Shoulder dystocia occurs when the baby's anterior shoulder becomes lodged behind the mother's pubic bone during childbirth after the head is delivered. It can cause life-threatening complications if not resolved quickly. Risk factors include macrosomia, diabetes, previous shoulder dystocia, and prolonged second stage of labor. The HELPER mnemonic outlines steps for management: Help, Episiotomy, Legs, Pressure, Enter, Remove, Roll. Complications can include injuries to the baby like brachial plexus injury and fractures, as well as maternal issues like third degree tears and postpartum hemorrhage.

1. SHOULDER DYSTOCIA SALSO COURSE Sarawak General Hospital

2. SHOULDER DYSTOCIA Anterior shoulder impacts against the symphysis pubis after the fetal head has delivered Life threatening Risk factors have low predictive value Be prepared for shoulder dystocia in all deliveries

3. INCIDENCE Overall 0.3 - 1.0% BW > 4.0 kg 5.0 - 7.0% BW > 4.5 kg 8.0 - 10.0% > 50% occurs in normal birthweight infant (< 4.0 kg) and is unanticipated (Obstet Gynaecol 1985, 66:762-8) Recurrence 1.5 - 14 %

4. MECHANISM Normal: Head through pelvic outlet, shoulders enter pelvic inlet in oblique diameter with posterior shoulder in sacral hollow Problem: at pelvic inlet Shoulder dystocia: Anterior shoulder remains hooked behind symphysis pubis and fails to rotate into a larger pelvic diameter (oblique or transverse)

5. MATERNAL RISK FACTORS Previous shoulder dystocia Macrosomia (known, suspected, previous) Diabetes Prepregnancy weight > 80kg Weight gain > 20kg Advanced maternal age Post term pregnancy Anencephaly Short stature Small or abnormal pelvis

6. LABOUR RISK FACTORS Prolonged first stage Prolonged second stage “Head bobbing” (Turtle sign) during second stage Instrumental delivery

7. TREATMENT Anticipation and preparation Avoid fundal pressure, excessive traction, twisting neck, bending neck pH of fetus drops 0.04 per minute. 7 minutes of cord compression will drop the pH by 0.28 As pH approaches 7.0, resuscitation becomes increasingly difficult

8. HELPERR H Help E Episiotomy L Legs: McRobert’s Manoeuver (30-60sec) P Pressure: Suprapubic (30-60sec) E Enter: Woods Screw Manoeuver (30-60sec) R Remove the posterior arm R Roll: the patient to hands and knees (Fracture clavicle, Symphysiotomy, Zavanelli abdominal replacement)

9. MATERNAL COMPLICATIONS 3rd degree tear Vaginal lacerations Postpartum haemorrhage Uterine rupture

10. FETAL COMPLICATIONS Brachial plexus injury Erb’s palsy:5th and 6th cervical roots Klumpke’s: 8th cervical and 1st thoracic roots Fractures Clavicle Humerus Fetal Hypoxia Death