Shoulder dystocia, Obstetrics and gynecology

1. Shoulder Dystocia
 Incidence: 0.23% to
2.09%
 Impaction of fetal
shoulders in
maternal pelvis
 Head to body
delivery time > 60s

2. Definition
 “…a delivery that requires additional
obstetric maneuvers following failure
of gentle downward traction on the
fetal head to effect delivery of the
shoulders.”
 ACOG, Practice Bulletin 40 (November 2002)

3. Definition
 “Prolonged head-to-body expulsion
time”
 Objectively defined as 60 seconds
 Deliveries with head-to-body interval of
> 60 seconds more commonly have
higher birth weight, shoulder dystocia,
and low 1 minute Apgar scores
 Beall et al 1998; Spong et al 1995

4. Functional Definition
 A delivery in which the shoulders do not
follow the head as usual, but rather are
delayed in delivering or require the use of
ancillary obstetric maneuvers to effect
delivery.
 The anterior shoulder may be impacted
behind the symphysis pubis, or (less
commonly) the posterior shoulder behind
the sacral promontory

5. Dystocia is the consequence of 3 abnormalities
that may exist singly or in combination
1-Abnormalities of the powers
 uterine contractility
 maternal expulsive forces
2-Abnormalities of the passage
 maternal boney pelvis
 the soft tissue of the reproductive tract
3-Abnormalities of the passenger
 presentation
 position
 development of the fetus
 size

6. How to assess these factors?
 Adequate powers  contractions that
-last for 60 sec
-reach 20-30 mmHg of pressure
-occur every 1-2 min
 Hypotonic contractions are responsible for 2/3 of
nulliparous dystocia
 If powers are adequate  check Passage for size &
abnormal shape and check the Passenger for size &
malpresentation

7. Aetiology
1. Large baby/ fetal macrosomia
2. Anencephaly
3. Contracted pelvis
4. Failure of the shoulder to rotate into
the anterior-posterior diameter of the
outlet following delivery of the head.
5. Foetal Ascitis

8. INTRODUCTION
 Definition:
Dystocia is difficult labor or abnormally slow
progression of labor
≥ 4 hrs of < 0.5 cm/ hr dilatation in the 1st stage
≥ 1 hr with no descent in the 2nd stage
 It can occur in 2 forms
A-Primary dysfunctional labour
B-Secondary arrest
 Expressions used to describe dystocia  CPD,
failure to progress (lack of progressive Cx dilatation
or lack of fetal descent)

9. FETAL CONSEQUENCES
 Shoulder dystocia may be associated with significant
fetal morbidity and even mortality. Gherman
 and co-workers (1998) reviewed 285 cases of
shoulder dystocia and found 25 percent were
associated with fetal injuries.
 Transient Erb or Duchenne brachial plexus palsies
were the most common injury, accounting for two
thirds;38 percent had clavicular fractures; and 17
percent sustained humeral fractures. There was one
neonatal death, and four newborns had persistent
brachial plexus injuries.

10. Complications
A. Fetal :-
1.Birth asphyxia
II. Traumatic injury
1.Fractures of Humerus or
clavicle
2.Erb’s palsy
Brachial plexus injuries
a) Short term complication
1. Metabolic acidosis
2.Shock
3.Renal failure
4. CNS depression
5. Seizures
b) Long term complication
1.Mental Retardation
2.Cerebral palsy
3.Seizures disorder
4.Speech defect

11. B. Maternal:-
1. Prolonged labour
2. Obstructed labour
3. Lacerations of the cervix, Vagina & perineum
4. Rupture of Uterus
5. PPH
6. Shock , death

12. Complications of Shoulder Dystocia
 Maternal
◦ Postpartum hemorrhage
◦ Rectovaginal fistula
◦ Symphyseal separation or diathesis, with or without transient
femoral neuropathy
◦ Third- or fourth-degree episiotomy or tear
◦ Uterine rupture
 Fetal
◦ Brachial plexus palsy
◦ Clavicle fracture
◦ Fetal death
◦ Fetal hypoxia, with or without permanent neurologic damage
◦ Fracture of the humerus

13. MATERNAL
CONSEQUENCES
 Postpartum hemorrhage, usually from
uterine atony, but also from vaginal and
cervical
 lacerations, is the major maternal risk

