Dystocia means difficulty in labour • Shoulder dystocia means difficulty in delivery of the shoulder • Mostly the anterior shoulder gets stucked behind the symphysis pubis Risk factor • Maternal diabetes (lot of insulin results in lots of fat deposition) • Macrosomic baby (more than 4 kg) • Maternal obesity • Prolonged labour • Induced labour • Instrumental delivery • Post maturity (beyond 42 weeks) • Previous history of shoulder dystocia • Multiparity (specially grandmulti) Identify the risk factors Q. A 33 Year old, G7P6 , at 39 weeks undergoes induction of labour i/v/o Gestational hypertension. Her previous pregnancies ended up in uneventful normal vaginal deliveries. BP – 160/96 mmHg. Her pre pregnancy weight was 115 kg and she has gained 13.5 kg in present pregnancy. The estimated fetal weight is 3.5 kg. • 22 hours after labour induction and 2 hours after pushing, the fetal head delivers and retracts at the perineum. Gentle traction fails to deliver the anterior shoulder. Ans. A 33 Year old, G7P6 , at 39 weeks undergoes induction of labour i/v/o Gestational hypertension. Her previous pregnancies ended up in uneventful normal vaginal deliveries. BP – 160/96 mmHg. Her pre pregnancy weight was 115 kg and she has gained 13.5 kg in present pregnancy. The esti mated fetal weight is 3.5 kg. • 22 hours after labour induction and 2 hours after pushing, the fetal head delivers and retracts at the perineum. Gentle traction fails to deliver the anterior shoulder. How to diagnose shoulder dystocia • Gentle routine traction fails to deliver the anterior shoulder with ease • Turtle sign (retraction of neck on perineum) • Normally next should be external rotation but head does not undergoes external rotation. Management • Call for help • There are chances of asphyxia (more delay, more risk) • DO NOT pull from below • DO NOT push from above • To avoid chances of brachial plexus injury • Make the mother to lie flat on her back • Bring the buttocks at the edge of the table • Empty the bladder • Consider episiotomy • Maintain suprapubic pressure • It helps to adduct the shoulders • Move to next maneuver if it fails in 30 seconds • McRobert maneuver- Hyperflexion of maternal; thigh and legs towards abdomen • If McRobert maneuver fails.. • Delivery of posterior arm • Rubins maneuver • If Rubin’s maneuver fails.. • Woods corkscrew maneuver - Complete turn of baby in 180 degree, Posterior shoulder becomes anterior and vice versa • Still unsuccessful.. • At this stage the baby might be near dead or severely asphyxiated. • Gaskin’s All four maneuver • Still unsuccessful.. • Extreme measure: • Symphisiotomy • Clavicular fracture • Cleidotomy (cutting the clavicle with scissors) • Zavanelli maneuver (pushing the head inside the vagina and conduct CS.)

1. OBSTETRICS AND
GYNAECOLOGICAL NURSING
Mrs. Disha Jondhale – Kharat
M.Sc OBGYN
Bel Air College of Nursing,
Panchgani, Mahabaleshwar

3. Shoulder dystocia
• Dystocia means difficulty in
labour
• Shoulder dystocia means
difficulty in delivery of the
shoulder
• Mostly the anterior shoulder
gets stucked behind the
symphysis pubis

4. Risk factor
• Maternal diabetes (lot of insulin results in lots of fat deposition)
• Macrosomic baby (more than 4 kg)
• Maternal obesity
• Prolonged labour
• Induced labour
• Instrumental delivery
• Post maturity (beyond 42 weeks)
• Previous history of shoulder dystocia
• Multiparity (specially grandmulti)

5. Identify the risk factors
• A 33 Year old, G7P6 , at 39 weeks undergoes induction of
labour i/v/o Gestational hypertension. Her previous
pregnancies ended up in uneventful normal vaginal deliveries.
BP – 160/96 mmHg. Her pre pregnancy weight was 115 kg
and she has gained 13.5 kg in present pregnancy. The
estimated fetal weight is 3.5 kg.
• 22 hours after labour induction and 2 hours after pushing, the
fetal head delivers and retracts at the perineum. Gentle traction
fails to deliver the anterior shoulder.

6. Identify the risk factors
• A 33 Year old, G7P6 , at 39 weeks undergoes induction of
labour i/v/o Gestational hypertension. Her previous
pregnancies ended up in uneventful normal vaginal deliveries.
BP – 160/96 mmHg. Her pre pregnancy weight was 115 kg
and she has gained 13.5 kg in present pregnancy. The
estimated fetal weight is 3.5 kg.
• 22 hours after labour induction and 2 hours after pushing, the
fetal head delivers and retracts at the perineum. Gentle traction
fails to deliver the anterior shoulder.

7. How to diagnose shoulder dystocia
• Gentle routine traction fails to
deliver the anterior shoulder with
ease
• Turtle sign (retraction of neck on
perineum)
• Normally next should be external
rotation but head does not
undergoes external rotation.

8. Management
• Call for help
• There are chances of asphyxia
(more delay, more risk)
• DO NOT pull from below
• DO NOT push from above
• To avoid chances of brachial
plexus injury

9. Management
• Make the mother to lie flat on her back
• Bring the buttocks at the edge of the table
• Empty the bladder
• Consider episiotomy
• Maintain suprapubic pressure
• It helps to adduct the shoulders
• Move to next maneuver if it fails in 30
seconds

10. McRobert maneuver- Hyperflexion of maternal; thigh and
legs towards abdomen

11. If McRobert maneuver fails..
Delivery of posterior arm Rubins maneuver -

12. If Rubin’s maneuver fails..
• Complete turn of baby in
180 degree.
• Posterior shoulder becomes
anterior and vice versa.
• Woods corkscrew maneuver

13. Still unsuccessful..
• At this stage the baby might
be near dead or severely
asphyxiated.
• Gaskin’s All four maneuver

14. Still unsuccessful..
Extreme measure:
• Symphisiotomy
• Clavicular fracture
• Cleidotomy (cutting the clavicle with scissors)
• Zavanelli maneuver (pushing the head inside the vagina and
conduct CS.)