Obstructed labor and shoulder dystocia for undergraduate
Obstructed laborObstructed labor
►When there is poor or no progress ofWhen there is poor or no progress of
labour in spite of good uterine contraction.labour in spite of good uterine contraction.
►Incidence :Incidence :- 1 -2% of referral cases in- 1 -2% of referral cases in
developing country.developing country.
Maternal causes (fault in passage)Maternal causes (fault in passage)
1.1. Contracted pelvisContracted pelvis
2.2. Pelvic tumor:- fibroid, ovarian tumorPelvic tumor:- fibroid, ovarian tumor
3.3. Tumor of rectum, bladder or pelvicTumor of rectum, bladder or pelvic
4.4. Abnormality in uterus & vagina:-stenosisAbnormality in uterus & vagina:-stenosis
in Cx. & vagina, contraction ring inin Cx. & vagina, contraction ring in
uterus, vaginal septum, rigid perineum.uterus, vaginal septum, rigid perineum.
►Partograph will recognizePartograph will recognize
impending obstruction earlyimpending obstruction early
►history of-prolonged labour and -the labour painhistory of-prolonged labour and -the labour pain
become severe and frequent and -bearing down.become severe and frequent and -bearing down.
General examination:-General examination:-
Features of maternal distress i.e.Features of maternal distress i.e.
Exhaustion & keto acidosisExhaustion & keto acidosis
Tachycardia >100/mTachycardia >100/m
Raise temperatureRaise temperature
Scanty urineScanty urine
Abdominal examinationAbdominal examination
-The retraction ring (bandl’s ring) is seen and-The retraction ring (bandl’s ring) is seen and
felt between the tonically contracted upperfelt between the tonically contracted upper
segment of the uterus and the distended ,segment of the uterus and the distended ,
tender and stretched lower segment.tender and stretched lower segment.
- Distended urinary bladder.Distended urinary bladder.
- FHS shows evidence of fetal distress orFHS shows evidence of fetal distress or
even absent.even absent.
Vaginal examination:-Vaginal examination:-
- The vulva usually swollen and edematous.The vulva usually swollen and edematous.
- The vaginal is dry, hot ,balloned.The vaginal is dry, hot ,balloned.
- The cervix is almost fully dilated or hangingThe cervix is almost fully dilated or hanging
- The presenting part is extremely moulded andThe presenting part is extremely moulded and
jammed in the pelvis.jammed in the pelvis.
- With large caput formation.With large caput formation.
- Proper assessment of pregnant womanProper assessment of pregnant woman
during ANC.during ANC.
- Proper assessment in early labour to detectProper assessment in early labour to detect
the cause if any.the cause if any.
- Partograph have to strictly follow.Partograph have to strictly follow.
Immediate managementImmediate management
1.1. Correct maternal dehydrationCorrect maternal dehydration
2.2. prevent contraction by tocolytic drugsprevent contraction by tocolytic drugs
3.3. Blood sample for grouping and crossBlood sample for grouping and cross
B. General management :-B. General management :-
1.1. Assessment of mother general condition.Assessment of mother general condition.
2.2. Broad spectrum antibiotics.Broad spectrum antibiotics.
4.4. Sodium bicarbonate infusion to correctSodium bicarbonate infusion to correct
C. Obstetric managementC. Obstetric management
1-1-Vaginal delivery:-Vaginal delivery:-
(Destructive opt.) dead fetus(Destructive opt.) dead fetus
-if head is low and vaginal delivery is not risky, forceps-if head is low and vaginal delivery is not risky, forceps
extraction may be done in alive foetus also.extraction may be done in alive foetus also.
2. Caesarean section:-2. Caesarean section:-
-A live fetus-A live fetus
-Over distended lower segment with impending rupture even-Over distended lower segment with impending rupture even
the foetus is dead.the foetus is dead.
Active management of 3Active management of 3rdrd
stage of labor.stage of labor.
CONTROLLED CORD TRACTION
-Rupture of uterus
-intra uterine asphyxia
• impaction of anterior shoulder aboveimpaction of anterior shoulder above
• inability to delivery shoulders by usualinability to delivery shoulders by usual
• 1 to 2 per 1000 deliveries1 to 2 per 1000 deliveries
• 16 per 1000 deliveries of babies >16 per 1000 deliveries of babies >
4000 g4000 g
Failure to deliver fetal shoulder without utilizingFailure to deliver fetal shoulder without utilizing
facilitating maneuversfacilitating maneuvers
Normal DystociaNormal Dystocia
The fetal bisacromial diameterThe fetal bisacromial diameter
normally enters the pelvis at annormally enters the pelvis at an
oblique angle with the posterioroblique angle with the posterior
shoulder ahead of the anteriorshoulder ahead of the anterior
Then Rotation to the anterior-Then Rotation to the anterior-
posterior position at the pelvicposterior position at the pelvic
outlet with external rotation ofoutlet with external rotation of
the fetal head.the fetal head.
