1. Shoulder
Dystocia
( ACOG Medical Student Education Module 2011)

2. Definition
 Difficulty in delivery of fetal shoulders
 Failure to deliver fetal shoulder without
utilizing facilitating maneuvers
 Prolonged head-to-body delivery time
 >60 seconds
 Incidence: 0.2-3% of all live births;
represents an obstetric emergency

4. Bilateral Shoulder
Dystocia
 The posterior
shoulder is not in the
hollow of the pelvis.
 This presentation
often requires a
cephalic
replacement.

5. Unilateral Shoulder
Dystocia
 Unilateral shoulder
dystocia is usually easily
dealt with by standard
techniques.

6. Pathophysiology
 Size discrepancy between fetal
shoulders and maternal pelvic inlet
 Macrosomia
 Large chest:BPD
 Absence of truncal rotation
 Fetal shoulders remain A-P or descent
simultaneously

7. Risk Factors
 Antepartum
 Macrosomia (>4500g ACOG)
 GDM (increases overall risk by 70%)
 Multiparity
 Intrapartum
 Prolonged deceleration phase of labor
 Prolonged 2nd stage
 Protracted descent
 Operative delivery (vacuum>forceps)

8.  D - Diabetes
 O- Obesity
 P- Post term pregnancy, prior large baby
 E- Excessive weight gain during
pregnancy
 No evidence based data:
 Male
 Short maternal stature
 Abnormal pelvic shape/size

9. Unpredictable
 25-50% have no defined risk factor!
 50% of cases occur in infants whose birth
weight is <4000g
 TURTLE SIGN: represented by the
retraction of the fetal head after expulsion,
may herald shoulder dystocia, shoulder
dystocia is not diagnosed until the usual
attempts at the delivery of the head fail.

10. Complications
 Maternal
 Hemorrhage
 4th degree laceration
 Fetal
 Fx of humerus or clavicle
 Brachial plexus injury (Erb’s/Klumpke’s
palsy)
 Asphyxia/cord compression
 Physician
 Litigation: 11% of all obstetrical suits

12. Management
 Goal: Safe delivery before neontal
asphyxia and/or cortical injury
 7 minutes!!!
 Episiotomy
 Suprapubic Pressure
 McRoberts Maneuver
 Woods or Rubin Maneuvers
 Zavenelli
 Push back the delivered fetal head into birth
canal and perform an emergent c/s

13. HELPERR Algorithm
 H: Call for Help; Shoulder dystocia is
called if shoulders cannot be delivered
with gentle traction
 E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when
attempting intra-vaginal maneuver
 L: Legs (McRoberts): Hyperflexion and
abduction of hips—initial maneuver

14.  P (Suprapubic Pressure): No fundal pressure; combination of
McRoberts and suprapubic pressure resolves most shoulder dystocias
 Enter (Internal Maneuvers): oblique diameter rotational maneuvers
 Woods screw (1943): Insert two fingers into posterior vagina and
apply pressure to the anterior aspect (clavicular) of the posterior
shoulder and abduct and rotate that shoulder, the posterior
shoulder could be rotated 180° degrees to the anterior, and this
would disimpact the obstructed anterior shoulder. The subsequent
addition of gentle downward traction with a contraction would then
result in delivery.
 Rubin(1964): either the anterior or posterior shoulder, which ever
was more accessible, be adducted and brought toward the fetal
chest. Insert two fingers on the posterior aspect (scapular) of the
anterior or posterior shoulder and also rotate the baby 180° to
reduce the obstruction.
 Remove: Delivery posterior arm
 Roll the patient: Gaskin maneuver or all four positions

15. McRoberts Maneuver
 42% success rate
 + Suprapubic pressure = 54-58%
 Brings pelvic inlet and outlet into more vertical
alignment
 Flattens sacrum
 Cephalad rotation of pubic symphysis
 Elevates anterior shoulder and flexes fetal spine
 Increases IUP by 97%
 Increases amplitude of contractions
 +31N of pushing force

