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1. SHOULDER DYSTOCIA shoulder dystocia as a prolonged head-to-body delivery interval of 60 seconds. Shoulder dystocia occurs when the fetal shoulders are obstructed at the level of the pelvic inlet. Shoulder dystocia results from a size discrepancy between the fetal shoulders and the pelvic inlet, which may be absolute or relative, because of malposition .

2. 50% to 60% of shoulder dystocias occur in infants who weigh less than 4000 g. the episiotomy or laceration into the rectum are the most common maternal complications associated with shoulder dystocia . Unilateral brachial plexus palsies are the most common neurologic injury sustained by the neonate. one third of brachial plexus palsies will be associated with a concomitant bone fracture, most commonly of the clavicle (94%).

3. Risk factors Maternal obesity Multiparity Advanced maternal age Maternal diabetes Postterm pregnancy Male infant Excessive weight gain in pregnancy African-American ethnicity Maternal birth weight over 4000 grams

4. prior history of macrosomia Prior history of shoulder dystocia Labor induction, epidural, operative vaginal delivery

5. MANAGEMENT The goal of management is to safely effect delivery of the infant before asphyxia and cortical injury occur from umbilical cord compression and impeded inspiration, and without causing peripheral neurologic injury or other trauma.

6. Initial Steps When shoulder dystocia is suspected, the gravida and labor room personnel should be given instructions in a clear and calm manner. Nursing, anesthesia , obstetric, and pediatric staff should be called to the room, if not already available, to provide assistance as needed. The mother should be told not to push while preparations are made and maneuvers are undertaken to reposition the fetus

7. Excessive neck rotation, head and neck traction, and fundal pressure should be avoided because this combination of maneuvers can stretch and injure the brachial plexus. These actions may further impact the shoulders and cause uterine rupture or other injury. A distended bladder, if present, is drained.

8. MANEUVERS FOR THE ALLEVIATION OF SHOULDER DYSTOCIA McRoberts maneuver: is a simple, logical, and effective measure and is typically considered as the first-line treatment. less invasive than other maneuvers . It requires two assistants, each of whom grasps a maternal leg and sharply flexes the thigh back against the abdomen

9. Straightens the maternal lumbosacral lordosis , thus removing the sacral promontory as an obstruction site. Permits the pelvis to open to its maximum dimension Brings the pelvic inlet into the plane perpendicular to the maximum expulsive force.

10. Rubin It cuases adduction of the fetal shoulder so that the shoulders are displaced from the anteroposterior diameter of the inlet, thereby allowing the posterior arm to enter the pelvis. Under adequate anesthesia , the clinician places one hand in the vagina behind the posterior fetal shoulder and then rotates it anteriorly (towards the fetal face). If the fetal spine is on the maternal left, the operator's right hand is used; the left hand is used if the fetal spine is on the maternal right. Alternatively, the Rubin maneuver can be attempted on the anterior shoulder, if it is more accessible.

11. Woods screw Woods likened shoulder dystocia to the "crossed thread" of a bolt into a nut. Although a bolt cannot be forced into a nut, it goes through easily when turned repeatedly. The Woods screw maneuver rotates the fetus by exerting pressure on the clavicular surface of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis . If the fetal spine is on the maternal left, the operator uses the left hand to push on the clavicle of the posterior arm and rotate the baby 180 degrees in a counterclockwise direction. The fetal head and neck should not be twisted

12. Delivery of the posterior arm Delivery of the posterior arm almost always relieves impaction of the anterior shoulder and resolves the dystocia . The technique, also called the Barnum maneuver , requires introducing a hand into the vagina to locate the posterior arm and shoulder, which is best performed under adequate anesthesia . If the fetal abdomen faces the maternal right, the operator's left hand should be used; if the fetal abdomen faces the maternal left, the right hand is used.

13. The posterior arm should be identified and followed to the elbow, at which point pressure is applied in the antecubital fossa . This flexes the elbow across the fetal chest and allows the forearm or hand to be grasped. The arm is then pulled out of the vagina, which brings the posterior shoulder into the pelvis.

14. cleidotomy The clavicle can be intentionally fractured to shorten the biacromial diameter. This is done by pulling the anterior clavicle outward. However, intentional clavicular fracture can be difficult to perform and can lead to injury of underlying vascular and pulmonary structures.

15. Zavanelli This procedure, also known as the Gunn- Zavanelli -O'Leary maneuver , requires replacement of the fetal head in the pelvis, followed by cesarean delivery.

16. Symphysiotomy Splitting the symphysis pubis is effective in opening the maternal pelvis and relieving the obstruction, but has high maternal morbidity and is rarely used. The skin over the symphysis pubis and fibrocartilaginous area is infiltrated with local anesthetic. The urethra is displaced laterally using the index and middle fingers placed against the posterior aspect of the symphysis and an incision made through the cartilaginous portion of the symphysis. We do not suggest symphysiotomy unless all other maneuvers have failed and cesarean delivery is not possible.

17. Complications Maternal injury = perineal tear PPH Uterine rupture Maternal death Fetal injury = brachial plexus injury Clavicular fracture Vascular injury Lung injury Prenatal asphysia Fetal death