Shoulder dystocia occurs when the fetal shoulders become stuck after delivery of the head. It has an incidence of 0.2-1% and can be unilateral or bilateral. Risk factors include obesity, diabetes, macrosomia and previous shoulder dystocia. It is diagnosed when gentle traction fails to deliver the baby. Management involves maneuvers to disimpact the shoulders like McRoberts position, suprapubic pressure, and rotating the posterior arm. More aggressive maneuvers include the Woods corkscrew or Zavanelli maneuver. Complications for the baby include injury, asphyxia and death while maternal complications are tears and hemorrhage. Prevention focuses on elective c-section or induction for high risk cases.

1. Shoulder dystochia
Dr Salma Iqbal
PGR I gynae B UNIT LMH KOHAT

2. LEARNING OBJECTIVES;
Learning Objectives At the end of this activity, learners will be able to:
1. learn definition
2. Types
3. Risk factors
4. significance
5. Its management maneuvers and prevention

3. SHOULDER DYSTOCIA
DEFINITION
‘Shoulder dystocia is the failure to deliver the fetal shoulders after the
delivery of the head when attempts at gentle downward traction are
unsuccessful’.

4. INCIDENCE
• Overall incidence varies between .2 and 1 percent.

5. TYPES;
1.Unilateral shoulder dystocia; In this type posterior
shoulder enter the pelvis while the anterior shoulder remains
hooked above the symphysis pubis.
2.Bilateral shoulder dystocia;In this type both
shoulders are held above the pelvic inlet either in antero-
posterior,oblique or even in transverse diameter.

6. PREDISPOSING FACTORS;
I. ANTENATAL;
a. Obesity
b. Diabetes
c. Multiparity
d. Post maturity
e. Mid pelvic instrumental delivery
II. INTRANATAL;
a.Fetal macrosomia
b.Anencephaly
c.Fetal ascitis

7. WARNING SIGNS AND DIAGNOSIS;
• Diagnosed when maneouvers normally used by midwife fail to
accomplish delivery.
• The delivery may have been uncomlicated initially but the head may have
advanced slowly and the chin may have had difficulty in sweeping over the
perineum.
• Once the head is delivered,it may look as if it is trying to return into the
vagina which is caused by the reverse traction(turtle’s sign).

8. TURTLE’s SIGN;
Doctors call shoulder dystocia
symptoms ‘the turtle sign’.
This means a fetal head will first
come out of the body but will then
seem to go back into the birth canal,
this is said to be like a turtle that
sticks its head out of its shell and put
it back in.

9. MANAGEMENT PRINCIPLE;
• DONT’S;
• Be panicky
• Give traction over baby’s head
• Apply fundal pressure
• DO’S;
• Call for extra help
• Clear the infant mouth and nose
• Involve the anesthetist and paedriatrician
• Perform episiotomy if not perform earlier.

10. MANAGEMENT;

11. MANEUVERS;
• INITIAL MANEUVERS
• SECOND LINE MANEUVERS
• DESTRUCTIVE PROCEDURES

12. INITIAL MANEUVERS;
• McROBERT MANEUVER (POSITION OF THE
PATIENT)
• EPISIOTOMY
• RUBIN’S MANEUVIR(suprapubic pressure)

13. SECONDLINE MANEUVERS;
• Delivery of posterior arm
• Wood’s cockscrew maneuver
• Zavanelli’s maneuver

14. DESTRUCTIVE
PROCEDURE;
1. CLEIDOTOMY
2. SYMPHYSIOTOMY

15. McROBERTS MANEUVER;

16. McROBERT’S MANEUVER;

17. RUBIN’S MANEUVER;
• If the shoulder is still not delivered,insert a hand into vagina and apply
pressure to anterior shoulder in direction of baby’s sternum to rotate the
shoulder and decrease the shoulder diameter.
• If needed apply pressure to the posterior shoulder in the direction of baby’s
sternum.

18. RUBIN’S MANEUVER;

19. DELIVERY OF POSTERIOR ARM;

20. WOOD’S COCKSCREW MANEUVER;
• Exerting rotational force by applying pressure to the posterior
shoulder toward the neonatal belly or front side.
• (insert a hand into the vagina ,grasp the humerus of posterior arm
and keeping the arm flexed at the elbow,sweep the arm across the
chest,grasp the hand and deliver the entire arm.with one hand on
each side of fetal head apply continuous traction downward to
move the anterior shoulder under the symphysis pubis.)

21. WOOD’S COCKSCREW MANEUVER;

22. ZAVANELLI MANEUVER;
• Fetal head is rotated to its pre-
restitution attitude,flexed
and elevated upto vagina and
back into the uterus.
A c/s achieves the delivery.

23. CONTI;

24. GASKIN MANEUVER(ALSO CALLED
ALL FOURS)
•In this maneuver the mother support herself
on her hands and knees to resolve shoulder
dystocia.

25. POST PROCEDURE CARE;
• Episiotomy repair
• Emotional support to the women and family

26. SIGNIFICANCE;
FETAL AND MATERNAL
COMPLICATIONS;
FETAL COMPLICATION;
1.Perinatal mortality ;
(associated with perinatal mortality rate as high as 19-289/1000 with respiratory arrest and asphyxia being the
commonist causes.
2. Neurologic damage;
(a).Seizures; (the servivors of prolong asphyxia will suffer from neonatal seizures.the extent and severity of permenant
neurological deficit in the form of cerebral palsy will depend upon degree of hypoxic insult)
(b).Brachial plexus injury;
3.Skeletal injury;

27. MATERNAL COMPLICATION;
1.Perineal,vaginal and cervical tear
2.Uterine rupture
3.PPH

28. PREVENTION;
1.Elective c/s
2.Induction of labour