Shoulder Dystocia

International

Shoulder Dystocia

Shoulder Dystocia
International

Objectives
Definition and
Incidence
Significance

Risk Factors
Diagnosis

Management

Shoulder Dystocia
International

Definition
impaction of anterior shoulder above

symphysis
inability to delivery shoulders by usual
methods

Incidence
1 to 2 per 1000 deliveries
16 per 1000 deliveries of babies > 4000 g

Shoulder Dystocia
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Shoulder Dystocia
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Shoulder Dystocia
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Complications of Shoulder Dystocia

Fetal/neonatal

death
asphyxia and sequelae
fractures - clavicle, humerus
brachial plexus palsy

Maternal

- postpartum hemorrhage
- uterine rupture

Shoulder Dystocia
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Risk Factors
post-term pregnancy
maternal obesity

fetal macrosomia
previous shoulder dystocia

operative vaginal delivery

prolonged labour

poorly controlled diabetes

Shoulder Dystocia
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Risk factors are present in

< 50% of cases

Shoulder Dystocia
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Diagnosis

head recoils against perineum,

turtle sign
spontaneous restitution does not
occur
failure to deliver with expulsive
effort and usual gentle direction

Shoulder Dystocia
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Turtle sign

Shoulder Dystocia
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Aim :

1. Release anterior shoulder from

impaction at symphisis
2. Reduce biacromial diameter
3. Enlarge pelvic capacity

Shoulder Dystocia
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Ask for help

Lift - the buttocks
- the legs

McRoberts
maneuver

Anterior disimpaction of shoulder

- suprapubic pressure (Massanti)
- rotate to oblique (Rubin)
Rotation of the posterior shoulder
-Woods maneuver
-Rubin+Wood Cockscrew
Manual removal of posterior arm (Schwartz)
Episiotomy consider
Roll over onto 2-4 or knee chest (Gaskin)

Shoulder Dystocia
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Avoid the Ps
Panic
Pulling (on the head)
Pushing (on the fundus)

Pivoting (sharply angulating the

head, using the coccyx as a
fulcrum)

Shoulder Dystocia
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Ask for HELP

get the mother on your side
partner, coach
nursing
notify physician back up or other
appropriate personnel

Shoulder Dystocia
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Lift - McRoberts Maneuver

Shoulder Dystocia
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Lift - McRoberts Maneuver

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34
(2007) 501531

Shoulder Dystocia
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Lift - McRoberts Maneuver

The McRoberts maneuver does not change the actual dimension of the maternal pelvis.
Rather, the maneuver straightens the sacrum relative to the lumbar spine, allowing cephalic
rotation of the symphysis pubis sliding over the fetal shoulder.
Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
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Shoulder Dystocia
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McRoberts' maneuver. A, Bisacromial diameter pinned behind pubic symphysis. B, Removing

the maternal legs from the stirrups and putting the knees up to the chest fulcrums the pubic
symphysis over the impacted anterior shoulder
John A. Marx, Robert S. Hockberger, Ron M. Walls. James G. Adams. Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.
Mosby 2006

Shoulder Dystocia
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Lifting the legs and

buttocks
(McRoberts maneuver)
flexion of thighs on
abdomen
requires assistance
70% of cases are resolved
with this manoeuvre alone

Shoulder Dystocia
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Anterior Disimpaction 1) Suprapubic Pressure

(Massanti Maneuvre)

NO fundal pressure
Abdominal approach:
suprapubic pressure
applied with heel of
clasped hand from the
posterior aspect of the
anterior shoulder to
dislodge it

Shoulder Dystocia
International

Anterior Disimpaction 1) Suprapubic Pressure

(Massanti Maneuvre)

NO fundal pressure
Abdominal approach:
suprapubic pressure Suprapubic pressure. Suprapubic
pressure is applied directing the
applied with heel of
anterior shoulder downward and
clasped hand from the laterally. If possible, pressure should be
posterior aspect of the directed from the side of the fetal spine
toward the face. Pressure should be
anterior shoulder to
applied by an assistant with either the
palm or fist.
dislodge it
Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
International

Suprapubic Pressure
(Massanti Maneuver)

Shoulder Dystocia
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Suprapubic Pressure
(Massanti Maneuver)

Shoulder Dystocia
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Anterior Disimpaction 2) Rubin Maneuver

vaginal approach
adduction of anterior
shoulder by pressure
applied to the posterior
aspect of the shoulder (the
shoulder is pushed toward
the chest)
consider episiotomy
NO fundal pressure

Shoulder Dystocia
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Rubin Maneuver

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Rubin Maneuver

Rubin's maneuver
decreases the
bisacromial
diameter. AP,
anteroposterior.

John A. Marx, Robert S. Hockberger, Ron M. Walls. James G. Adams. Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.
Mosby 2006

Shoulder Dystocia
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Rubin Maneuver
Rubin's maneuver decreases the bisacromial
diameter. AP, anteroposterior.
The Rubins maneuver. This maneuver involves applying
pressure to the most accessible part of the fetal shoulder
(ie, either the anterior or posterior shoulder) to effect
shoulder adduction (A). (B) Curved arrows shows
rotation of fetal shoulders.

