SHOULDER DYSTOCIA

1. MRS. SONY SARA P.J
ASSO. PROFESSOR
MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

2. SHOULDER DYSTOCIA

3. Content Overview
• Introduction
• Definition
• Incidence
• Causes
• Risk factors
• Degrees of shoulder dystocia
• How to predict the shoulder dystocia
• Management
• Maneuvers used in shoulder dystocia
• Complications
• Conclusion
• Reference

4. Introduction
• Shoulder dystocia has emerged as one of the most
important clinical and medico legal complication
of vaginal delivery.
• When shoulder dystocia is anticipated the
obstetrician should mentally rehearse the
sequence of steps necessary to treat this problem
and be ready to perform logically, in a step by step
fashion.

5. Definition – Shoulder Dystocia
• It refers to a situation where, after delivery of the
head, the anterior shoulder of the fetus becomes
impacted on the maternal pubic symphysis or less
commonly) posterior shoulder becomes impacted
on the sacral promontory.

6. Incidence
• It is an obstetric emergency with an incidence of
approximately 0.6% - 0.7% in all deliveries.

7. Causes
• Increase in fetal weight.
• Increase in body size in relation to head size.
• Increased shoulder/head circumference

8. Risk factors
Antepartum :
DOPE
 Diabetes mellitus
 Maternal Obesity (90kg before pregnancy or 110kg
at delivery
 Post term pregnancy
 Past history of shoulder dystocia
 Excessive fetal weight (>4.5kg)or maternal weight
gain(>20kg)

9. Risk factors Cont..
Intrapartum :
• Prolonged First stage of Labour
• Secondary Arrest (when there is initially good
progress in labour and then progress stops,
usually due to Malposition of the baby)
• Prolonged Second stage of Labour (time whilst
fully dilated and pushing)
• Augmentation of Labour with Oxytocin
• Assisted Vaginal Delivery(e.g. Forceps or
Ventouse)

10. Risk factors Cont..
Predictive factors :
• Maternal diabetes with estimated fetal weight is
>4.25kg
• Macrosomia & 2nd stage arrest with midpelvic
ventouse or forceps

11. Severe : Bilateral
 Both Posterior & the
Anterior shoulder do
not cross the pelvic
brim.
Degrees of Shoulder Dystocia
Mild : Unilateral
 The Posterior shoulder
enters the pelvic cavity
while the Anterior
shoulder hooked behind
the symphysis pubis.

12. Prediction of Fetal Macrosomia
 Clinical examination :
The diagnosis of fetal Macrosomia is imprecise.
Accuracy of Estimated Fetal Weight using
Ultrasound is no better than that obtained with
Clinical palpation.
 Ultrasonography

13. Clinical Picture
S.No Early Symptoms Late Symptoms
1. Slow crowning Usual down traction of
the head does not result
in appearance of the
anterior shoulder.
2. Fatty cheeks Vascular congestion of
the face.
3. Turtle sign(head is drawn tight
agains the perineum)
Vaginal examination is
difficult.
4. Restitution is slow or does not
occur

14. Management
 Individuals who must be present in the room if
shoulder dystocia is anticipated or encountered.
• Skilled obstetrician
• Anaesthesiologist
• Paediatrician
• Nursing staff

15. Management
First line
maneuvers
• Call for help
• Liberal
episiotomy
• Avoid fundal
pressure
• Mc Robert’s
maneuver and
suprapubic
pressure
Second line
maneuvers
• Delivery of
posterior
shoulder
• Wood’s
corkscrew
maneuver
• Rubin’s
maneuver
Third line
maneuvers
• Cleidotomy
• Zavanelli
maneuver
• Symphysiotomy

16. Management Cont..
Preliminary steps :
 Call for help
 Drain the bladder
 Perform generous episiotomy
 Avoid 5p’s
• Panic
• Pulling
• Pushing
• Pressure on the fundus
• pivoting

17. 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.
• Excess angulation (>45 ̊ )is to be avoided.
Management Cont..

18. Maneuvers used in
Shoulder Dystocia

19. Maneuvers
• McRobert’s maneuver
• Suprapubic pressure
• Gaskin Maneuver/All Four Maneuver
• Woods Maneuver
• Rubins Maneuver
• Delivery of the Posterior Shoulder

20. Mc Roberts Maneuver

21. Mc Roberts Maneuver Cont..
• Marked Flexion of the Maternal thighs into the
abdomen.
• Decrease the Angle of Pelvic Inclination
• Cephalic Rotation of the pelvis frees the Anterior
shoulder.

