Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.

1. Shoulder dystocia
Shrooti shah
Lecturer
National Medical College Nursing Campus

2. Definition
When fetal head is delivered, but shoulders are stuck
and cannot be delivered it is known as shoulder
dystocia.
Failure of the shoulders to traverse the pelvis
spontaneously after delivery of the head.

3. Shoulder dystocia
The anterior shoulder becomes trapped behind on the
symphysis pubis, whilst the posterior shoulder may be
in the hollow of the sacrum or high above the sacral
promontory.

4. Incidence
Overall incidence varies between 0.2 and 1 percent

5. Predisposing factors
Fetal macrosomia
Obesity
Diabetes
Midpelvic instrumental delivery
Post maturity
Multiparity
Anencephaly
Fetal ascitis

6. Warning signs and diagnosis
The delivery may have been uncomplicated 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 reverse
traction.
Diagnosed when maneouvers normally used by the
midwife fail to accomplish delivery.

7. Turtle sign

8. Management principles
DONTs’:
– Do not be panicky
– Do not give traction over baby’s head
– Do not apply fundal pressure
Dos’
– Call for extra help
– Clear the infant’s mouth and nose
– Involve the anaesthesist and the paediatrician
– Perform episiotomy if not performed earlier

9. Management

10. Management…
1. Pre-procedure steps and considerations:
– Shout for help
– Explain procedure
– Follow general principles of basic care and infection
prevention
– Perform episiotomy

11. Management…
2. Perform the Mc Roberts maneuver:

12. McRoberts maneuver

13. Rubin’s Maneuver
3. If the shoulder is still not delivered: insert a hand into
the vagina and apply pressure to the anterior shoulder
in the direction of the baby’s sternum to rotate the
shoulder and decrease the shoulder diameter.
• If the needed, apply pressure to the posterior shoulder
in the direction of the baby’s sternum

14. Wood’s maneuver
4. If the shoulder is still not delivered despite the above
measures:
• Insert a hand into the vagina
• Grasp the humerus of the 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 the fetal head, apply
firm, continuous traction downward to move the anterior
shoulder under the symphysis pubis

15. Management…

16. Cockscrew maneyver
If the posterior arm cannot be extracted, perform
the cockscrew maneuver.

17. Cleidotomy
If all of the measures fail to deliver the anterior
shoulder:
– Another option is to fracture the baby’s anterior
clavicle to decrease the width of the shoulder. This is
done by pressing the anterior clavicle against the
symphysis pubis.
– After birth, facilitate urgent and immediate newborn
care or transfer of the newborn.

18. Zavanelli manoeuvre

19. Post Procedure care
Repair the episiotomy
If needed, provide emotional support to the woman and
family following a traumatic birth and possible death of
the newborn or injury to the baby.