Topics: Childbirth, Obstetrics, Shoulder dystocia Pages: 13 (544 words) Published: May 9, 2015
Presented by Dr . E . G. Migwi

• -an uncommon obstetric complication of cephalic
vaginal deliveries
• -the fetal shoulders do not deliver after the head
has emerged from the mother’s introitus.
• -One or both shoulders become impacted against
the bones of the maternal pelvis (mechanical
reasons).size or positional discrepancy, thus
almost always after 34 weeks.

Anterior shoulder impacted behind the
symphysis pubis and also posterior shoulder
impacted behind the sacral promontory

Risk factors
Impossible to predict/ can occur without risk factors.
1. Ante partum
• -History of shoulder dystocia in a prior vaginal delivery • -Fetal macrosomia (having a disproportionately large body compared to head)
• -Diabetes/impaired glucose tolerance 
• -Excessive weight gain (15.8757 kg) during pregnancy
• -Obesity (body mass index >30 kg/m 2)
• -Asymmetric accelerated fetal growth in non-diabetic patients • -Post term pregnancy

2. Intrapartum
• -Precipitous second stage (< 20 min)
• -Prolonged second stage 
Without regional anesthesia (>2 h for nulliparous
patients, or >1 h for multiparous patients)
With regional anesthesia (>3 h for nulliparous
patient, >2 h for others
• -Induction of labor for "impending macrosomia".

Technique / management
• Cord pH drops with increasing head-to-body
delivery interval, but the drop does not
become clinically significant for about 5
• Each maneuver should take 30 seconds ,

Fetal Maneuvers

Maternal Maneuvers

Rubin maneuver

McRoberts maneuver

Jacquemier maneuver
(posterior arm delivery)

Suprapubic pressure

Woods screw maneuver

Gaskin maneuver (all-fours)

Zavanelli maneuver (cephalic

Sims maneuver (lateral


Ramp maneuver

Shute forceps maneuver


• Episiotomy not listed -The only reason to perform an
episiotomy in the setting of shoulder dystocia is to
eliminate soft tissue resistance that is interfering with
the ability to insert the whole hand into the hollow of
the sacrum posteriorly to perform fetal maneuvers
– prompt, skillful and well rehearsed
• HELPERR- mnemonic to aid remembering the

H calls for help midwife, obstetrician, anaesthetist, and neonatologist. E Episiotomy
L legs in Mc Roberts’s position. Hyper flexed at the hips with thighs abducted P Suprapubic pressure – at the posterior aspect of the anterior shoulder. Continuous or rocking
E enters the pelvis for internal maneuvers.
Rubin 2
Wood screw
Reverse wood screw
R release of the posterior arm -Jacquemier maneuver

• R roll over the patient on all fours – Gaskin maneuver

Other maneuvers
• *Zanvanelli maneuver. Replacement of the
head into the vagina, and performing a csection
• *Symphysiotomy: results in severe maternal
morbidity - urethral injury, incontinence,
altered gait, chronic pelvic pain
• *clavicle fracture

• Complications
• -Postpartum hemorrhage- due to fetal macrosomia, dysfunctional contractility due to mechanical obstruction
• -Third- or fourth-degree perineal laceration or episiotomy extension can also occur (-wound breakdown, fistula formation, dyspareunia, and fecal incontinence.) • -Neonatal clavicle fracture 
• -Neonatal fractured humerus
• -Brachial plexus injury - most common complication of shoulder dystocia. Caused by deviation or rotation of the fetal head from the shoulder. Best way to reduce it is by using moderate traction and directing the traction in line with the fetal spine

Among infants with permanent shoulder dystocia–associated brachial plexus injuries, an antecedent precipitous second stage is 3 times more common than a prolonged second stage • -neonatal hypoxic ischemic encephalopathy and death

• -Clinician injury

• the timing and sequence of events
• what each person did
• -fill and incident report for risk management
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