Shoulder Dystocia

Shoulder dystocia

Shoulder dystocia occurs when there is impaction of the anterior shoulder behind the maternal pubic symphisis. It is an obstetric emergency A diagnosis of shoulder dystocia can be made when the body fails to delivery within 1 minute of the head or when the baby’s head comes out with contractions and returns into the vagina when contractions stop (’Turtle sign’)

• Risk factors for shoulder dystocia
  • Fetal macrosomia (big baby)
  • Maternal diabetes (big baby)
  • Post-term pregnancy (big baby)
  • Maternal obesity
  • Prolonged second stage (as a consequence of shoulder dystocia)
  • Operative vaginal delivery
  • History of shoulder dystocia
• Signs and symptoms
  • Baby’s head comes out with contractions and returns when contractions stop (Turtle sign)
  • Body fails to deliver within 1 minute of the head
• Initial management
  • Call for Help
  • Evaluate for Episiotomy
• External maneuvers
  • McRobert’s maneuver: hyperflexion of the maternal thighs against the abdomen to flatten the sacrum and cause cephalad rotation of the pubis
  • Suprapubic Pressure: causes cephalad rotation of the pubic head to release the shoulder from the pubic bone
  • Gaskin maneuver: Roll the patient to her hands and knees
• Entry rotational (internal) maneuvers
  • Attempt to deliver the posterior shoulder by reaching into the vagina and sweeping the arm out of the vagina. Can also use a catheter looped under the armpit to pull the shoulder
  • Rubin’s manoeuver: Reach into the vagina and put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis
  • Wood’s screw manoeuver: Performed during Rubin’s maneuver. One hand applies anterior pressure to the posterior shoulder, while the other hand (or a catheter looped under the armpit) applies posterior pressure to the anterior shoulder rotating the fetus 180 degrees to dislodge the impaction
  • Reverse Wood’s screw manoeuver: Rotate in the opposite direction
• Salvage maneuvers
  • Symphysiotomy: needs local anaesthesia, catheterization and digital preservation of the urethra
  • Zavanelli manoeuver: push the head back into the vagina for caesarean delivery
  • Emergency caesarean delivery
  • Break the clavicle
  • Dislocate the sternoclavicular joint
  • Corkscrew manoeuver (rotates the shoulder to a more diagonal/transvere position)
  • Episiotomy
• Complications
  • Erb’s palsy (waiter’s tip deformity; arm adducted and pronated)
  • Fractures (e.g. clavicular)
  • Fetal: birth asphyxia, fractures (arm or collar bone), nerve damage (brachial plexus injury, Erb’s palsy), cerebral palsy – degrees of neuropraxia
  • Maternal – PPH, cervico-vaginal lacerations or tears, 4th degree tears, bladder atony, uterine rupture, PTSD