22. Suprapubic pressure

23. Suprapubic pressure Cont..
• 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.

24. Gaskin maneuver/All-Four Maneuver

25. Gaskin maneuver/All-Four Maneuver Cont..
• The All Four Maneuvers achieved by assisting the
mother onto her hands and knees.
• The act of turning the mother may be the most
useful aspects of this maneuver.
• In shoulder dystocia the impaction is at the pelvic
inlet and the force of gravity will keep the fetus
against the anterior aspects of the mothers uterus
and pelvis.

26. Wood’s Screw Maneuver

27. Wood’s Screw Maneuver Cont..
• The shoulders must be rotated utilizing pressure
on the scapula and clavicle.
• The head is never rotated.
• The delivery may be facilitated by counter
clockwise rotation of the anterior shoulder to the
more favourable oblique pelvic diameter or
clockwise rotation of the posterior shoulder.
• During this procedure the expulsive effort should
be stopped and the head is never grasped.

28. Rubin’s Maneuver

29. Rubin’s Maneuver Cont..
• Move to the side of the bed opposite to the infants
face.
• Instruct the mother to stop pushing
• Apply firm pressure on the back of the infants
anterior shoulder and turn in the direction of
infants face to decrease shoulder to shoulder
diameter.

30. Delivery of the posterior shoulder

31. Delivery of the posterior shoulder Cont..
• To bring the fetal wrist within reach, exert
pressure with the index finger at the ante cubital
junction.
• Sweep the fetal forearm down over the front of the
chest.

32. Delivery of the posterior shoulder Cont..
• 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.

33. When all else will fail...
• The Chavis maneuver
• The Hibbard maneuver
• Cleidotomy
• The Zavanelli maneuver
• Symphysiotomy

34. 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.

35. The Hibbard Maneuver

36. The Hibbard Maneuver Cont..
• A firm pressure is applied against the infants jaw
and neck in a posterior and upward direction.
• An assistant is ready to apply fundal pressure after
proper suprapubic pressure.
• As anterior shoulder slips free, fundal pressure is
applied and pressure against the neck is shifted
slightly toward the rectum.
• It results in an upward-inward rotation of the
newly freed anterior shoulder and leads to further
descent in position.

37. The Hibbard Maneuver Cont..
• As a result of the previous maneuvers the
transverse diameter of the shoulder is reduced.
• Lateral flexion of the head releases the posterior
shoulder into the hollow of the sacrum.

38. Cleidotomy
• The anterior clavicle is pressed against the rami of
the pubic.
• Care should be taken to avoid puncturing the lung
by angling the fracture anteriorly.

39. Zavanelli Maneuver
• First described in 1988
• Consist of cephalic replacement and then
caesarean delivery.
• If replacement done within 4 min: good APGAR
• Early indicated for bilateral shoulder dystocia.

40. Symphysiotomy
• It is a dangerous procedure with substantial risk
to maternal health and well being.
• It is difficult to justify the procedure for shoulder
dystocia in modern medicine.

41. Complication
Fetal Maternal
1. Death due to asphyxia.
2. Injuries
• Cerebral haemorrhage
• Brachial plexus palsy
• Fracture of the clavicle
• Brachial plexus injury and
fracture.
3. Remote :
• Mental retardation
• Speech defects.
1. Injuries
2. Postpartum haemorrhage
3. Infection
4. Rupture of uterus
5. Lacerations of vagina, cervix
and perineum

42. Conclusion
• Shoulder dystocia is an acute obstetric emergency.
One cannot predict when and in whom this can
occur. Risk factor can be identified and staff need
to be ready and aware through regular education
and training session and drills to manage shoulder
dystocia.

43. Reference
• D.C.Dutta,”Textbook of Obstetrics including
Perinatology and Contraception". Seventh Edition.
• J.B. Sharma, “Midwifery & Gynaecological Nursing”
Avichal Publishing company:1st edition
• Jacob, Annamma (2009). A Comprehensive Textbo
ok of Midwifery.Second Edition. New Delhi: Jaypee
Brothers Medical Publishers.
• www.slideshare.net>elshnar>shoulder dystocia
• www.slideshare.net>vandanabagribucktowar>sho
ulder dystocia.