In shoulder dystocia there isIn shoulder dystocia there is
– Absence of truncal rotationAbsence of truncal rotation
Fetal shoulders remain A-P or descent simultaneouslyFetal shoulders remain A-P or descent simultaneously
• head recoils against perineum, ‘turtle’ signhead recoils against perineum, ‘turtle’ sign
• spontaneous restitution does not occurspontaneous restitution does not occur
• failure to deliver with expulsive effort andfailure to deliver with expulsive effort and
usual gentle directionusual gentle direction
Prophylactic Cesarean?Prophylactic Cesarean?
Not recommended by ACOGNot recommended by ACOG
– Consider if…Consider if…
>5000g in mother without DM>5000g in mother without DM
>4500g in mother with DM>4500g in mother with DM
• PPullingulling (on the head)(on the head)
• PPushingushing (on the fundus)(on the fundus)
• PPivotingivoting (sharply angulating the(sharply angulating the
head, using the coccyx as a fulcrum)head, using the coccyx as a fulcrum)
Avoid the P’s
Ask for help
Lift - the buttocks
- the legs
Anterior disimpaction of shoulder
- rotate to oblique
- suprapubic pressure
Rotation of the posterior shoulder
- Woods’ manoeuver
Manual removal of posterior arm
Move patient toALL four position
} McRobert’s manoeuver
• get the mother onget the mother on
your sideyour side
• partner, coachpartner, coach
• notify physician backnotify physician back
up or otherup or other
appropriate personnelappropriate personnel
Ask for HELP
LLifting the legs and buttocksifting the legs and buttocks
-McRobert’s Maneuver-McRobert’s Maneuver
• Flexion of thighs on abdomen
• 70% of cases are resolved
with this maneuver alone
Lifting the legs and buttocks -McRobert’s
• suprapubic pressure appliedsuprapubic pressure applied
with heel of clasped hand fromwith heel of clasped hand from
the posterior aspect of thethe posterior aspect of the
anterior shoulder to dislodgeanterior shoulder to dislodge itit
Anterior Disimpaction - 1) Suprapubic Pressure
Adduction of the most accessible
shoulder moves the fetus into an
oblique position and decreases the
Anterior Disimpaction - 2) Rubin Manoeuver
• vaginal approach
RRotate the posterior shoulder - Woods’otate the posterior shoulder - Woods’
Abduct posterior shoulder exerting pressure onAbduct posterior shoulder exerting pressure on
anterior surface of posterior shoulderanterior surface of posterior shoulder
MManual removal of the posterior armanual removal of the posterior arm
grasp the posterior arm and
sweep it across the anterior
chest to deliver
MMove patient to All-Fours Maneuver(Gaskin Maneuver)ove patient to All-Fours Maneuver(Gaskin Maneuver)
Changes pelvic dimensions in a similar way toChanges pelvic dimensions in a similar way to
Mc Roberts maneuverMc Roberts maneuver
Apply downward traction to disimpact theApply downward traction to disimpact the
posterior shoulderposterior shoulder
• May facilitate Wood’s Manoeuver orMay facilitate Wood’s Manoeuver or
allow room for delivery of the posteriorallow room for delivery of the posterior
As a last resortAs a last resort
• clavicular fractureclavicular fracture
• cephalic replacement (Zavenellicephalic replacement (Zavenelli
• be prepared for PPHbe prepared for PPH
• inspect for maternal lacerationsinspect for maternal lacerations
and traumaand trauma
• examine the baby for evidence ofexamine the baby for evidence of
• explain the delivery andexplain the delivery and
• chart what was donechart what was done
• Anticipate and be prepared (most are
• Stay calm, don’t panic, pull, push or pivot
• Remember the “ALARM-E”
Ask for help
Lift - the buttocks
- the legs
- suprapubic pressure(abdominal)
- - rotate to oblique (vaginal)
Rotate the posterior shoulder - Woods’ manoeuver
Manual removal of the posterior arm,OR
Move patient to ALL four position
Episiotomy - consider
} McRobert’s Manoeuver
A 25 year-old healthy woman has a normal laborA 25 year-old healthy woman has a normal labor
and a spontaneous delivery of the fetal head. Onand a spontaneous delivery of the fetal head. On
expulsion of the head, a shoulder dystocia isexpulsion of the head, a shoulder dystocia is
recognized. Before instituting maneuvers the nextrecognized. Before instituting maneuvers the next
step is to:step is to:
– A) Tell the patient not to pushA) Tell the patient not to push
– B) Apply fundal pressureB) Apply fundal pressure
– C) Increase or initiate Oxytocin administrationC) Increase or initiate Oxytocin administration
– D) Cut a large episiotomyD) Cut a large episiotomy
A) Tell the patient not to pushA) Tell the patient not to push
– The training and experience of clinicianThe training and experience of clinician
should dictate sequence of maneuvers thatshould dictate sequence of maneuvers that
will be used; however, initially it is best to dowill be used; however, initially it is best to do
nothing that will further impact the anteriornothing that will further impact the anterior
shoulder above the pubic symphysis. Theshoulder above the pubic symphysis. The
simplest way to avoid further impaction is tosimplest way to avoid further impaction is to
ask the patient to stop pushing.ask the patient to stop pushing.