SHOULDER

DYSTOCIA (Sh.D)
An Evidence Based
Approach
Dr.Mohamed El Sherbiny
MD Obstetrics&Gynecology
Senior Consultant
Damietta General Hospital
Damietta Egypt
 SHOULDER DYSTOCIA
Evidence Based Sources:
•PubMed
•Cochrean library
• ACOG Issues Guidelines
• National Guideline Clearinghouse
 :Definition
Shoulder dystocia (Sh. D) is the
inability to deliver the fetal
shoulders after delivery of the
head, without the aid of
specific maneuvers (ie. other
than gentle downward traction
on the head) .
Spong et al. 1995; Beal et al 1998 ; Bruner 1998
 Definition
Objective definition :

Mean head-to-body
delivery time > 60 seconds
Spong et al. 1995; Beal et al 1998 ; Bruner 1998
 As operative vaginal delivery of
malposition and malpreresntation
has declined, Sh.D has emerged as
one of the more important clinical
and medico-legal complications of
vaginal delivery

Baskett, 2001
 Shoulder
dystocia
will still the
obstetric
nightmare
 PATHOPHYSIOLOGY
Shoulder dystocia results from
a size discrepancy between the
fetal shoulders and the pelvic inlet
when:
2. The bisacromial diameter is large
relative to the biparietal diameter
3. Pelvic prim is flat rather
than gynecoid

.
 Types of Shoulder
Dystocia

1- High Shoulder Dystocia

2-Low Shoulder Dystocia

 High -1 Shoulder Dystocia
• Both shoulders fail to
engage
(Bilateral Sh.D). (Rare)
• More common with mid
-pelvic assisted delivery
• This presentation often
requires a cephalic
replacement.
(The most
difficult)
 Low-2 Shoulder Dystocia

• Failure of
engagement of the
anterior shoulder
(Unilateral Sh.D).
,The commonest:
Usually easily dealt
with by Standard
techniques
 Incidence
Varies according to:
2. Criteria for diagnosis.
3. Prophylactic manoeuvre done

Subjective: 0.6-1.6%
Objective: Much lower
ACOG Bulletin,22, Novamber2000
 Release techniques
Complications of Sh D

1.Maternal
2.Fetal
Maternal Complications (25%)

• Postpartum hemorrhage 11%

• Vaginal laceration 19%
• Perineal tears 2nd&3rd 4%
• Cervical laceration 2%
The largest study (285 cases)
Gherman et al Am J Obstet Gynecol176:656, 1997
FetalRelease
Complications of Sh D
techniques
Fetal Complications of Sh D

Injuries are a common outcome

associated with shoulder
dystocia and may occur despite
use of proper standard obstetric
manoeuvers
ACOG practice 1997 (B: II-2)
Fetal Complications of Sh D
Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported
injuries associated with shoulder
dystocia
ACOG practice 1997 (A: II-2)
Fetal Complications of Sh D

Traction combined with

fundal pressure has been
associated with a high rate
of brachial plexus injuries
and fractures
ACOG practice 1997 (B: II-2)
Fetal Complications of Sh D

Fewer than 10% of

deliveries complicated by
shoulder dystocia will result
in a persistent brachial
plexus injury.
ACOG practice 1997(A: II-2)
 Fetal Complications
Release techniques
Head –shoulder interval > 7min.

Brain injury
(sensitivity & specificity :70 %)
• With hypoxic fetus it is much shorter

Quzounian et al Am J Obstet Gynecol 178;S76,1998

Can shoulder
dystocia be
predicted ?
 RISK FACTORS FOR SHOULDER
DYSTOCIA
PRECONCEPTIONAL:
 Maternal birth weight
 Prior shoulder dystocia 12%
 Prior macrosomia
 Pre-existing diabetes
 Obesity
 Multiparity
 Prior gestational diabetes
 Advanced maternal age
O'Leary &, Leonetti; 1990
 RISK FACTORS FOR SHOULDER
DYSTOCIA

