SHOULDER DYSTOCIA

Presented by:
Trias Ditia B. P., S. Ked.
DEFINITION OF DYSTOCIA

There are several labor abnormalities that may

interfere with the orderly progression to
spontaneous delivery. Generally, these are
referred to as dystocia. Dystocia literally means
difficult labor and is characterized by abnormally
slow labor progress
Abnormal labor may be due to:
Power: Uterine contractions are
inadequate, or mother's strength to push
less
Passenger: size of fetus or abnormal
proportions, presentation, or position
Passage: small pelvis or obstructed
birth canal
SHOULDER DYSTOCIA
• Shoulder dystocia occurs in 0.15% to 1.70% of all
vaginal deliveries and is defined as an impaction
of the fetal shoulder after delivery of the head.
• It is associated with increased fetal morbidity and
mortality secondary to brachial plexus injuries
and asphyxia.
• the fetal head is born, but the shoulder is restrained and
cannot be born
• the fetal head is born but there is no external rotation
• the head stays attached to the vulva, and even dances
back (turtle sign)
FETAL COMPLICATION
• FETAL DEATH
• FETAL asphyxia
• Brachial plexus palsy
• Cervical fracture
MATERNAL COMPLICATION
• Bleeding post partum
• Ruptur perinium level III & IV
• Infection
• Pelvic floor damage
• Ruptur uteri
 RISK FACTORS OF SHOULDER
DYSTOCIA

• Macrosomia
• Maternal obesity
• Previous macrosomic
infant
• Diabetes mellitus
• Gestational diabetes

Johnson et al., 2015

MANAGEMENT
ALARMER ALGORITHM
• Avoid 4P
• Ask for help
• Lift/hyperflexi of the legs: Mc Robert’s Maneuver
• Anterior shoulder disimpaction
 Suprapubic pressure
 Rotate to oblique
• Rotation of the posterior shoulder:
 Rubin Maneuver
 Wood’s screw maneuver
• Manual removal of the posterior arm
• Episiotomi
• Roll woman over onto “all fours” (Gaskin)
Ask For Help
• Anticipation and preparation are important. Help should
be available as extra hands may be needed during the
delivery. ask for help from another person or assistant.
• Once the shoulder dystocia is identified, no significant
pressure should be applied to the head until the shoulders
are delivered. Fundal pressure should never be applied
as it only exacerbates the shoulder impaction
 Lift/hyperflexi of the legs
• McRoberts maneuver is
performed by hyperflexion
and abduction of the
maternal hips, flattening the
lumbar spine, and rotating
the pelvis to increase the
anterior-posterior outlet
diameter
Anterior shoulder disimpaction
oWith the woman in mcrobert’s
positioning
o Suprapubic pressure –
abdominal approach
o Using both hands, apply the
heel of clasped hands just
above the pubic bone
o With straight arm, use your
body to apply pressure
downward from the posterior
aspect of anterior shoulder to
dislodge it
o Do not apply fundal pressure
Rubin Maneuver
• Rubin Maneuver: : The anterior fetal shoulder is rotated obliquely with a
vaginal hand. This maneuver may also be performed in a posterior manner.
then hold the fetal shoulder anteriorly so that the shoulder rotates into an
oblique / transverse position
Wood Corkscrew Maneuver
• Wood corkscrew : First check the position of the fetal back
using 2 fingers. Then the shoulder is rotated 180 degrees
so that the posterior shoulder becomes the anterior
shoulder.
• There is no “right order” in which the maneuvers
described in the following text should be performed, and
maneuvers can and should be used more than once, as
needed.
Manual delivery of the posterior arm: By grabbing
the posterior hand, the posterior arm can be flexed
and swept across the fetal chest, delivered first,
thereby creating more room for the anterior shoulder.
Episiotomy: Incision of the perineum provides
additional room and should be considered if it
might facilitate delivery or additional maneuvering.
incision on the perineum to enlarge the birth canal
so that the baby can leave freely
Gaskin Maneuver
Roll women into ‘all fours’
Facilitated in the unanesthetized patient, she is turned over on “all fours,”
inverting the anterior and posterior shoulders
MORE INVASIVE PROCEDURE
• Neonatal clavicular fracture: Palpate the clavicles and
apply outward pressure with the thumb to avoid lung or
subclavian artery injury.

• In extreme cases, the Zavanelli maneuver (in which the

fetal head is flexed and pushed back up into the uterus as
preparations for emergent cesarean section are made)
Avoid 4P
• Panic
• Pulling the fetus head
• Pushing the fundus
• Pivotting: rotating the head too keenly with coccygeus as
support)
THANK YOU
FOR YOUR ATTENTION