Shoulder Dystocia

District 1 ACOG
Medical Student Education Module 2011

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

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

Risk Factors
Antepartum
Macrosomia (>4500g)
DM/GDM (increases overall risk by 70%)
Multiparity

Intrapartum

Prolonged deceleration phase of labor

Prolonged 2nd stage
Protracted descent
Operative delivery (vacuum>forceps)

Risk factors cont

No evidence based data:

Male
AMA
Short maternal stature
Abnormal pelvic shape/size

Unpredictable
25-50% have no defined risk factor!
50% of cases occur in infants whose birth
weight is <4000g
84% of patients did not have prenatal dx.
of macrosomia by US
82%of infants with brachial plexus palsy
did not have macrosomia

Complications
Maternal
Hemorrhage
4th degree laceration

Fetal
Fx of humerus or clavicle
Brachial plexus injury (Erbs/Klumpkes
palsy)
Asphyxia/cord compression

Physician
Litigation: 11% of all obstetrical suits

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

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

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

HELPER 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 hipsinitial maneuver

HELPER Algorithm cont.

P (Suprapubic Pressure): No fundal pressure;
combination of McRoberts and suprapubic
pressure resolves most shoulder dystocias
Enter (Internal Maneuvers):
Woods: Insert hand into posterior vagina and rotate
posterior shoulder clockwise or counterclockwise
Rubin: Push posterior or anterior shoulder toward
fetal chest to adduct shoulders

Remove: Delivery posterior arm

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

Prolog Question #1
A 25 year-old healthy woman has a normal
labor and a spontaneous delivery of the fetal
head. On expulsion of the head, a shoulder
dystocia is recognized. Before instituting
maneuvers the next step is to:

A) Tell the patient not to push

B) Apply fundal pressure
C) Increase or initiate Oxytocin administration
D) Cut a large episiotomy

Answer
A) Tell the patient not to push
The training and experience of clinician
should dictate sequence of maneuvers that
will be used; however, initially it is best to do
nothing that will further impact the anterior
shoulder above the pubic symphysis. The
simplest way to avoid further impaction is to
ask the patient to stop pushing.