Shoulder dystocia

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

2. IncidenceIncidence
Shoulder dystocia is an unpredictable obstetric Shoulder dystocia is an unpredictable obstetric
complication with the incidence of 0.15% to 2%. complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia An increase in the incidence of shoulder dystocia
has been recorded over the last 20 yearshas been recorded over the last 20 years
Incidence appears to be increasing as birth Incidence appears to be increasing as birth
weights increase.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. DefinitionDefinition
““Difficulty encountered in the delivery Difficulty encountered in the delivery
of the fetal shoulders after delivery of of the fetal shoulders after delivery of
the head.” the head.”
It is the complication of vaginal It is the complication of vaginal
delivery that requires additional delivery that requires additional
obstetric manoeuvres to release the obstetric manoeuvres to release the
shoulders of the baby.shoulders of the baby.
Due to impaction of the fetal shoulder Due to impaction of the fetal shoulder
behind the symphysis pubis.behind the symphysis pubis.
Ceska Gynekol 2010 ; 75(4):274-79

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

7. DiagnosisDiagnosis
One often described feature is the turtle sign which One often described feature is the turtle sign which
involves the appearance and retraction of the fetal head involves the appearance and retraction of the fetal head
(analogous to a turtle withdrawing into its shell) and the (analogous to a turtle withdrawing into its shell) and the
erythematous, red puffy face indicative of facial flushing.erythematous, red puffy face indicative of facial flushing.
This occurs when the baby's shoulder is impacted in the This occurs when the baby's shoulder is impacted in the
maternal pelvismaternal pelvis
Ceska Gynekol 2010 ; 75(4):274-79

8. Risk FactorsRisk Factors
ANTEPARTUM FACTORSANTEPARTUM FACTORS
Maternal ObesityMaternal Obesity
Maternal Diabetes Maternal Diabetes
MellitusMellitus
Post-term PregnancyPost-term Pregnancy
Excessive Weight GainExcessive Weight Gain
INTRAPARTUM FACTORSINTRAPARTUM FACTORS
Prolonged Second Stage Prolonged Second Stage
of Laborof Labor
Oxytocin InductionOxytocin Induction
Midforceps and Vacuum Midforceps and Vacuum
ExtractionExtraction
Remember, many cases of shoulder dystocia
occur with no readily identified risk factors!!!!

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

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

11. Maternal ComplicationsMaternal Complications
Postpartum HemorrhagePostpartum Hemorrhage
Vaginal LacerationsVaginal Lacerations
Cervical LacerationsCervical Lacerations
Puerperal InfectionPuerperal Infection

12. Individuals who MUST be present in the Individuals who MUST be present in the
room if shoulder dystocia is anticipated or room if shoulder dystocia is anticipated or
encounteredencountered
•Attending physicianAttending physician
•AnesthesiologistAnesthesiologist
•PediatricianPediatrician
•Nursing StaffNursing Staff
•““Extra Hands”Extra Hands”
Management of Shoulder DystociaManagement of Shoulder Dystocia

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

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

15. PreventionPrevention
Prophylactic McRoberts ManeuverProphylactic McRoberts Maneuver
Prophylactic Cesarean DeliveryProphylactic Cesarean Delivery

16. Preliminary Measures: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. ManeuversManeuvers
• • McRoberts ManeuverMcRoberts Maneuver
• • Suprapubic PressureSuprapubic Pressure
• • Gaskin ManeuverGaskin Maneuver
• • EpisiotomyEpisiotomy
• • Woods Maneuver/Rubin ManeuverWoods Maneuver/Rubin Maneuver
• • Delivery of posterior shoulderDelivery of posterior shoulder
• • Zavanelli ManeuverZavanelli Maneuver
• • SymphysiotomySymphysiotomy

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

19. McRobert’s ManeuverMcRobert’s Maneuver

20. Mazzanti TechniqueMazzanti Technique

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

22. Rubin TechniqueRubin Technique

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

24. Suprapubic PressureSuprapubic 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 ManeuverWoods’ 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. 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 !!
Woods’ Corkscrew ManeuverWoods’ Corkscrew Maneuver

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

29. 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.
Delivery of the Posterior ArmDelivery of the Posterior Arm

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

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

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

33. 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.
The Hibbard ManeuverThe Hibbard Maneuver

34. The Hibbard ManeuverThe 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. 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.
The Hibbard ManeuverThe Hibbard Maneuver

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

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

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

39. Complications Associated with Complications Associated with
SymphysiotomySymphysiotomy
Vesicovaginal FistulaVesicovaginal Fistula
Osteitis PubisOsteitis Pubis
Retropubic AbscessRetropubic Abscess
Stress IncontinenceStress Incontinence
Long Term Walking Disability / PainLong Term Walking Disability / Pain

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

41. NoNo
Sensitivity of clinical estimates of BW > 4500 gms Sensitivity of clinical estimates of BW > 4500 gms
is only 20%is only 20%
USG is not very accurate at extremes of EFWUSG is not very accurate at extremes of EFW
Most cases of shoulder dystocia occur in infants Most cases of shoulder dystocia occur in infants
of average weightof average weight
The incidence of birth trauma in large infants is The incidence of birth trauma in large infants is
not trivialnot trivial
•(2.5% with BW > 4500 gms)(2.5% with BW > 4500 gms)
Can Cesarean Sections for Suspected Macrosomia
Reduce the Rates of Shoulder Dystocia?

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

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