14. Anatomy of the Brachial Plexus
 Nerve roots from C5-C8 and T1
 Merge into three trunks
◦ Superior (C5, C6)
◦ Middle (C7)
◦ Inferior (C8, T1)
 Each splits into anterior and posterior
divisions

15. Anatomy of the Brachial Plexus
 The six divisions regroup into three
cords
◦ Posterior – all 3 posterior trunk divisions
(C5-T1)
◦ Lateral – anterior divisions of upper and
middle trunks (C5-C7)
◦ Medial – continuation of lower trunk (C8,
T1)

16. Anatomy of the Brachial Plexus

18. Brachial Plexus Injuries
 Strain or stretch
 Partial disruption
 Complete avulsion

19. Brachial Plexus Injuries
 Injury primarily to lateral trunk (C5,6,
7) leads to Erb’s palsy – adducted
shoulder, extended elbow, and flexed
wrist (“waiter’s tip”)
 Injury primarily to the medial trunk (C8,
T1) leads to Klumpke’s palsy –
paralyzed hand with good shoulder
and elbow function

20. Maternal Complications
 Post-partum hemorrhage occurs in
11%
 4th degree laceration occurs in 3-4%

21. Diagnosis
•head recoils against perineum, ‘turtle’
sign
•spontaneous restitution does not occur
•failure to deliver with expulsive effort and
usual gentle direction

22. Shoulder Dystocia-The turtle sign
Mother is pushing with each contraction and the baby’s head starts
to come out. However, with each push, the baby’s head comes out
and then retracts back in towards the perineum. You quickly
recognize this as the “turtle sign”

24. HELPERR Mnemonic
 The HELPERR mnemonic is a clinical tool that offers a
structured framework for coping with shoulder dystocia.
 These maneuvers are designed to do one of three things:
◦ Increase the functional size of the bony pelvis through flattening of
the lumbar lordosis and cephalad rotation of the symphysis (i.e.,
the McRoberts maneuver)
◦ Decrease the bisacromial diameter, the breadth of the shoulders, of
the fetus through application of suprapubic pressure.
◦ Change the relationship of the bisacromial diameter within the
bony pelvis through internal rotation maneuvers.
Next Slide

25. H Call for Help:
This refers to activating the pre-arranged protocol or requesting the
appropriate personnel to respond with necessary equipment to the labor
and delivery unit
E Evaluate for episiotomy:
Episiotomy should be considered throughout the management of
shoulder dystocia but is necessary only to make more room if rotation
maneuvers are required. Shoulder dystocia is a bony impaction, so
episiotomy alone will not release the shoulder.
Because most cases of shoulder dystocia can be relieved with the
McRoberts maneuver and suprapubic pressure, many women can be
spared a surgical incision.
L Legs (the McRoberts maneuver):
This procedure involves flexing and abducting the maternal hips,
positioning the maternal thighs up onto the maternal abdomen. This
position flattens the sacral promontory and results in cephalad
rotation of the pubic symphysis. Nurses and family members present
at the delivery can provide assistance for this maneuver.
P Pressure (Suprapubic):
The hand of an assistant should be placed suprapubically over the fetal
anterior shoulder, applying pressure in a cardiopulmonary resuscitation
style with a downward and lateral motion on the posterior aspect of the
fetal shoulder. This maneuver should be attempted while continuing
downward traction.
H
E
L
P
E
R
R

26. E Enter maneuvers (internal rotation):
These maneuvers attempt to manipulate the fetus to rotate the anterior
shoulder into an oblique plane and under the maternal symphysis.
1. Rubin II
At vaginal examination apply pressure as
indicated. If shoulders move into the oblique
diameter, attempt delivery.
2. Rubin II + Woods corkscrew maneuver
If unsuccessful, add the Woods corkscrew
maneuver and continue rotation in the same
direction. Use both hands and apply
pressure as indicated. If shoulders now
move into the oblique, attempt delivery. If
this is unsuccessful, continue rotation 180
degrees and deliver.
3. Reverse Woods corkscrew maneuver
If the last maneuver is unsuccessful, change
to reverse Woods corkscrew maneuver.
Slide fingers down to back of posterior
shoulder and attempt 180-degree rotation in
the opposite direction.
H
E
L
P
E
R
R