Antenatal:
• Excessive maternal weight gain
• Macrosomia
• G. diabetes
• Short stature
• Post term
O'Leary &, Leonetti; 1990
 RISK FACTORS FOR SHOULDER
DYSTOCIA
Intrapartum:
2. Protracted or arrested active phase
3. Protracted or failure of descent of
head
4. Need for midpelvic assisted delivery

Hopwood,1982 ; Baskett &,Allen, 1995

 RISK FACTORS FOR SHOULDER
DYSTOCIA
Most of the prenatal and antenatal risk
factor are interrelated with fetal
macrosomia. So the main risk factor is:

Fetal
Macrosomia
 Macrosomia
Although macrosomia
is clearly the main risk
,factor
50-60 % of Shoulder
Dystocia are of < 4 Kg !!
Acker et al, Obst. Gynecol 66:762, 1985
Baskett &Allen Obstet Gynecol 86:14, 1995
 Prediction

Most cases of shoulder dystocia

cannot be predicted
because
accurate methods for identifying
which fetuses will experience
ACOG Practice 1997 (B: II-2).
 Macrosomia
Fetal body configuration may be more
important than macrosomia per se

Greater shoulder /head circumference:

• Infant of diabetic mother

• Post term (21% at 42 weeks)
Macrosomia And Shoulder Dystocia
Non Diabetic+
Wight (Kg)
vacuum . Diabetic or
forceps

4 : 4.25 5.2% 8.4% 12.2%

4.25: 4.5 9.1% 12.3% 16.7%

4.5 : 4.75 14.3% 19.9% 27.3%

4.75: 5 21.1% 23.5% 34.8%

Nesbitt et al, Am J Obstet Gynecol 179;476, 1998
 Unfortunately
• The diagnosis of fetal macrosomia is
imprecise.
• For suspected fetal macrosomia, the
accuracy of estimated fetal weight
using ultrasound biometry is no better
than that obtained with clinical
palpation (Leopold's manoeuver).
ACOG Issues Guidelines on Fetal Macrosomia 2000(Level
2000 :A)
Can shoulder
dystocia be
Prevented ?
 Macrosomia
There are 2 controversial
prophylactic measures
1-Prophylactic labor
induction
2-Elective CS
 Induction of Labor
Suspected fetal macrosomia is
not an indication for induction
of labor, because induction
does not improve maternal or
fetal outcomes.
ACOG Issues Guidelines on Fetal Macrosomia 2000(Level B):
.
 Induction of Labor
Labor induction for suspected fetal
macrosomia results in an
increased CS delivery rate
without improving perinatal
outcomes.
Sanchez-Ramos Obstet Gynecol Systemic Review
November 2002:100:997-1002 .
Induction For Gestational Diabetes
There is very little evidence to support
either elective delivery or expectant
management at term.
A single randomized controlled trial
suggest that induction of labor in GDM
treated with insulin reduces the risk of
macrosomia.
Boulvain et al:Cochrane Review,2001. In: The Cochrane
Library, Issue 2 2003. Oxford: Update Software.
 Prevention of Sh. D. :.c.s
Planned cesarean delivery on the basis of
suspected macrosomia in the general
population is not a reasonable strategy
because the number and cost of
additional cesarean deliveries required to
prevent one permanent injury is
excessive
ACOG 1997 (B: II-2).
Furthermore 3% of
brachial plexus injury
are associated with C.S.
 When is CS
recommended in
macrosomia?
ACOG Issues Guidelines on Fetal
Macrosomia 2000
Prophylactic CS may be considered
for suspected fetal macrosomia
with estimated fetal weights of:
g in non diabetic women 5,000 <
g in diabetic women 4,500 <
(Level :C)
.
 ACOG Issues Guidelines on Fetal
Macrosomia 2000

With an estimated fetal weight more

than 4,500 g, with :
• A prolonged second stage of labor
or
• Arrest of descent in the second stage
It is an indication for CS delivery.
Level B
.
MANAGEMENT
(Within5- 7 minutes)

