Shoulder dystocia

When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as 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.

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.

20. Thank you