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 1

pressure on
anterior aspect of
posterior shoulder
may be combined
with anterior
disimpaction
manoeuvers
NO fundal
pressure

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 2

Woods screw
maneuver
can be done
simultaneously
with anterior
dissimpaction

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 3

may be repeated
if delivery not
accomplished by
Steps 1 & 2

Shoulder Dystocia
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Rotation of Posterior Shoulder - Step 4

Shoulder Dystocia
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Shoulder Dystocia
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The Woods corkscrew maneuver.

This maneuver involves applying
pressure to the clavicular surface of
the posterior arm, allowing rotation
(A) such that the anterior shoulder
dislodges (B) from behind the
maternal symphysis. Curved arrow
shows rotation. Straight arrow
shows manual rotation of infants
body in coordination with rotation
by hand below
Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
International

Manual removal of posterior arm

flex arm at elbow
(pressure in
antecubital fossa to
flex arm)
sweep arm over
chest
grasp wrist/forearm
or hand
deliver arm

Shoulder Dystocia
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Manual removal of the posterior arm

Delivery of the posterior arm. To deliver the
posterior arm, pressure should be applied at the
antecubital fossa to flex the fetal forearm. The
forearm or hand is subsequently grasped and the
arm swept out over the infants chest and
delivered over the perineum. Rotation of the trunk
to bring the posterior arm anteriorly is sometimes
required. (A) First, turn fetal head to allow entry of
practitioners hand to facilitate manipulation. (B)
Second, support fetal head with one hand and
sweep second hand posteriorly. (C) Next, flex
infants arm at antecubital fossa to allow
practitioner to grasp posterior forearm or hand.
(D) Deliver posterior arm. This allows rotation of
the fetus with the goal of disimpacting the
anterior shoulder. (E) Further rotate fetus to
facilitate delivery.

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
International

Episiotomy

may facilitate Woods

Manoeuver or allow room for
delivery of the posterior arm

Shoulder Dystocia
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Roll Over

= all-fours (Gaskin maneuver)

May allow easier access to
posterior shoulder
Radiographic studies : pelvic
diameters increase (10 mm true
obstetric conjugate & sagital
pelvic outlet)

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Gaskin maneuver
The Gaskin position. The
all fours position exploits
the effects of gravity and
increased space in the
hollow of the sacrum to
facilitate delivery of the
posterior shoulder and
arm.

Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
International

Gaskin maneuver

Shoulder Dystocia
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As a last resort

clavicular fracture
cephalic replacement (Zavenelli
manoeuvre)
symphysiotomy

Shoulder Dystocia
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Zavenelli manoeuvre

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Last Resort
(A, B) This figure shows
delivery of the posterior arm
with facilitation of delivery by
hysterotomy. The intraabdominal hand can be used
to rotate the anterior
shoulder to allow vaginal
delivery; or a Zavanelli
maneuver can be performed
subsequently, allowing
cesarean delivery.

Shoulder Dystocia
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Symphysiotomy

Shoulder Dystocia
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Afterwards

be prepared for PPH

inspect for maternal lacerations and
trauma
examine the baby for evidence of
injury
explain the delivery and manoeuvers

chart what was done

Shoulder Dystocia

Recommendation that a shoulder dystocia

intervention form should include the following
information

International

When and how the dystocia was diagnosed

Progress of labor (active phase and second stage)
Position and rotation of the infants head
Presence of episiotomy
Anesthesia required
Estimation of force of traction applied
Order, duration, and results of maneuvers used
Duration of shoulder dystocia
Documentation of adequate pelvimetry before initiating labor
induction or augmentation
Neonatal and obstetric impressions of the infant after delivery
Information given to gravida that shoulder dystocia had occurred
Amy G. Gottlieb, Henry L. Galan. Shoulder Dystocia: An Update. Obstet Gynecol Clin N Am 34 (2007) 501531

Shoulder Dystocia
International

Conclusions

anticipate and be prepared (most

are unpredictable)
remember the mnemonic
ALARMER
stay calm, dont panic, pull, push
or pivot

Shoulder Dystocia
International

Ask for help

Lift - the buttocks
- the legs

McRoberts Maneuver

Anterior disimpaction
- rotate to oblique
- suprapubic pressure

Rotate the posterior shoulder - Woods maneuver

Manual removal of the posterior arm
Episiotomy consider
Roll over

Shoulder Dystocia
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THANK YOU

Shoulder Dystocia
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Shoulder Dystocia
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Hibbard Manuever

Shoulder Dystocia
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Schwartz Dixon

Shoulder Dystocia
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Shoulder Dystocia

Shoulder Dystocia
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Shoulder Dystocia
Management
Help obstetrician, pediatrician
Episiotomy
Legs elevate (McRoberts)
Pressure - suprapubic
Enter vagina Rubins and Woods screw
Roll or Remove posterior arm
Zavanelli, clavicular #, symphysiotomy