“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.” Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.

1. Shoulder Dystocia
“Making the Best of a Bad Situation”
Sandesh Kamdi, M. Pharm

2. Incidence
Shoulder dystocia is an unpredictable obstetric
complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia
has been recorded over the last 20 years
Incidence appears to be increasing as birth
weights increase.
Ceska Gynekol 2010 ; 75(4):274-79

3. Although half of shoulder dystocias occur in infants
weighing less than 4000 gms…. The incidence of
shoulder dystocia is directly related to fetal size.
Ceska Gynekol 2010 ; 75(4):274-79

4. Definition
“Difficulty encountered in the delivery
of the fetal shoulders after delivery of
the head.”
It is the complication of vaginal
delivery that requires additional
obstetric manoeuvres to release the
shoulders of the baby.
Due to impaction of the fetal shoulder
behind the symphysis pubis.
Ceska Gynekol 2010 ; 75(4):274-79

5. Bilateral Shoulder Dystocia
A bilateral shoulder dystocia.
The posterior shoulder is not in
the hollow of the pelvis.
This presentation oftern
requires a cephalic
replacement.
Clinical Obstetrics, Churchill Livingstone, New York, 1987.)

6. Unilateral Shoulder Dystocia
Unilateral shoulder
dystocia is usually easily
dealt with by standard
techniques.
Clinical Obstetrics and Gynecology, 1984l 27:106)

7. Diagnosis
One often described feature 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 impacted in the
maternal pelvis
Ceska Gynekol 2010 ; 75(4):274-79

8. Risk Factors
Remember, many cases of shoulder dystocia
occur with no readily identified risk factors!!!!
ANTEPARTUM FACTORS INTRAPARTUM FACTORS
Maternal Obesity Prolonged Second Stage
Maternal Diabetes of Labor
Mellitus Oxytocin Induction
Post-term Pregnancy Midforceps and Vacuum
Excessive Weight Gain Extraction

9. Risk factors
Fetal macrosomia and maternal
diabetes most strongly associated
with shoulder dystocia
No single risk factor or
combination of risk factors are
predictive for which infants will
experience shoulder dystocia
ACOG Practice Pattern No. 40 2002

10. Fetal Complications
Fetal Fractures -
• In 18 to 25% of cases
Erb’s Palsy -
• Although 80% will resolve by 18
months
Perinatal Asphyxia – Uncommon
Brachial plexus injury
Neonatal Death - Rare

11. Maternal Complications
Postpartum Hemorrhage
Vaginal Lacerations
Cervical Lacerations
Puerperal Infection

12. Management of Shoulder Dystocia
Individuals who MUST be present in the
room if shoulder dystocia is anticipated or
encountered
• Attending physician
• Anesthesiologist
• Pediatrician
• Nursing Staff
• “Extra Hands”

13. Who’s the Boss?
It is important that the conduct of any shoulder
dystocia be managed by the most experienced
person in the room.
This individual ( generally the attending
physician) must have the ability to intervene at
any time and should be the only one giving orders.

14. Preliminary Steps
Call for help and have the team assembled
Drain the bladder
Perform a generous episiotomy
TAKE YOUR TIME, THIS IN AN EMERGENCY, BUT
IT IS NOT A RACE!!!

15. Prevention
Prophylactic McRoberts Maneuver
Prophylactic Cesarean Delivery

16. Preliminary Measures:
Gentle pressure on the fetal vertex
in a dorsal direction will move the
posterior fetal shoulder deeper into the
maternal pelvic hollow, usually
resulting in easy delivery of the
anterior shoulder.
Excession angulation (>45
degrees) is to be avoided.
(Gabbe, et al., Obstetrics: Normal and Problem
Pregnancies, Churchill Livingstone, New York, 1986)

17. Maneuvers
• McRoberts Maneuver
• Suprapubic Pressure
• Gaskin Maneuver
• Episiotomy
• Woods Maneuver/Rubin Maneuver
• Delivery of posterior shoulder
• Zavanelli Maneuver
• Symphysiotomy

18. McRobert’s Maneuver
Marked flexion of the maternal thighs unto
the abdomen
Decreases the angle of pelvic inclination
Cephalic rotation of the pelvis frees the
anterior shoulder

19. McRobert’s Maneuver

20. Mazzanti Technique

21. Key points
Instruct the mother to stop pushing until
suprapubic pressure has been applied
Apply direct downward pressure above the
maternal symphysis
– Dislodges the anterior shoulder by pushing it
under the maternal symphysis
Do not use fundal pressure

22. Rubin Technique

23. Key points
Move to the side of the bed opposite of the infant’s face
Instruct the mother to stop pushing
Apply firm pressure on the backside of the infant’s
anterior shoulder and shove in the direction of the infant’s
face
– Decreases shoulder to shoulder diameter
Note: Applying pressure in front of the anterior shoulder and shoving in the
opposite direction of the infant’s face increases the shoulder to shoulder
diameter up to 2 cm

24. Suprapubic Pressure
Moderate suprapubic pressure is often the
only additional maneuver necessary to disimpact
the anterior fetal shoulder. Stronger pressure can
only be exerted by an assistant.
(Gabbe, et al., 1986)

25. Woods’ Corkscrew Maneuver
Woods' corkscrew
maneuver. The shoulders
must be rotated utilizing
pressure on the scapula
and clavicle.
The head is never rotated.
(B.Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)

26. Woods’ Corkscrew Maneuver
Delivery may be facilitated by
counterclockwise
rotation of the anterior
shoulder to the more
favorable oblique pelvic
diameter, or clockwise rotation
of the posterior shoulder.
During these maneuvers,
expulsive efforts should be
stopped and the head is
never grasped !!

