Prediction and prevention
of Shoulder dystocia (what is new ?)
Introduction
Shoulder dystocia has emerged as one of
the most important clinical and medico legal
complication of vaginal delivery.
When shoulder dystocia is anticipated the
obstetrician should mentally rehearse the
sequence of steps necessary to treat this
problem and be ready to act in a logical , step by
step fashion.
⚫The reported incidence varies from 0.2 to 1.7%
in cephalic vaginal deliveries.
Certain patterns increases the likelihood of
shoulder dystocia
⚫1. a protracted or arrested active phase of
first stage of labour is associated with an
increased incidence of shoulder dystocia
⚫2. Protracted or arrested descent in the
second stage of labour is another marker.
⚫3. Assisted mid pelvic delivery carries a
higher risk of shoulder dystocia but it does
not occur in 95% of such deliveries.
Defination
⚫Shoulder dystocia is defined when the fetal
head has delivered but the shoulder do not
deliver spontaneously or with normal amount of
gentle downward traction.
⚫Clinical diagnosis is confirmed when the head
delivers but external rotation does not occur
and the head recoils tightly against the
perineum. ( TURTLE SIGN )
⚫When the head to completion of delivery
interval of more than 60 secs or need to use
additional manoeuvres to deliver the shoulder.
⚫Shoulder dystocia is of two types
⚫Unilateral shoulder dystocia – when anterior
or posterior shoulder is impacted.
⚫Bilateral shoulder dystocia – when bilateral
shoulders lie above the pelvic brim.
Prediction
⚫ Following predisposing factors have been identified but,
in general, lack specificity.
⚫Antepartum risk factors
⚫1. Macrosomia
⚫2. Diabetes- this is due to greater shoulder/head
circumference ratio because of the insulin
senstive nature of the tissues that contribute to
shoulder girth , compared to brain growth which
is not affected by hupoglycaemia and
hyperinsulinism.
⚫3. Obesity- chances are 0.6% in women less than
90kgs to 5% in women more than 113kgs.
⚫ 4. Post term pregnancy- incidence of macrosomia is
12% at 40 weeks and 21% at 42 weeks. In later weeks of
pregnancy the fetal chest and shoulders continue to
grow steadily, whereas the biparietal diameter growth
slows , increasing the likelihood of an unfavourable
shoulder/head circumference ratio.
⚫ 5. Previous shoulder dystocia
⚫ Because macrosomia is the commonest association
with shoulder dystocia and neonatal injury, it has
been proposed that elective cs of fetus estimated to
weigh more than 4500gm and even 4000gm should
be persued.
⚫ 6.Abnormal pelvic anatomy
⚫ 7.Short stature (less than 5feet tall)
⚫ 8.Previous large infant (>4000gms)
⚫ 9.Anencephaly
⚫ 10.Multiparity
⚫ 11.Fetal ascites
Intrapartum risk factors
⚫Operative vaginal delivery
⚫ Arrest in the late first stage of labour
⚫Arrest of descent in second stage of labour
⚫Precipitous delivery
ACOG guidelines on shoulder dystocia
⚫ Shoulder dystocia cannot be predicted or prevented
because accurate methods for doing so do not exist.
⚫ Elective induction or caesarean delivery for all
women with a suspected macrosomic fetus is not
appropriate.
⚫ When evaluating the risks and benefits of caesarean
and vaginal delivery in patients with a history of
shoulder dystocia , the obstetrician should consider.
estimated weight
gestational age
maternal glycemic status
previous history of shoulder dystocia.
Complications
⚫Fetal – 1. Asphyxia fetus is not hypoxic
before shoulder dystocia occurs there should
be 4 to 5 mins before the possibility of
permanent hypoxic damage.
⚫2.Brachial plexus injury is the most common
and serious complication.
⚫occurs in 5-15% of neonates .
⚫Most common type is Erb-Duchenne involving
C5 and C6 nerve roots . The range of permanent
palsy in those infants with brachial plexus is 4-
32%.
⚫3.Fractures occuring in 15% . Majority of
these are clavicular,
with fracture of humerus account for less
than 1%.
Maternal complication
⚫ 1.Genital tract lacerations more common due
to the tight feto pelvic relationship.
additional room needed for manoeuver
extension of episiotomy and 3rd and 4th degree
tears are more common.
⚫ Post partum haemorrahage due to
combination of -uterine atony,
prolonged labour,
large infant
increased blood loss from lacerations and
extensive episiotomy.
Managing shoulder dystocia
⚫For managing shoulder dystocia we use
term HELPERR
⚫H – call for help
⚫E – evaluate for episiotomy
⚫L – legs ( MC ROBERTS maneuver )
Mc Roberts Maneuver -symphysis rotates superiorly
which lifts the fetus and flexes the fetal spine toward the anterior shoulder.
P – Suprapubic pressure
E- Enter maneuvers ( Internal rotation ) –
manipulates the fetus to rotate the anterior shoulder into an oblique plane and under
maternal symphysis.
R-Rubin 2 maneuver
⚫Placing two fingers behind posterior aspect of
anterior shoulder toward the fetal chest . This
will adduct fetal shoulder girdle, reducing its
diameter.
Wood screw maneuver
⚫Two fingers on the anterior aspect of the fetal
posterior shoulder, applying gentle upward
pressure 180 degrees ,thus the posterior
shoulder which is below the level of pelvic
brim is screwed around under the level of
pubic arch and then it is delivered from
anterior position.
Deliver the posterior arm
⚫Flex the elbow and sweep the forearm across
the chest. Grasping of the upper arm should
be avoided as there is risk of fracture of
humerus.
R- Roll the patient ( Gaskin or all four maneuver ) -
increases the flexibility of sacroiliac joint and gravity push the posterior shoulder anteriorly.
Maneuvers of last resort
⚫Zavanelli maneuver : Cephalic replacement
followed by cs.
⚫Cliedotomy
⚫Abdominal rescue
⚫Symphysiotomy
ZAVANELLI MANEUVER/cephalic replacement
Summary
⚫Shoulder dystocia cannot be reliably predicted
in the antenatal period .
⚫Clinical estimation of macrosomia is as as
accurate as ultrasound.
⚫Elective cs is not recommended solely on the
grounds of suspected macrosomia.
⚫No consistent patterns of labour and/or
delivery reliably predict shoulder dystocia.
⚫Cs for cumulative risk factors in the antenatal
and/or intrapartum period may be reasonable
on a selective basis.
⚫ All personnels involved with the care of the women in
labour should be familiar with a logical sequence of
manoeuvers to manage shoulder dystocia.
⚫ No evidence is available that any one standard
manoeuver to deal with shoulderdystocia is superior to
another. However rotating the shoulders to the oblique
diameter and mc roberts manoeuver are easily
performed,logical,often successful , and associated
with minimal fetal trauma.
⚫ Strong downward traction on the fetal head and neck
should be avoided as it is associated with high rate of
brachial plexus injury.
Thank you
