correct application of needful maneuvers.

 RISK FACTORS
MATERNAL FETAL
• Obesity
• Gest.Diabetes  Macrosomia
• Previous h\o Shoulder
 Large for gestational age.
• dystocia
• Multiparity (A baby may be LGA without
• Post term pregnancy being macrosomic)
• Short stature
• Abn.pelvic anatomy
 Pathophysiology
 A “mismatch” between fetal size and maternal
pelvic capacity
 Positional variations – vertical rather than
oblique orientation of shoulders
 Increased diameter of shoulder girdle
 Subcutaneous fat deposition may be increased in
infant of diabetic mother – especially with sub-
optimal glucose control
 Signs Helping you to diagnose

• Turtle sign
• Unable to deliver anterior shoulder even after
gentle traction.
turtle sign
 Management..

HELPERR mnemonic- a clinical tool

that provides a structured framework for
clinician to deal with shoulder dystocia.
 Objective
 To reduce time consumed from delivery of head until delivery
of body of fetus for survival of the fetus
TO BE REMEMBERED
Shoulder dystocia is never predicted priorly.
None of the maneuver is superior to another to release the impacted shoulder
Each maneuver should take place from 30-60 second, baby should be
delivered by max 5-6 min.

EPISIOTOMY is given to provide additional space for manipulation not for

delivery of impacted shoulder..
Management contd….
 Clinical Management
 Step One: Recognize the presence of a
shoulder dystocia
 Step Two: Be sure enough help is present
 Nursing
 Obstetrics
 Pediatrics
 Anesthesiology
 Clinical Management
 Step Three: Apply primary maneuvers
 Mc Roberts maneuver
 Oblique suprapubic pressure
 Step Four: Apply secondary maneuvers; no
prescribed order
 Rubin; Woods screw; Reverse woods screw; All-
fours; Clavicular fracture
 Step Three – Primary Maneuvers
 McRoberts maneuver
 Patient positioned with hips at edge of the broken-
down birthing bed
 Both hips are sharply flexed with knees remaining
flexed (“knees to shoulders”)
McRoberts Maneuver
Contd……
 McRoberts Maneuver
 This maneuver assists delivery by:
 Straightening maternal lumbar lordosis
 Rotates symphysis superiorly and anteriorly
 Improving angle between pelvic inlet and direction
of maximal expulsive force
 Elevates anterior shoulder allowing posterior
shoulder to descend
 Woods screw maneuver
 Apply pressure on the clavicle to effect rotation of the
shoulders out of the vertical orientation
 As fetus rotates, anterior shoulder should pass under
symphysis
 May be a good choice for a right-handed operator
when the fetal occiput is oriented to the maternal
right
Woods screw maneuver
 Rubin’s maneuver
 Apply pressure to the fetal scapula to effect
rotation of the shoulders out of the vertical
orientation
 As fetus rotates, anterior shoulder should pass
under symphysis
 May be a good first choice for a right-handed
operator when the fetal occiput is directed to
the maternal left
 Delivery of Posterior Arm
 The operator inserts a hand into the vagina and
locates the posterior arm.
 The operator applies pressure in the
antecubital fossa to flex the elbow across the
chest
 The operator grasps the forearm or hand and
pulls it out of the vagina
 Delivery of Posterior Arm
 The anterior shoulder should pass under the
symphysis
 Rotation maneuvers (Woods or Rubin’s) can
be applied if needed
 This maneuver will tend to be more difficult
with one’s non-dominant hand
Delivery of Posterior Arm
 Delivery of Posterior Arm
 Potential complications
 Fracture of humerus
 Fracture of clavicle
 Gaskin All Fours Maneuver
 Attributed to midwife Ina May Gaskin
 An option for a patient without anesthesia
 Traction is applied in the opposite direction
(still toward the floor, but now directed
towards delivery of the posterior shoulder
first)
Still not out?!
What now???
 Step Six – Final Steps
 Zavanelli maneuver (cephalic replacement)
 Rotate head back to OA (“reverse restitution”)
 Flex neck
 Upward pressure
 Cesarean section
 Step Six – Final Steps
 Symphysiotomy
 Not commonly done when cesarean is available
 Insert Foley catheter
 Use vaginal hand to laterally displace urethra to avoid

injury
 Incise symphysis through mons pubis
 Do not:
 Panic
 Apply any more lateral traction than would be applied
in an uncomplicated delivery
 Apply fundal pressure – may worsen the shoulder
impaction or even rupture the uterus
 Cut a nuchal cord until after the shoulders are
released
 Do:
 Remain calm
 Communicate well
 Call for help
 Document clearly and legibly
 Send cord gases
 Review with the family exactly what happened and
answer questions
 Follow the baby’s course in the nursery
 Notify Risk Management
 Complications
Maternal
Hemorrhage- 11%
Soft tissue injury-4%
Anal sphincter injury
Rectovaginal fistula
Symphyseal diathesis
Rupture Uterus.
 Complications contd….
FETAL
 Brachial plexus injury(transient,permanent)

Or ERB’S palsy4-15%
 Fracture of clavicle.

 Fracture of humerus.

 Fetal hypoxia.

 Fetal death.
 IMPORTANT FACTS
 Occurs with equal frequency in both primipara
and multigravida.
 Recurrence rate 14%
 Perinatal mortality ranging from
21\1000.morbidity 16-48%
 Mc Robets maneuver with suprapubic pressure
itself help >50% in shoulder dystocia.
 Take home message

 Early identification of risk factors and

attaining appropriate means of delivery
 Call for seniors help.
 Always a team work.
 Pre inform pediatrician.
 References
 www.medescape.com
 Obs –gyn Emergency by Danyl jamison Macon
county.
 www.aafp.org
 www.lifepassager.net
 ALSO
 Willams obstetrics.
WE ALL THANK U