27. R Remove the posterior arm:
Removing the posterior arm from the birth
canal also shortens the bisacromial
diameter, allowing the fetus to drop into the
sacral hollow, freeing the impaction.
The elbow then should be flexed and the
forearm delivered in a sweeping motion over
the fetal anterior chest wall.
Grasping and pulling directly on the fetal arm
may fracture the humerus.
R Roll the patient:
The patient rolls from her existing position to the all-fours position.
Often, the shoulder will dislodge during the act of turning, so that this
movement alone may be sufficient to dislodge the impaction.
In addition, once the position change is completed, gravitational forces
may aid in the disimpaction of the fetal shoulders.
H
E
L
P
E
R
R

28. Management
 An experienced obstetrician, should be available
on the labour ward for the second stage of labour
when shoulder dystocia is anticipated.
 However, it is recognized that not all cases can be
anticipated and therefore all birth attendants
should be ready with the techniques required to
facilitate delivery complicated by shoulder
dystocia.
 Timely management of shoulder dystocia requires
prompt recognition.

29.  Immediately after recognition of shoulder
dystocia, extra help should be called.
 In a hospital setting, this should include further
assistance, an obstetrician, a pediatric resuscitation
team and an anesthetist.
 Maternal pushing should be discouraged, as this
may lead to further impaction of the shoulders,
thereby exacerbating the situation.
 The woman should be maneuvered to bring the
buttocks to the edge of the bed.
How should shoulder dystocia be
managed?

30. Episiotomy
 Episiotomy is not necessary for all cases.
 Some obstetrician have advocated that
episiotomy is an essential part of the
management in all cases but it does not affect
the outcome of shoulder dystocia.
 The episiotomy does not decrease the risk of
brachial plexus injury with shoulder dystocia.
 An episiotomy should therefore be considered
but it is not mandatory.

31. McRoberts’ manoeuvre
 The McRoberts’ manoeuvre is the
single most effective intervention,
with reported success rates as high
as 90%.
 It has a low rate of complication and
therefore should be employed first.

32.  The McRoberts’ manoeuvre is flexion and
abduction of the maternal hips, positioning
the maternal thighs on her abdomen.
 It straightens the lumbo-sacral angle,
rotates the maternal pelvis cephalad and
is associated with an increase in uterine
pressure and amplitude of contractions.
McRoberts’ manoeuvre

33. 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
McRoberts manoeuvre: X ray pelvimetry study

34.  Supra-pubic pressure can be employed together
with Mc Roberts’ manoeuvre to improve success
rates.
 External supra-pubic pressure is applied in a
downward and lateral direction to push the posterior
aspect of the anterior shoulder towards the fetal
chest .
 It is advised that this is applied for 30 seconds.
 Supra-pubic pressure reduces the bi-sacromial
diameter and rotates the anterior shoulder into the
oblique pelvic diameter.
 The shoulder is then free to slip underneath the
symphysis pubis with the aid of routine traction.

35. .
Mc Roberts’ manoeuvre +
Supra-pubic pressure

36. Advanced manoeuvres should be used if the
McRoberts’ manoeuvre and suprapubic pressure
fail.
 If these simple measures fail, then there is a
choice to be made between the all-fours-
position and internal manipulation.
 For a slim mobile woman without epidural
anaesthesia and with a single attendant, the all
fours- position is probably the most appropriate.
 For a less mobile woman with epidural
anaesthesia in place and a senior obstetrician
in attendance, Internal rotation manoeuvres
(Woods manoeuvre ) are more appropriate.

37. Deliver posterior arm
(Barnum Maneuver)
grasp the
posterior arm
and
sweep it
across the
anterior
chest to
deliver

38. .
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.

39. Wood's Screw maneuver
First described in the literature in 1943, this procedure
involves the progressive rotation of the posterior shoulder in
corkscrew fashion to release the opposite impacted anterior
shoulder. In its classic description, pressure is applied on the
posterior shoulder's anterior surface. A variation of this -- the
Rubin's maneuver -- involves pushing on the posterior
surface of the posterior shoulder. In addition to the
corkscrew effect, pressure on the posterior shoulder has the
advantage of flexing the shoulders across the chest. This
decreases the distance between the shoulders, thus
decreasing the dimension that must fit out through the
pelvis.