16. Preliminary Measures:
 Gentle pressure on the fetal
vertex in a dorsal direction will move
the posterior fetal shoulder deeper
into the maternal pelvic hollow,
usually resulting in easy delivery of
the anterior shoulder.
 Excession angulation (>45
degrees) is to be avoided.
(Gabbe, et al., Obstetrics: Normal and Problem
Pregnancies, Churchill Livingstone, New York, 1986)

17. The McRoberts manoeuvre

18. Suprapubic Pressure
 Moderate suprapubic pressure is often the
only additional maneuver necessary to disimpact
the anterior fetal shoulder. Stronger pressure can
only be exerted by an assistant.
(Gabbe, et al., 1986)

19. Oblique Diameter
Rotational Maneuver
 Delivery may be facilitated by
counterclockwise
rotation of the anterior
shoulder to the more
favorable oblique pelvic
diameter, or clockwise
rotation of the posterior
shoulder.
 During these maneuvers,
expulsive efforts should
be stopped and the head
is never grasped !!

20. Delivery of the
Posterior Arm
 To bring the fetal wrist
within reach, exert
pressure with the index
finger at the antecubital
junction.
(E. Sandberg. American Journal of Obstetrics and Gynecology, 1985; 152: 481.)

21. Delivery of the
Posterior Arm
 Sweep the
fetal
forearm
down over
the front of
the chest.

22. Delivery of the
Posterior Arm
 If less invasive
maneuvers fail to affect
this impaction, delivery
should be facilitated by
manipulative delivery of
the posterior arm by
inserting a hand into the
posterior vagina and
ventrally rotating the arm
at the shoulder with
delivery over the
perineum.

23. All- Fours
Manoeuver
It consists of placing the patient onto
her hands and knees

24. The Chavis Maneuver
 Described in 1979.
 A “shoulder horn” consisting of a
concave blade with a narrow handle is
slipped between the symphysis and the
impacted anterior shoulder.
 This used like a shoe-horn as a lever
where the symphysis is the fulcrum.

25. The Hibbard Maneuver
 Release of the anerior shoulder
is initiated by firm pressure
against the infant's jaw and neck
in a posterior and upward
direction. An assistant is poised,
ready to apply fundal pressure
after proper suprapublic
pressure
 As the anterior shoulder slips
free, fundal pressure is applied,
and pressure against the neck is
shifted slightly toward the
rectum.
Proper suprapubic pressure is
continued.

26. The Hibbard Maneuver
 Continued fundal and
suprapublic pressure
results in an upward-
inward rotation of the
newly freed anterior
shoulder and a further
descent in a position
beneath the pubic
symphysis.

27. The Hibbard Maneuver
 As a result of the previous maneuvers,
the transverse diameter of the shoulders
is reduced.
 Lateral (upward) flexion of the head
releases the posterior shoulder into the
hollow of the sacrum.

28. Fracture of the
Clavicle
 The anterior clavicle is pressed against
the ramis of the pubis.
 Care should be taken to avoid puncturing
the lung by angling the fracture
anteriorly.
 Theoretically, a fracture of the clavicle is
less serious than a brachial nerve injury
and often heals rapidly.

29. The Zavanelli
Maneuver
 First described in 1988
 Consists of cephalic replacement and
then cesarean delivery.
 Mixed reviews in the literature.

30. Summary
 Cannot accurately predict
 BE PREPARED!
 Consider risk factors
 Be prepared to perform various maneuvers
 Diagnose and treat quickly
 Obtain assistance from nursing staff and
NICU

31. Prophylactic
Cesarean?
 Not recommended by ACOG
 Exceptions:
 Consider if…
 >5000g in mother without DM
 >4500g in mother with DM

32.  Shoulder dystocia is well suited for
simulation training.
 The obstetric birth simulator NOELLE
(Gammard Scientific, FL, USA) is one
such model.