Shoulder Dystocia

1. 5

2. Shoulder Dystocia

3. GOALS
1. Understand the risk factors associated with
shoulder dystocia
2. Able to diagnose & manage shoulder dystocia
3. Documentation & risk management to reduce
obstetric litigation

4. 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.
Diagnosed when any of the obstetric maneuver is
needed to release the shoulder after gentle axial
traction has failed

5. One of the most dreaded obstetric complications
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.
Incidence: Varies; 6 in 1000 (RCOG 2012)

7. RISK FACTORS
Antepartum risks
Macrosomia
Maternal diabetes
Previous history of
shoulder dystocia
Maternal obesity
Induction of labour
Intrapartum risks
Prolonged first stage
Secondary arrest
Prolonged second stage
Oxytocin augmentation
Assisted vaginal
delivery

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

9. 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

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

11. Shoulder Dystocia: The drill

12. Suprapubic pressure
The direction of
pushing should be in
the direction of
where the baby is
facing

13. WOODSCREW Maneuvreanal.

14. 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.

15. ROLL OVER This position is called “on all-fours”,
or Gaskin’s manoeuvres, 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.

16. 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 emergency
caesarean

17. Post delivery
Watch-out for complications
Counseling for both patient and partner
Documentation
- Accurate & comprehensive
- Important to document which fetal shoulder was anterior