shoulder dystocia, labour

1. Shoulder Dystocia
Dr. Rabinarayan SatapathyDr. Rabinarayan Satapathy
Asst. ProfessorAsst. Professor
Dept. of Obst.& GynaeDept. of Obst.& Gynae
S.C.B. Medical College,CuttackS.C.B. Medical College,Cuttack

3. Definition
• “…a delivery that requires
additional obstetric maneuvers
following failure of gentle
downward traction on the fetal
head to effect delivery of the
shoulders.”
• ACOG, Practice Bulletin 40 (November
2002)

4. Definition
• “Prolonged head-to-body
expulsion time”
• Objectively defined as 60
seconds
• Deliveries with head-to-body
interval of > 60 seconds more
commonly have higher birth
weight, shoulder dystocia, and
low 1 minute Apgar scores
– Beall et al 1998; Spong et al 1995

5. Functional Definition
• A delivery in which the
shoulders do not follow the head
as usual, but rather are delayed
in delivering or require the use
of ancillary obstetric maneuvers
to effect delivery.
• The anterior shoulder may be
impacted behind the symphysis
pubis, or (less commonly) the
posterior shoulder behind the
sacral promontory

6. Shoulder dystocia
• Shoulder dystocia can be one of the
most frightening emergencies in the
delivery room
• Although many factors have been
associated with shoulder dystocia,
most cases occur with no warning
• Defined as a delivery in which
additional maneuvers are required to
deliver the fetus after normal gentle
downward traction has failed
– Shoulder dystocia occurs when the fetal
anterior shoulder impacts against the
maternal symphysis

8. Epidemiology
• The overall incidence of shoulder dystocia
varies based on fetal weight
– 0.6-1.4%: 2500g(5lb,8oz) to 4000g(8lb,13oz)
– 5-9%: 4000g to 4500g(9lb,14oz), born to
mothers without diabetes
• 3969g (8lb,12oz) – our patient
• Shoulder dystocia occurs with equal
frequency in primigravid and multigravid
women
– More common in infants born to women with
diabetes
• The single most common risk factor for
shoulder dystocia is the use of a vacuum
extractor or forceps during delivery
• However, most cases occur in fetuses of
normal birth weight and are unanticipated,
limiting the clinical usefulness of risk-factor
identification

9. Risk Factors for Shoulder
Dystocia
• Maternal
– Abnormal pelvic
anatomy
– Gestational
diabetes
– Post-dates
pregnancy
– Previous
shoulder
dystocia
– Short stature
• Fetal
– Suspected
macrosomia
• Labor related
– Assisted vaginal
delivery (forceps
or vacuum)
– Prolonged active
phase of first-
stage labor
– Prolonged
second-stage
labor

10. Labor pattern Nullipara Multipara
First stage
Duration
24.7 hours 18.8 hours
Protracted dilation
<1.2 cm/h <1.5 cm/h
Arrested dilation
>2 h >2 h
Second stage
Arrest of descent (epidural)
>3 h >2 h
Arrest of descent (no
>2 h >1 h
Values represent approximately two standard deviations from the mean
Diagnostic criteria for abnormal
patterns in active labor

12. Complications of Shoulder
Dystocia*
• Maternal
– Postpartum
hemorrhage (11%)
– Rectovaginal fistula
– Symphyseal
separation
• With or without
transient femoral
neuropathy
– 3rd
or 4th
degree
(3.8%) episiotomy or
tear
– Uterine rupture
• Fetal
– Brachial plexus palsy
(4-15%)†
– Clavicle fracture
– Fetal hypoxia
• With or without
permanent
neurologic
damage
– Fracture of the
humerus
– Fetal death
†Nearly all palsies
resolve within six to
12 months, with
fewer than 10%
resulting in
permanent injury
*These rates remain constant, independent of operator experience

13. HELPERR pneumonic
• H – Help
– Call for additional assistance
• E – Evaluate for episotomy
• L – Legs (McRobert’s Maneuver)
• P – Pressure (suprapubic)
• E – Enter the vagina
• R – Remove the posterior arm
• R – Roll the patient
– To hands and knees

14. HELPERR pneumonic
(cont.)
• Although there is no indication that
any one of these techniques is
superior to another, together they
effectively relieve the impacted
shoulder
• The order of the steps is not as
important as the fact that they each
be employed efficiently and
appropriately
• Persistence in any one ineffective
maneuver should be avoided
• Clinical judgment always should guide
the progression of procedures used

15. Clinical Management
• Step One: Recognize the
presence of a shoulder dystocia
• Step Two: Be sure enough help
is present
– Nursing
– Obstetrics
– Pediatrics
– Anesthesiology

