Shoulder dystocia is when the baby's anterior shoulder gets stuck behind the pubic bone after the head delivers. It can cause injuries and is a risk factor for litigation. The document outlines steps to diagnose, manage, and prevent complications of shoulder dystocia through early detection of risk signs, use of maneuvers like McRoberts position and suprapubic pressure, and documenting interventions taken. While risk factors exist, shoulder dystocia can occur unexpectedly so providers must be prepared to address it at every delivery.

1. SHOULDER DYSTOCIA

2. GOALS
1. To learn how to diagnose & manage shoulder
dystocia
2. Steps to prevent fetal asphyxia while avoiding
physical injury
3. Documentation & risk management to reduce
obstetric litigation

3. DEFINITION
 Shoulder dystocia is the impaction of the
anterior shoulder against the symphysis pubis
after the head has been delivered
 Occurs when the breadth of the shoulder is
greater than the biparietal diameter of the
head.

4.  Shoulder dystocia remains one of the most dreaded
obstetric complications and one that is often
unanticipated.
 It is one of the primary causes of perinatal mortality
and morbidity, maternal morbidity and a costly source
of litigation.
 One must be prepared for the possibility of shoulder
dystocia in all deliveries, and have a prepared plan of
management.

6.  1:500 deliveries
 Predisposing factors includes large babies, maternal
diabetes, prolonged pregnancy, short stature,
instrumental deliveries, previous shoulder dystocia
 Up to 10 minutes to dislodge shoulder
 Call for experienced staff and assistants stat
OBSTETRIC EMERGENCIES!!

7. **However, most cases occur
without risk factors. Therefore, all
clinicians need to be prepared
for unexpected shoulder dystocia
at all deliveries **

8. EARLY DETECTION
 “Head bobbing": the head coming down towards the
introitus with pushing, but retracting back between
contraction
 “Turtle sign at delivery": The delivered head becomes
tightly pulled back against the perineum

9. COMPLICATIONS
MATERNAL
 Perineal trauma
 Uterine atony
 Uterine rupture
 PPH
FETUS
 Brachial plexus injury
 Clavicle or humerus
fracture
 Neurological deficit /
HIE
 Death

10. H- Call for HELP!!!
E- Episiotomy
L- Leg in Mc Robert’s Position
P- Suprapubic pressure
E- Enter Wood’s screw manouevere
R- Removal of posterior arm
R- Roll over
R- Repeat all method
Shoulder Dystocia: The
drill

11. McRobert’s position
Suprapubic pressure
•Hyperflex the hips
•Abduct the hips
Flex the knees
Preferably done with
2 assistant, each at
both sides of the
patient
The direction of
pushing should be
in the direction of
where the baby is
facing

12. COCKSCREW Maneuvreanal.

13. Deliver The Posterior Arm
Flex the forearm at the
elbow if the forearm is
extended.
Deliver the arm by
sweeping it across the
chest and face.

14. ROLL OVER This position is called
“on all-fours”, knee-
chest position or
hands-and-knee
position.
REPEAT  Repeat the above procedures
from McRoberts maneuver
 If the above maneuvers are
unsuccessful, all maneuvers
may be tried again.
 The order is which each and
the entire manoeuvre is
attempted may be revised.

15. IF ALL PROCEDURES FAIL…….
 Symphysiotomy – cutting the symphysis pubis to
allow delivery of the anterior shoulder
 Clavicular fracture (@cleidotomy) – allows further
adduction of the fetal shoulder, reducing the
diameter of the shoulders, thus allowing delivery
 Zavanelli maneuvre – push the baby’s head back into
the uterus and proceed with Em. caesarean

16. POST DELIVERY
 Watch-out for complications
 Counseling for both patient and partner
 Documentation
- Accurate & comprehensive
- Important to document which fetal shoulder was anterior