.
 Management
1-Suprapubic pressure
2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy
 ACOG Issues Guidelines
Recommendation 1991
1-Call for help: assistants,
anesthesiologist
2-Initial gentle attempt of
traction.
3-Generous episiotomy.
4-Suprapubic pressure.
 ACOG Issues Guidelines
Recommendation 1991
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
&
Suprapubic pressure
in the direction of the
Foetal face .
 McRoberts manoeuvre: X ray pelvimetry study

No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000
 Mc Roberts manoeuvre
IU pressure by 97% (P<0.0001)
U. contraction amplitude by 25% (P<0. 001)
Applied additional 31 Newtons pushing force

Buhimschi et al Lancet 358:470 ,2001

 ACOG Issues Guidelines
Recommendation 1991
If Mc Roberts failed:
6-Woods manoeuvre:
•The hand is placed
behind the posterior
shoulder of the fetus.
•The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released. .
ACOG Issues Guidelines
Recommendation 1991

7-Delivery of the
posterior arm :
.
By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder

delivery
over the
perineum
 ACOG Issues Guidelines
Recommendation 1991
8-Other techniques
include:
• Intentional fracture of the
clavicles or the humerus
Or
• Zavanelli Maneuver.
.
The Zavanelli Manoeuver

Reversing the
mechanism of
delivery of the vertex
under tocolytic
1. The head first manually rotated to
the occipito anterior
(Pre-restitution) position
2.Flexion of the head, Returning it to
the vagina with upward constant
firm pressure, followed by CS
The Zavanelli Manoeuver
Zavanelli maneuver
• It would usually only be applicable in
those rare cases of bilateral Sh.D.
• It involves an emergency procedure
that is not without risks of its own .
• It has minimal applicability as it
needs
Immediate CS
The Zavanelli Manoeuver
Zavanelli maneuver
In an analysis of 92 cases of shoulder dystocia
managed by Zavanelli Maneuver:
• Success rate : 92 %
• Stillbirth: 7%
• Neonatal death : 9%.
• Brain damage : 11%
Maternal complication:
Rupture uterus ,vaginal rupture ,severe infection,

Sanberg; Obstet Gynecol.;93:312. 1999

 All- Fours Manoeuver
It consists of placing the patient onto
her hands and knees
 All- Four Manoeuver
• It allows rotational movement of the
sacroiliac joints resulting in a l-cm to 2-
cm increase in the sagittal diameter of the
pelvic outlet.
• It disimpact the shoulders, and
allowing it to slide over the sacral
promontory.
•Effective also for bilateral Sh.D.
 All- Fours Manoeuver
In an analysis of 82 cases of shoulder
dystocia managed by all-four manoeuver
:
• Success rate : 83%
• Maternal complications 1.2%
•Neonatal complications : 4.9%,
•Time for complete delivery : 2 to 3 Ms.
Drummond et al. J Reprod Med. ;43:439; 1998.
ACOGRelease
Issues Guidelines
techniques 1997
There is no evidence that any
one maneuver is superior to
another in releasing an
impacted shoulder or
reducing the chance of
injury.
.(B: II-2)
ACOGRelease
Issues Guidelines
techniques 1997
However, the Mc Roberts
maneuver is easily facilitated
and has a high success rate
without an associated
increased risk of injury to the
newborn .(B: II-2)
Bilateral Shoulder Impactions
All- Fours Manoeuver:
Used at all circumstances except if the
patient has received epidural analgesia,
heavy analgesia or anesthesia

Zavanelli Manoeuver:
Used if the patient has received epidural
analgesia or heavy analgesia
with obstetric facilities for emergency CS
 Prophylactic Procedures

When shoulder dystocia is

anticipated , prophylactic
McRobert position is
recommended
 Shoulder Dystocia Drill
Shoulder dystocia drill should be as
important as CPR for the mother
and neonate.
This should be taught and practiced
regularly, by all staff involved
with delivery
Thank You