16. Clinical Management
• Step Three: Apply primary
maneuvers
– Mc Roberts maneuver
– Oblique suprapubic pressure
• Step Four: Apply secondary
maneuvers; no prescribed order
– Rubin; Woods screw; Posterior
arm; All-fours; Clavicular fracture

17. Clinical Management
• Step Five (concurrent):
– Repeat steps three and four
(different operator?)
– Consider if an episiotomy is needed
(intentional 4th
degree?)
• Step Six: Apply final (heroic)
maneuvers
– Zavanelli; symphysiotomy

18. H - Help
• This refers to activating the pre-arranged
protocol or requesting the appropriate
personnel to respond with necessary
equipment to the labor and delivery unit
• If standard levels of traction do not relieve
the shoulder dystocia, the physician must
move quickly to other maneuvers while
asking for help and notifying the family
• A critical step in addressing the emergency
management of shoulder dystocia is ensuring
that all involved hospital personnel are
familiar with their roles and responsibilities

19. E - Evaluate for episotomy
• Episiotomy should be considered when a
shoulder dystocia is encountered, although
because the primary problem is a bony
impaction, episiotomy by itself will not
release the impaction
• Episiotomy does provide additional room for
the physician's hand when internal rotation
maneuvers are required
• Given the success of the McRobert’s
maneuver and suprapubic pressure in
relieving a large percentage of cases of
shoulder dystocia, performing an episiotomy
can wait until later in the sequence

20. L – Legs (McRobert’s
maneuver)
• The simplicity of the McRobert’s maneuver and its
proven effectiveness make it an ideal first step in
the management of shoulder dystocia
• This procedure results in a cephalad rotation of
the symphysis pubis and a flattening of the sacral
promontory
– These motions push the posterior shoulder over the
sacral promontory, allowing it to fall into the hollow
of the sacrum, and rotate the symphysis over the
impacted shoulder
• When this maneuver is successful, the fetus
should be delivered with normal traction
• The McRobert’s maneuver alone is believed to
relieve more than 40% of all shoulder dystocias
and, when combined with suprapubic pressure,
resolves more than 50% of shoulder dystocias

22. P – Pressure (suprapubic)
• When applying suprapubic pressure, an assistant's
hand should be placed on top of the mother's
abdomen over the fetal anterior shoulder,
applying pressure in a compression/relaxation
cycle analogous to cardiopulmonary resuscitation,
so that the shoulder will adduct and pass under
the symphysis
• Pressure should be applied from the side of the
mother, with the heel of the assistant's hand
moving in a downward and lateral motion on the
posterior aspect of the fetal impacted shoulder
• Initially, the pressure can be continuous, but if
delivery is not accomplished, a rocking motion is
recommended to dislodge the shoulder from
behind the pubic symphysis
• Fundal pressure is never appropriate and only
serves to worsen the impaction, potentially
injuring the fetus or mother

24. E – Enter maneuvers
• Rotation maneuvers may require episiotomy
to gain posterior vaginal space for the
physician’s hand
• The Rubin II maneuver consists of inserting
the fingers of one hand vaginally behind the
posterior aspect of the anterior shoulder of
the fetus and rotating the shoulder toward
the fetal chest
• This motion will adduct the fetal shoulder
girdle, reducing its diameter
• The McRobert’s maneuver also can be applied
during this maneuver and may facilitate its
success

25. E – Enter maneuvers
(cont.)
• If the Rubin II maneuver is unsuccessful, the
Woods corkscrew maneuver may be attempted
• The physician places at least two fingers on the
anterior aspect of the fetal posterior shoulder,
applying gentle upward pressure around the
circumference of the arc in the same direction as
with the Rubin II maneuver
• The Rubin II and Woods corkscrew maneuvers
may be combined to increase torque forces by
using two fingers behind the fetal anterior
shoulder and two fingers in front of the fetal
posterior shoulder
• Procedurally, this step often is difficult because of
limited space for the physician's hand
• Downward traction should be continued during
these rotational maneuvers, simulating the
rotation of a screw being removed

26. E – Enter maneuvers
(cont.)
• If the Rubin II or Woods corkscrew
maneuvers fail, the reverse Woods corkscrew
maneuver may be tried
• In this maneuver, the physician's fingers are
placed on the back of the posterior shoulder
of the fetus, and the fetus is rotated in the
opposite direction as in the Woods corkscrew
or Rubin II maneuvers
• This maneuver adducts the fetal posterior
shoulder in an attempt to rotate the
shoulders out of the impacted position and
into an oblique plane for delivery

27. Rubin II
At vaginal examination apply pressure
as indicated. If shoulders move into the
oblique diameter, attempt delivery
Rubin II + Woods corkscrew
maneuver
If unsuccessful, add the Woods
corkscrew maneuver and continue
rotation in the same direction. Use both
hands and apply pressure as indicated.
If shoulders now move into the oblique,
attempt delivery. If this is unsuccessful,
continue rotation 180 degrees and
deliver