40. 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

41. Advanced manoeuvres should be used if the
McRoberts’ manoeuvre and suprapubic pressure
fail.
 If these simple measures fail, then there is a
choice to be made between the all-fours-
position and internal manipulation.
 For a slim mobile woman without epidural
anaesthesia and with a single attendant, the all
fours- position is probably the most appropriate.
 For a less mobile woman with epidural
anaesthesia in place and a senior obstetrician
in attendance, Internal rotation manoeuvres
(Woods manoeuvre ) are more appropriate.

42. By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder
delivery
over the
perineum
Delivery of the posterior arm.

43. What measures should be taken if first- and
second-line manoeuvres fail?
 Third-line manoeuvres require careful
consideration to avoid unnecessary
maternal morbidity and mortality.
 It is difficult to recommend a time limit for
the management of shoulder dystocia, as
there are no conclusive data available.

44. What measures should be taken if first- and
second-line manoeuvres fail?
 Third-line manoeuvres require careful
consideration to avoid unnecessary
maternal morbidity and mortality.
 It is difficult to recommend a time limit for
the management of shoulder dystocia, as
there are no conclusive data available.

45. Zavanelli manoeuvre
 Cephalic replacement of the head, and delivery by caesarean section has
been described but success rates vary.
 Zavanelli manoeuvre may be most appropriate for rare bilateral shoulder
dystocia, where both the shoulders impact on the pelvic inlet, anteriorly
above the pubic symphysis and posteriorly on the sacral promontory.

46.  The maternal safety of this procedure is
unknown, however, and this should be
borne in mind, knowing that a high
proportion of fetuses have irreversible
hypoxia-acidosis by this stage.
Zavanelli manoeuvre

47. fracture the anterior clavicle by pushing
it against the pubic ramus or using a
closed pair of scissors
Clavicular Fracture
The anterior clavicle is pressed against the ramis of the pubis.
Care should be taken to avoid puncturing the lung by angling the
fracture anteriorly.
Theoretically, a fracture of the clavicle is less serious than a
brachial nerve injury and often heals rapidly.

48. Symphysiotomy
 There is a high incidence of serious maternal
morbidity and poor neonatal outcome.
 After delivery, the birth attendants should be
alert to the possibility of postpartum
haemorrhage and third- and fourth-degree
perineal tears.
Vesicovaginal Fistula
Osteitis Pubis
Retropubic Abscess
Stress Incontinence
Long Term Walking Disability / Pain
Complications Associated with Symphysiotomy

51. Shoulder Dystocia
AOCG Guidelines
1) Call for help - assistants, anesthesiology,
pediatrician. Initiate gentle traction of the fetal
head at this time. Drain the bladder if distended.
2) Generous episiotomy.
3) Suprapubic pressure with normal downward
traction on fetal head.
4) McRoberts maneuver.
Then, if these maneuvers fail,
5) Wood's screw maneuver.
6) Attempt delivery of posterior arm.

52. SHOULDER DYSTOCIA
 Summary
1.cannot be predicted or prevented-no accurate
methods
2.ultrasonic measurements to estimate macrosomia
have limited accuracy
3.planned c/sec due to macrosomia
-not reasonable strategy
4.planned c/sec may be reasonable
-nondiabetes (>5,000g)
-diabetes (4,5000g)

53. SHOULDER DYSTOCIA
 Management
:shoulder dystocia-cannot be predicted
:well versed in the management principles
:great importance to survival
-reduction in the interval of time from delivery
of the head to body
:gentle traction, assisted by maternal expulsive effort
next, large episiotomy, analgesia, clear the infant’s
mouth and nose

54. SHOULDER DYSTOCIA
1.Moderate suprapubic pressure
-by an assistant while downward traction
2.McRoverts maneuver
-flexing the legs upon the abdomen
-not increase pelvic diameter
straightening of the sacrum
symphysis pubis-toward the maternal head
decrease the angle of pelvic inclination

55. SHOULDER DYSTOCIA

56. SHOULDER DYSTOCIA
3.Woods corkscrew maneuver
-rotating the posterior
shoulder 180 degrees
-anterior shoulder could be
released

57. SHOULDER DYSTOCIA
4.Delivery of the posterior
shoulder
-post. arm: across the chest
then delivery
-next, shoulder girdle rotation
into one of the oblique
diameters of the pelvis
delevery of ant. shoulder

58. SHOULDER DYSTOCIA
5.Rubin maneuver
-1st, the fetal shoulder are
rocked from side to side
by applying force to the
abdomen
-if not successful,
push the ant. shoulder toward
the anterior surface of the
chest

