its a brief presentation ..........hope u vil like it.............

2. Submitted by
Kavitha kalesan
Bsc Nursing,Thevara

3. DEFINITION
The term shoulder dystocia is defined to describe
a wide range of difficulties encountered in the
delivery of the shoulders.
It occurs when either the
anterior or the posterior
fetal shoulder impacts on
the maternal symphysis
or on the sacral promontory.

4. PREDISPOSINGFACTORS
1. Fetal macrosomia
2. Obesity
3. Diabetes
4. Midpelvic instrumental delivery
5. Post maturity
6. Multi parity
7. Anencephaly
8. Fetal ascites

5. COMPLICATIONS
 FETAL :-
a) Asphyxia
b) Brachial plexus injury due to stretch
c) Erb
d) Klumpke palsy
e) Fracture humerus

6. Contd…

7.  MATERNAL :-
a) PPH
b) Cervical, vaginal, perineal tears

8. SIGNS/SYMPTOMS
 One characteristic of a minority of shoulder
dystocia deliveries is the turtle sign, which
involves the appearance and retraction of the
fetal head (analogous to a turtle withdrawing
into its shell), and the erythematous(red),
puffy face indicative of facial flushing. This
occurs when the baby's shoulder is obstructed
by the maternal pelvis.

9. RISKFACTORS
 About 16% of deliveries where shoulder dystocia
occurs will have conventional risk factors.
Factors which increase the risk/are warning signs:
 The need for oxytocins
 A prolonged first or second stage of labour
 Turtle sign
 Head bobbing in the second stage
 Failure to restitute
 No shoulder rotation or descent
 Instrumental delivery

10. PREDICTION
 Previous shoulder dystocia, prolonged first or
second stage of labour are the important ones.
Maneuvers to prevent shoulder dystocia may be
used prophylactically in cases where it is
anticipated.

11. DIAGNOSIS
1) Definite recoil of the head back against the
perineum ( turtle-neck sign)
2) Inadequate spontaneous restitution
3) Fetal face becomes plethoric.

12. MANAGEMENTPRINCIPLES
a) Extra help is to be called
b) To clear infant’s mouth and nose
c) Not to give traction over baby’s head
d) Never to apply fundal pressure as it causes
further impaction of the shoulder
e) To perform wide mediolateral episiotomy as it
provides space posteriorly.
f) To involve the anesthetist and the
pediatrician(for infants resuscitation)

13. MANAGEMENT
 Management of shoulder dystocia has become a
focus point for many obstetrical nursing units in
North America. Courses such as the Canadian
More-OB program encourage nursing units to
do routine drills to prevent delays in delivery
which adversely affect both mother and fetus. A
common treatment mnemonic is ‘ALARMER’

14. CONTD……
 Ask for help. This involves preparing for the help
of an obstetrician, for anesthesia, and for
pediatrics for subsequent resuscitation of the
infant that may be needed if the methods below
fail.
 Leg hyper flexion (McRoberts' maneuver)

15. CONTD……..
 Anterior shoulder disimpaction (pressure)
 Rubin maneuver
 Manual delivery of posterior arm
 Episiotomy
 Roll over on all fours
The advantage of proceeding in the order of ALARMER is
that it goes from least to most invasive, thereby reducing
harm to the mother in the event that the infant delivers
with one of the earlier maneuvers. In the event that these
maneuvers are unsuccessful, a skilled obstetrician may
attempt some of the additional procedures listed above.
Intentional clavicular fracture is a final attempt at
nonoperative vaginal delivery prior to Zavanelli's
maneuver or symphysiotomy, both of which are
considered extraordinary treatment measures.

16. Contd…..

17. Contd……….
 Head and neck should be grasped and taken
posteriorly while suprapubic pressure is applied
by an assistant slightly towards the side of fetal
chest. This will reduce the bisacromial diameter
and rotate the anterior shoulder towards the
oblique diameter. This maneuver is simple as
well as effective It needs only one assistant
 Mc Roberts maneuver : Abduct the maternal
thighs and sharply flex them onto her abdomen.
There is rotation of symphysis pubis upwards

18. Contd………………………
and decrease in angle of pelvic inclination. This does not
increase pelvic dimensions but straightens the sacrum
relative to lumbar vertebrae. It needs two assistants.

19. Contd…………
 WOOD’S Maneuver: General anesthesia is
administered. The posterior shoulder is rotated to
anterior position(180 degree) by a corkscrew
movement. This is done by inserting two fingers
in the posterior vagina. Suprapubic pressure is
applied. This pushes the bisacromial diameter
from the antero-posterior diameter to an oblique
diameter. This helps easy entry of the bisacromial
diameter into the pelvic inlet.

20. Contd……………..

21. Contd………
 EXTRACTION OF THE POSTERIOR ARM:-
The operators hand is introduced into the vagina
along the fetal posterior humerus. The arm is then swept
across the chest and thereafter delivered by gentle
traction. This procedure may cause fracture clavicle or
humerus or both.

22. Contd………….
Other techniques may be used when all the
above maneuvers have failed.
 CLEIDOTOMY:- One or both clavicles may be
cot with scissors to reduce the shoulder girth.
This is applicable to a living anencephalic baby
as a first choice or in a dead fetus.

23.  ZAVANELLI MANEUVER:- (pushing the fetus
back to the uterus and delivering by cesarean section) or
symphysiotomy are done rarely.