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1. Shoulder dystocia

2. Defintion: Inability of the shoulders to deliver spontaneously Following the delivery of the head. there is impaction of the anterior shoulder on the symphysis pubis in the anteroposterior diameter, in such a way that the remainder of the body cannot be delivered by usual methods. . The head may be tight against the perineum. This is known as the “turtle” sign.

3. Incidence The overall incidence ranges from 0.2% to 2%. Complications of shoulder dystocia: Fetal and neonatal: Hypoxia&asphyxia Fracture clavicle and humorous Brachial plexus injury Death

4. Maternal complication: Postpartum hemorrhage. Uterine atony Maternal laceration 3rd & 4th degree perineal tear.

5. Predisposing factors: Suspected fetal macrosomia Maternal diabetes. Post-term pregnancy Multiparity Obesity Excessive weight gain (more than 20 kg gain showed an increase in shoulder dystocia from 1.4% to 15.2% Previous shoulder dystocia (recurrence rate of 10% to 13.8%) Prolonged labour Operative vaginal delivery

6. Unpredictable: 25-50% have no defined risk factor! 50% of cases occur in infants whose birth weight is <4000g 84% of patients did not have prenatal dx. of macrosomia by US 82%of infants with brachial plexus palsy did not have macrosomia

7. Diagnosis Immediate recognition of shoulder dystocia is essential . Signs include: Head recoils against perineum, the “turtle” sign Spontaneous restitution does not occur Failure to deliver with expulsive effort and usual maneuver.

8. Once recognized… Do NOT ask the patient to push. Do NOT apply fundal pressure. ( Grade C ) Do NOT panic !!

9. H Call for h elp SD drill..team work. documentation.

10. Evaluate for E pisiotomy Not for all cases ( Grade B ) Before delivery. Helps when applying the maneuvers

11. L L egs ( McRobert’s ) Safe Simple Effective ( used alone resolves 40 % of SD ) Hyperflexion and abduction of the hip

12. Straighten the sacrum. Moves the symphsis pubis toward the maternal head🡪 frees the impacted shoulder

13. P Suprapubic P ressure determine the position of the fetal back Initially ..continuous Then ..in CPR-like rocking motion.

14. E E nter=internal Maneuvers : Rubin Wood’s Screw

15. Rubin : Rubin I : rocking the fetus shoulder from side to side. Rubin II : reach for the most easily shoulder & push it forward decrease the bisacromial diameter .

16. Rubin II

17. Wood’s screw Rotate the posterior shoulder 180 degrees approach post. Shoulder from front . ant. Shoulder from behind .

18. Wood’s

19. If fails… Reverse wood’s screw posterior shoulder from behind.

20. R R emove the posterior Arm

21. sweep arm over the chest Insert a hand in the vagina..flex the elbow Deliver the post. arm

22. R R oll the patient

23. Might be disorienting for the unfamiliar doctor Increase the obstetric conjugate by 1.5 cm Gravity?? Movement itself?? Same maneuvers can be applied

24. Each step 30-60 Sec For a total 3- 5 minutes (All Maneuvers) No indication that any of these maneuvers is superior , they represent a valuable tool to help clinicians take effective steps to relieve impacted shoulder ( Category C )

25. All fails!! Last resort; Deliberate clavicular fracture. Zavenilli maneuver. ( tocolysis , replace head-> CS ) Symphysiolotmy. ( risk of UT/SP injury ) Cleidotomy. ( with a dead fetus ) Abdominal surgery + hysterotomy ( case reports,same maneuvers )