27. Delivery of the Posterior Arm
To bring the fetal wrist
within reach, exert
pressure with the index
finger at the antecubital
junction.
(E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)

28. Delivery of the Posterior Arm
Sweep the fetal
forearm down over the
front of the chest.

29. Delivery of the Posterior Arm
If less invasive
maneuvers fail to affect
this impaction, delivery
should be facilitated by
manipulative delivery of
the posterior arm by
inserting a hand into the
posterior vagina and
ventrally rotating the arm
at the shoulder with
delivery over the
perineum.

30. When All Else Fails...
The Rubin Maneuver
The Chavis Maneuver
The Hibbard Maneuver
Fracture of the Clavicle / Cleidotomy
The Zavanelli Maneuver
Symphysiotomy

31. The Rubin Maneuver
Step 1: The fetal shoulders are rocked from
side to side by applying force to the
maternal abdomen.
Step 2: If step one is not successful, push
the presenting fetal shoulder toward the
chest. This will often cause abduction of
both shoulders and create a smaller
shoulder to shoulder diameter.

32. The Chavis Maneuver
Described in 1979.
A “shoulder horn” consisting of a concave
blade with a narrow handle is slipped
between the symphysis and the impacted
anterior shoulder.
This used like a shoe-horn as a lever where
the symphysis is the fulcrum.

33. The Hibbard Maneuver
Release of the anerior shoulder is
initiated by firm pressure against
the infant's jaw and neck in a
posterior and upward direction.
An assistant is poised, ready to
apply fundal pressure after proper
suprapublic pressure
As the anterior shoulder slips free,
fundal pressure is applied, and
pressure against the neck is
shifted slightly toward the rectum.
Proper suprapubic pressure is
continued.

34. The Hibbard Maneuver
Continued fundal and
suprapublic pressure
results in an upward-
inward rotation of the
newly freed anterior
shoulder and a further
descent in a position
beneath the pubic
symphysis.

35. The Hibbard Maneuver
As a result of the previous maneuvers, the
transverse diameter of the shoulders is reduced.
Lateral (upward) flexion of the head releases the
posterior shoulder into the hollow of the sacrum.

36. Fracture of the Clavicle
The anterior clavicle is pressed against the
ramis of the pubis.
Care should be taken to avoid puncturing
the lung by angling the fracture anteriorly.
Theoretically, a fracture of the clavicle is
less serious than a brachial nerve injury
and often heals rapidly.

37. The Zavanelli Maneuver
First described in 1988
Consists of cephalic replacement and then
cesarean delivery.
Mixed reviews in the literature.

38. ... Don’t Even Think About It...
Symphysiotomy is a dangerous procedure
with substantial risk to maternal health
and well being.
It is difficult to justify this procedure for
shoulder dystocia in modern medicine.

39. Complications Associated with
Symphysiotomy
Vesicovaginal Fistula
Osteitis Pubis
Retropubic Abscess
Stress Incontinence
Long Term Walking Disability / Pain

40. Although shoulder dystocia represents a
catastrophic event in obstetrics, a well-
reasoned plan of action with adequate
support and skilled personnel can reduce
fetal morbidity.
Proper patient selection and awareness of
risk factors for shoulder dystocia can also
reduce morbidity.

41. Can Cesarean Sections for Suspected Macrosomia
Reduce the Rates of Shoulder Dystocia?
No
Sensitivity of clinical estimates of BW > 4500 gms
is only 20%
USG is not very accurate at extremes of EFW
Most cases of shoulder dystocia occur in infants
of average weight
The incidence of birth trauma in large infants is
not trivial
• (2.5% with BW > 4500 gms)

42. Top Reasons for Successful Claims Against
Obstetricians in Cases of Shoulder Dystocia
Inappropriate obstetrical delivery notes
Absence of delivery notes
Failure to document the dystocia
Failure to document use of McRobert’s maneuver
Lack of prenatal documentation or follow-up of
• Abnormal or borderline GTT
• Unexpected large maternal weight gain.
Harvard Risk Management Foundation (1994)
www.rmf.org

43. Things To Do After Dystocia Occurs
Check for and treat reproductive tract injuries
Pediatric neurology and neonatology consultation
Document a detailed delivery note, including maneuvers
used
Explain the occurrence of dystocia to the parents of the
infant
Do not finger-point
Be truthful, but avoid discrepancies in notes by doctors,
midwives and nurses.
Harvard Risk Management Foundation (1994)
www.rmf.org