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Since this phenomenon occurs because of a relative size or positional discrepancy between the fetal and pelvic bony dimensions, it nearly always occurs in parturients undergoing cephalic vaginal delivery after 34 weeks’ gestation.
During the fetal head’s cardinal movements of descent, flexion, and internal rotation within the bony pelvis, the shoulders descend to reach the pelvic inlet.
During the head’s subsequent extension, delivery, and external rotation, prior to final expulsion, the shoulders need to rotate within the bony pelvis in a winding fashion to arrive in the most accommodating dimension of the pelvis, its oblique diameter. If either the fetal shoulder dimensions are too large or the maternal pelvis is too narrow, or both, to permit shoulder rotation to the oblique pelvic diameter, persistent anteroposterior orientation of the fetal shoulders may result in the anterior shoulder being obstructed behind the symphysis pubis impeding delivery and leading to shoulder dystocia. If the sacral promontory also obstructs the posterior shoulder, bilateral (and more difficult) shoulder dystocia occurs.
Unilateral shoulder dystocia is usually easily dealt with by standard techniques. (B. Harris, Shoulder dystocia. Clinical Obstetricsand Gynecology, 1984l 27:106)
The posterior shoulder is not in the hollow of the pelvis. This presentation often requires a cephalic replacement. (C.Pauerstein [ed.], Clinical Obstetrics, Churchill Livingstone, New York, 1987.)
Fundal worsen impaction and may result in uterine rupture
-Hyperflex hips(raises symphysis pubis about 9mm, provide clearance to release the anterior shoulder behind the symphysis, lumbosacral spine flattened-advance posterior fetal shoulder into the hollow of sacrum) and knees, abduct and outward rotation of hips -Encourage maternal pushing -Lateral neck traction / downward axial traction on the fetus
To dislodge the anterior shoulder form symphysis by pushing it into oblique diameter -Stand on platform on the same side of the fetal spine -Lateral suprapubic pressure -Use the flats of assistant’s hands -Apply behind anterior shoulder -Continuous pressure -If unsuccessful after 30 sec, use rocking motion
Anterior shoulders -hand into posterior aspect of vagina -moving it up to posterior aspect of anterior shoulder -push anterior shoulder from behind into oblique position
Posterior shoulder -push posterior aspect of posterior shoulder through 180°, with change of hand at 90°
Use right hand if baby facing maternal left Enter posterior aspect of vagina Retrieve posterior hand or forearm Sweep across the chest & face Deliver the posterior arm
Causing increase in maternal morbidity Detailed explanation of what was done and why done; also what may happen to the mother and the baby after delivery and in the future should be discussed with the parents.
Brachial plexus injury (BPI) is one of the most important fetal complications of shoulder dystocia, complicating 2.3% to 16% of such deliveries. Most cases of BPI resolve without permanent disability, with fewer than 10% resulting in permanent neurological dysfunction.
A neonatologist should take care to the baby for: 1) Resuscitation as the baby may be in distress 2) Injury: BPI (Erb’s palsy) is one of the most important complications of shoulder dystocia, complicating 2.3% to 16% of such deliveries.
• Obstetric emergency
• vaginal cephalic delivery that requires additional
obstetric maneuvers to deliver the fetus after the
head has delivered and gentle traction has failed
• occurs when either the anterior, or less commonly
the posterior fetal shoulder impacts on the
maternal symphysis, or sacral promontory,
Source : RCOG Guidelines
• Impaction of fetal shoulders at the pelvic outlet
after the delivery of the head
Source: Handbook of Obstetrics & Gynaecologic Emergencies
• Difficulty in delivery of the fetal shoulders
Source: Obstetrics by Ten Teachers
RISK FACTORS – Pre-labour
• Previous shoulder dystocia
• Induction of labour
• Infants of diabetic mothers
• Fetal macrosomia >4.5kg
- excessive weight gain during pregnancy
- maternal obesity (BMI>30)
- asymmetric accelerated fetal growth in non-diabetic
- post-term pregnancy
RISK FACTORS – Intrapartum
• Prolonged first stage of labour
• Secondary arrest
• Prolonged second stage of labour
• Oxytocin augmentation
• Assisted vaginal delivery
The risk factor assessment and progress of labour may help in
prediction of it but they are insufficient.
But trials include:
A. Management of suspected fetal macrosomia
B. History of previous shoulder dystocia and its sequelae
C. Partograph may signal you the delay of the stages and any
suspected fetal macrosomia
• Early induction of labour
- Doesn’t prevent SD in non-diabetic woman with
suspected macrosomic fetus
- Reduce incidence of SD at term for GDM mothers
• Elective LSCS
- Should be considered if pregnancies complicated
by pre-existing or gestational DM, regardless of
treatment, with an estimated fetal weight of
greater than 4.5 kg.
the head of
Preparation for labour
All birth attendants should be aware of the methods
for diagnosing shoulder dystocia and the techniques
required to facilitate delivery.
Birth attendants should routinely look for the signs of
Timely management of shoulder dystocia requires
• Difficulty with delivery of the face and chin
• The head remaining tightly applied to the vulva or
even retracting (turtle-neck sign)
• Failure of restitution of the fetal head
• Failure of the shoulders to descend
Fetal head emerges and
retracts against the
Routine traction in an axial direction can be used to
diagnose shoulder dystocia but any other traction
should be avoided.
Routine traction is defined as ‘that traction required
for delivery of the shoulders in a normal vaginal
delivery where there is no difficulty with the
Axial traction is traction in line with the fetal spine
i.e. without lateral deviation.
Call for Help, initiate RED ALERT!
• State clearly
• Experienced obstetrician, midwife, nurses,
• Secure IV line
• Lithotomy position, legs in stirrup with buttocks at edge
• Empty/catheterise the bladder
Time window for brain hypoxia is 5 minutes.
* Fundal pressure should not be used.
* Encourage the mother not to push.
• To create more space for greater access to the
• An episiotomy is not always necessary.
Roll the patient to her hands & knees
* The baby most likely in hypoxic-acidotic state…
Zavanelli maneuver (mostly for bilateral dystocia)
Future: Posterior axillary sling
• Anterior clavicle is pressed against the ramis of the
• Avoid puncturing the lung by angling the fracture
• Theoretically, a fracture of the clavicle is less
serious than a brachial nerve injury and often heals
Consists of cephalic replacement
+ caesarean delivery.
• Relax uterus with terbutaline
• Rotate head back to OA
• Flex neck
• Upward pressure
• To Operation Theatre
• Insert Foley catheter
• Use vaginal hand to
urethra to avoid
• Incise symphysis
through mons pubis
• Brachial plexus injury
• Fetal fractures - humerus or clavicle
• Erb’s palsy
• Perinatal asphyxia
• Neonatal death
Brachial Plexus Injury
• Most cases resolve
• Larger infants at higher
• Due to excess traction,
• Damage to the
plexus is unlikely due
• Mode of delivery – LSCS or vaginal delivery
• Important to discuss with patient and her husband