59. SHOULDER DYSTOCIA
6.Hibbard (1982)
-press the fetal jaw and neck in the direction of
the maternal rectum
-strong fundal pressure
anterior shoulder delivery
-only fundal pressure, absence of other maneuver
:77% complication
fetal prthoprdic and neurologoc damage

60. SHOULDER DYSTOCIA
7.Zavanelli maneuver
-cephalic replacement into
the pelvis and then c/sec
-return fetal head
flex head
push head back into vagina
-terbutaline: Ut relaxation
-fetal injury
neonatal death
stillbirth, brain damage

61. SHOULDER DYSTOCIA
8. Fracture of the clavicle
-pressing the anterior clavicle against the ramus of
the pubis
-heal rapidly
-not nearly as serious as a brachial nerve injury
9.Cleidotomy
-cutting of the clavicle
-usually used on the a dead fetus

62. SHOULDER DYSTOCIA
10. Symphysiotomy
-maternal morbidity increased
-urinary tract injury

63. SHOULDER DYSTOCIA
 Shoulder dystocia drill
1.call for help
2.generous episiotomy
3.suprapubic pressure
-simple, only one assistant
-while normal downward traction
4.McRoverts maneuver
-two assistants
resolve most case
if fail, next steps may be attempted

64. SHOULDER DYSTOCIA
 Shoulder dystocia drill
1.call for help
2.generous episiotomy
3.suprapubic pressure
-simple, only one assistant
-while normal downward traction
4.McRoverts maneuver
-two assistants
resolve most case
if fail, next steps may be attempted

65. HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Hydrocephlus is an excessive accumulation of
cerebrospinal fluid with consequent cranial
enlargement
:associated defects are common (neural tube defect)
#head circumference: 32-38cm, fluid: 500-1500ml
hydrocephalus: 50-80cm, fluid: 5l
:1/3-breech, but whatever presentation,
gross CPD and serious dystocia

66. HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Diagnosis
:sonography
-compare the diameter of the lateral ventricle to
the BPD of the head
-evaluate the thickness of the cerebral cortex
-compare the size of the head to that of the
thorax and abdomen

67. HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Diagnosis
:sonography
-compare the diameter of the lateral ventricle to
the BPD of the head
-evaluate the thickness of the cerebral cortex
-compare the size of the head to that of the
thorax and abdomen

68. HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
 Technique of cephalocentesis
#cephalic presentation
-Cx :3-4cm dilatation
vetricle may be tapped (8-inch, 17-gauge needle)
#breech presentation
-after breech and trunk delivered
the face toward the martenal back
transvaginally, below the ant. vaginal wall
protect the birth canal

69. HYDROCEPHALUS
AS A CAUSE OF DYSTOCIA
#via martenal abdomen into the fetal head
-bladder: empty
skin: cleansed
the needle: in the midline below the maternal
umbilicus
-before oxytocin stimulation
-more successfully: sono-guided

70. FETAL ABDOMEN
AS A CAUSE OF DYSTOCIA
 Enlargement of the fetal abdomen
:greatly distended bladder
ascites
enlargement of the kidney or liver
edematous fetal abdomen
:before delivery, decision is made
:but, prognosis is very poor

71. Shoulder Dystocia Management
 Suprapubic Pressure

72. Shoulder Dystocia Management
 Wood’s Screw Maneuver – high risk for
humeral fx

73. Shoulder Dystocia Management
 Wood’s Screw Maneuver

74.  Release of the anerior shoulder
is initiated by firm pressure
against the infant's jaw and
neck in a posterior and upward
direction. An assistant is
poised, ready to apply fundal
pressure after proper
suprapublic pressure
 As the anterior shoulder slips
free, fundal pressure is applied,
and pressure against the neck
is shifted slightly toward the
rectum.
Proper suprapubic pressure is
continued.
The Hibbard Maneuver

75. The Hibbard Maneuver
 Continued fundal and
suprapublic pressure
results in an upward-
inward rotation of the
newly freed anterior
shoulder and a further
descent in a position
beneath the pubic
symphysis.

76.  As a result of the previous maneuvers,
the transverse diameter of the
shoulders is reduced.
 Lateral (upward) flexion of the head
releases the posterior shoulder into the
hollow of the sacrum.
The Hibbard Maneuver