Table Of Contents
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