28. R – Remove the posterior
arm
• Removal of the posterior arm involves placing the
physician's hand in the vagina and locating the
fetal arm, which sometimes is displaced behind
the fetus and must be nudged anteriorly
– The physician's hand, wrist, and forearm may need
to enter the vagina, necessitating an episiotomy or
extension
• The fetal elbow is then flexed, and the forearm is
delivered in a sweeping motion over the anterior
chest wall of the fetus
• The upper arm should never be grasped and
pulled directly, because this step may result in a
fracture of the humerus
• The posterior hand, followed by the arm and
shoulder, will be reduced, facilitating delivery of
the infant
• The anterior shoulder will then fall under the
symphysis and deliver

29. R – Roll the patient
• Rolling the patient onto her hands and knees,
known as the all-fours or Gaskin maneuver, is a
safe, rapid, and effective technique for the
reduction of shoulder dystocia
• Once the patient is repositioned, the physician
provides gentle downward traction to deliver the
posterior shoulder with the aid of gravity
• The all-fours position is compatible with all
intravaginal manipulations for shoulder dystocia,
which can then be reattempted in this new
position
• All-fours positioning may be disorienting to
physicians who are unfamiliar with attending a
delivery in this position
• Performing a few “normal” deliveries in this
position before encountering a case of shoulder
dystocia may prepare physicians for more
emergent situations

30. Maneuvers of last resort
• If the maneuvers described in
HELPERR are unsuccessful,
several techniques have been
described as “last-resort”
maneuvers
• Once the infant is delivered,
quick assessment and
employment of resuscitation
efforts, if necessary, are vital

31. Maneuvers of last resort
(cont.)
• Deliberate clavicle fracture
– Direct upward pressure on the mid-portion of
the fetal clavicle; reduces the shoulder-to-
shoulder distance
• Zavanelli maneuver
– Cephalic replacement followed by cesarean
delivery; involves rotating the fetal head into a
direct occiput anterior position, then flexing
and pushing the vertex back into the birth
canal, while holding continuous upward
pressure until cesarean delivery is
accomplished
– An operating team, anesthesiologist, and
physicians capable of performing a cesarean
delivery must be present, and this maneuver
should never be attempted if a nuchal cord
previously has been clamped and cut

32. Maneuvers of last resort
(cont.)
• General anesthesia
– Musculoskeletal or uterine relaxation with
halothane (Fluothane) or another general
anesthetic may bring about enough uterine
relaxation to affect delivery
– Oral or intravenous nitroglycerin may be used
as an alternative to general anesthesia
• Abdominal surgery with hysterotomy
– General anesthesia is induced and cesarean
incision performed, after which the surgeon
rotates the infant transabdominally through
the hysterotomy incision, allowing the
shoulders to rotate, much like a Woods
corkscrew maneuver
– Vaginal extraction is then accomplished by
another physician

33. Documentation
• Documentation of the management of
shoulder dystocia should concentrate on the
maneuvers performed and the duration of
the event
• Terms such as mild, moderate, or severe
shoulder dystocia offer little information
about the situation or care encountered
• Other team members assisting the delivery
should be listed, as well as cord pH, if
obtained
• Specific notation regarding which arm was
impacted against the pubis should be made
in the event that subsequent nerve palsy
develops
• The delivery should be reviewed with the
parents, and the management and prognosis
for any infant palsy should be explained

34. Steps One and Two
• Personnel (continued)
– Anesthesiology
– Obstetrics
• Attending to supervise and step in as
needed
• 2 residents at minimum
– Ideally 2 at perineum
– One to assist with maneuvers
(suprapubic pressure) away from
perineum

35. Step Three – Primary
Maneuvers
• McRoberts maneuver
– Patient positioned with hips at
edge of the broken-down birthing
bed
– Both hips are sharply flexed with
knees remaining flexed (“knees to
shoulders”)
– Ideally performed by staff, not
family, to assure it is adequately
performed
– No benefit to “prophylactic”
McRoberts

36. McRoberts Maneuver

37. McRoberts Maneuver
• This maneuver assists delivery
by:
– Straightening maternal lumbar
lordosis
– Rotates symphysis superiorly and
anteriorly
– Improving angle between pelvic
inlet and direction of maximal
expulsive force
– Elevates anterior shoulder allowing
posterior shoulder to descend

38. McRoberts Maneuver

39. Oblique suprapubic
pressure
• Usually applied in concert with
McRoberts maneuver
• Directed downward and laterally
in order to effect rotation of the
fetal anterior shoulder under the
symphysis
• Should be applied from the fetal
posterior

