Presentation on shoulder dystocia

1. SHOULDER DYSTOCIA
REVISED JANUARY 2017
BLSO
BASIC LIFE SUPPORT IN OBSTETRICS
Typed by:
Pot. CI Tintu Elizabeth Eapen
SDU, Maternity hospital

2. INTRODUCTION:
Shoulder dystocia has emerged as one of the most important clinical and medico
legal complication of vaginal delivery where a wide range of difficulties
encountered in the delivery of the shoulders. When shoulder dystocia is
anticipated the obstetrician should mentally rehearse the sequence of steps
necessary to treat this problem and be ready to act in a logical , step by step
fashion.

3. OBJECTIVES:
 Recognize the risk factors of shoulder dystocia.
 Demonstrate a systematic approach to manage shoulder dystocia.
 Demonstrate appropriate maneuvers to reduce a shoulder dystocia.

4. Normal labour- Quick review

5. DEFINITION:
Shoulder dystocia occurs when either
the anterior or the posterior fetal shoulder
impacts on the maternal symphysis or on
the sacral promontory after the delivery of
the head.

6. INCIDENCE:
 Overall incidence varies between 0.2 and 1 percent.
 More common with large infants
 However, > 50% occur normal weight infants

7. RISK FACTORS:
 Macrosomia
 Gestational diabetes
 Operative vaginal delivery (mid pelvic instrumental delivery- vacuum or forceps)
 Previous history of dystocia
 Maternal characteristics (obesity, abnormal pelvis, short stature)
 Multiparity
 Anencephaly

8. CLINICAL FEATURES:
 Turtle neck sign:-Definite recoil of the head back against the perineum
 Fetal face becomes plethoric
 Failure of shoulder to descend.

9. MANAGEMENT:
.
1st line Maneuvers
2nd line Maneuvers

10. Call for Help, initiate RED ALERT!
• State clearly
• Experienced obstetrician, midwife, nurses, neonatologist, anesthetist
• Secure IV line
• Lithotomy position, legs in stirrup with buttocks at edge of bed
• Empty/catheterize the bladder
Time window for brain hypoxia is 5 minutes.
 Fundal pressure should not be used.
 Encourage the mother not to push.

11. Episiotomy
• To create more space for greater access to the pelvis
• An episiotomy is not always necessary.

12. Legs: McRoberts Maneuvers (First line Maneuvers)
 Acute flexion and abduction of
thighs
- Reduces the angle of pelvic
inclination by 10degree
- Straightens the pelvic curve
 Suprapubic pressure
- On ant shoulder of fetus and
press posteriorly to cause adduction
 Posterior traction on fetal head

13. External Pressure - suprapubic pressure

14. Enter Pelvis:
Rubin I & II + Woodscrew’s Maneuver
(Second line Maneuver/Rotational maneuvers)

15. RUBIN MANEUVER I (also known as reverse Wood's screw
maneuver)
Rotation of anterior shoulder under
symphysis pubis by giving suprapubic
pressure.
The bisacromial diameter is rotated
from anteroposterior to oblique lie.
Fundal pressure should not be applied
because it may cause uterine rupture or
further impaction of the shoulder.

16. RUBIN MANEUVER II
 It is performed by inserting one hand vaginally
behind the posterior aspect of anterior shoulder
of the baby and rotating the shoulder towards
the chest of the baby.
 Combine with suprapubic pressure to facilitate vaginal rotation.
 For primipara, an episiotomy may be performed before inserting the vaginal
hand.

17. WOOD’S MANEUVER
 It should be combined with Rubin’s
manoeuvre
 Place two fingers of the free hand against
the front of the posterior shoulder and apply
pressure to free the shoulders by turning (in
a corkscrew manner) at 180 degree.
 Delivery of posterior shoulder.

18. Remove the posterior Arm
 Insert hand into vagina on posterior
aspect of posterior arm/humerus
 Deliver the posterior arm by
sweeping the fetal arm over the
anterior chest wall
 Deliver the posterior arm/shoulder
 Apply gentle downward traction of
the fetal head/arm to facilitate
delivery

19. Roll the patient to her hands and knees
(GASKIN MANEUVER)

20. Maneuvers of last resort (Third line maneuver)
ZAVANELLI
MANEUVER
Pushing the fetus back to the
uterus and delivering by C- section
SYMPHYSIOTOMY
The cartilage of the
symphysis pubis may be
surgically divided to increase
the size of the pelvic outlet
CLEIDOTOMY
Deliberate fracture
of the clavicle

21. COMPLICATIONS:
MATERNAL FETAL
 PPH
 Rectovaginal fistula
 Uterine rupture
 Psychological trauma
 Symphyseal separation
 Soft tissue injuries:
- anal sphincter tear
- femoral neuropathy
 Brachial plexus palsy
 Clavicle fracture
 Humerus fracture
 Fetal acidosis
 Fetal hypoxia with or without
permanent neurologic damage
 Fetal death

22. .
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23. SUMMARY
 Shoulder dystocia is an obstetric emergency that can lead to lasting injury to
the baby. It is usually unpredictable, but there are risk factors that make it
more likely, especially having had a previous baby with a shoulder dystocia and
diabetes.
 Prompt management in a multi-disciplinary team will lead to the best outcomes
and training in skills drills is essential.