40. Oblique suprapubic
pressure

41. Step Four – Secondary
Maneuvers
• There is no conclusive evidence
that one maneuver is superior
to another
• In each patient, the operator
must decide which maneuver
will be most effective
• This is a good time to decide
about an episiotomy – is there
room to get your hand in?
• Time to initiate perinatal code
(4-2012)

42. Woods screw maneuver
• Apply pressure on the clavicle to
effect rotation of the shoulders
out of the vertical orientation
• As fetus rotates, anterior
shoulder should pass under
symphysis
• May be a good choice for a
right-handed operator when the
fetal occiput is oriented to the
maternal right

43. Woods screw maneuver

44. Woods screw maneuver
• Potential complication:
– Fetal clavicular fracture IN
DIRECTION OF APEX OF LUNG

45. Rubin’s maneuver
• Apply pressure to the fetal
scapula to effect rotation of the
shoulders out of the vertical
orientation
• As fetus rotates, anterior
shoulder should pass under
symphysis
• May be a good first choice for a
right-handed operator when the
fetal occiput is directed to the
maternal left

46. Rubin’s maneuver
• May result in need for less
traction and less brachial plexus
strain than McRoberts maneuver
– Gurewitsch, 2005

47. Delivery of Posterior Arm
• The operator inserts a hand into
the vagina and locates the
posterior arm.
• The operator applies pressure in
the antecubital fossa to flex the
elbow across the chest
• The operator grasps the forearm
or hand and pulls it out of the
vagina

48. Delivery of Posterior Arm
• The anterior shoulder should
pass under the symphysis
• Rotation maneuvers (Woods or
Rubin’s) can be applied if
needed
• This maneuver will tend to be
more difficult with one’s non-
dominant hand

49. Delivery of Posterior Arm

50. Delivery of Posterior Arm
• Potential complications
– Fracture of humerus
– Fracture of clavicle

51. Gaskin All Fours
Maneuver
• Attributed to midwife Ina May
Gaskin
• An option for a patient without
anesthesia
• Traction is applied in the
opposite direction (still toward
the floor, but now directed
towards delivery of the posterior
shoulder first)

52. Intentional clavicular
fracture
• Apply pressure over mid-clavicle
in a vector AWAY from the lung
• May be difficult to perform
• If successful, may reduce the
diameter of the shoulder girdle
• Potential complication:
– Lung injury

53. Still not out?!What now???

54. Step Five – Regroup
and Repeat
• Considerations:
• Time passed so far?
• Episiotomy?
• Different operator?
• Make OR preparations!

55. Step Six – Final Steps
• Zavanelli maneuver (cephalic
replacement)
– Relax uterus with terbutaline
– Rotate head back to OA (“reverse
restitution”)
– Flex neck
– Upward pressure
– To OR

56. Step Six – Final Steps
• Symphysiotomy
– Not commonly done when
cesarean is available
– Last ditch effort
• Insert Foley catheter
• Use vaginal hand to laterally displace
urethra to avoid injury
• Incise symphysis through mons pubis

57. Do not:
• Panic
• Apply any more lateral traction
than would be applied in an
uncomplicated delivery
• Apply fundal pressure – may
worsen the shoulder impaction
or even rupture the uterus
• Cut a nuchal cord until after the
shoulders are released

58. Do:
• Remain calm
• Communicate well
– Mark time of head delivery
– Consider calling out time in one
minute increments
• Call for help
• Document clearly and legibly

59. Do:
• Be sure to “debrief” as a team
after the delivery is completed
– Opportunity to analyze situation
and critique team performance
– Opportunity to be sure
documentation is consistent
– Who did what becomes very
important
• Send cord gases

60. Do:
• Review with the family exactly
what happened and answer
questions – soon after delivery,
but probably not immediately
• Follow the baby’s course in the
nursery
• Notify Risk Management

61. References
• Shoulder Dystocia (Practice Bulletin 40). American
College of Obstetricians and Gynecologists.
November 2002.
• Rodis, JF. Management of fetal macrosomia and
shoulder dystocia. Up to date, v 14.1; last
updated October 12, 2005.
• Brachial Plexus. Wikipedia, the online
encyclopedia.
http://en.wikipedia.org/wiki/Brachial_plexus
Accessed March 21, 2006.
• Beall, MH, et al. Objective definition of shoulder
dystocia: a prospective evaluation. Am J Obstet
Gynecol 1998;179:934.
• Spong CY, et al. An objective definition of
shoulder dystocia: prolonged head-to-body
interval and/or the use of ancillary obstetric
maneuvers. Obstet Gynecol 1995;86:433
• Gurewitsch ED et al. Comparing McRoberts’ and