SHOULDER DYSTOCIA

Obstetric Emergencies

What is Shoulder Dystocia?

Definition: a delivery that requires additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. It occurs when:
The foetal shoulder impacts on the maternal pelvic inlet
Pubic symphysis (anterior shoulder)
Anterior shoulder more common

Sacral promontory (posterior shoulder)

Incidence: 0.6% (N.American & UK population studies)

Risk Factors
Previous dystocia (recurrence rate: 1-16%) Macrosomia
Large majority dont develop shoulder dystocia 48% of shoulder dystocia occurs in infants <4000g

GDM Maternal BMI> 30kg/m 2 Induction of Labour Prolonged 1st/2nd stage of labour Secondary arrest Oxytocin augmentation Assisted vaginal delivery

NOTE: a large majority of cases occur with no RFs

Complications
Perinatal M&M high (Even when managed appropriately)
Brachial plexus injury (4-16% deliveries)
Most resolve w/o permanent disabilities 10% permanent brachial plexus dysfunction

Hypoxia-acidosis

Maternal Morbidity increased

PPH (11%) 4th degree tears (3.8%) * NOTE: Incidence of these are unchanged by manoeuvres required to effect delivery.

Prevention
Suspected foetal macrosomia
Without maternal diabetes Elective LSCS NOT recommended With maternal diabetes should be considered
Reduces the potential morbidity If foetus >4500g

Previous shoulder dystocia

LSCS OR NVD are appropriate
BUT no requirement to routinely advise elective LSCS

How is shoulder dystocia diagnosed?

Routine traction in an axial direction
Routine traction: traction required for delivery of the shoulders in a NVD where there is no difficulty with the shoulders
NOTE: cadaveric studies lateral/downward traction more likely nerve avulsion

Signs of shoulder dystocia

Difficult delivery of face/chin Head remaining tightly applied to vulva or retracts Failure of restitution of foetal head Failure of shoulders to descend

Management
Intrapartum
If shoulder dystocia is anticipated (but not all cases anticipated)
An experienced obstetrician should ideally be on-call & available for 2nd stage labour

Delivery
Timely management requires prompt recognition
CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) report 47% of babies died w/in 5 mins of the head being delivered Therefore, important to avoid other problems e.g. Hypoxia acidosis, unnecessary trauma...etc.

HELPERR

Post-delivery
Monitor for the possibility of:
PPH 3rd or 4th degree tears

HELPERR
H: Call for Help E: Evaluate for episiotomy L: Legs (McRoberts manoeuvre) P: Suprapubic pressure E: Enter manoeuvres (internal rotation) R: Remove posterior arm R: Roll the patient

Steps to manage - Delivery

1. Call for help
Maternal pushing should be discouraged
May cause further impaction of shoulders

Woman manoeuvred to bring buttocks to edge of bed DONT apply fundal pressure
Associated w/ high neonatal complications and uterine rupture

2. 3.

Episiotomy not necessary for all cases

Reserved for facilitation of posterior arm delivery or internal rotation of shoulders

Single most effective intervention

McRoberts Manoeuvre
Should be performed first Success rates up to 90% Low rates of complication Apply in downward and lateral direction
To push anterior shoulder towards foetal chest

4. 5.

Suprapubic pressure is useful

Advanced manoeuvres
2nd line manoeuvres (If McRoberts manoeuvre/Suprapubic pressure fail)
Internal manipulation/delivery of posterior arm All-fours position
Appropriate for: slim/mobile woman, without epidural anaesthesia, with midwifery attendant

3rd

line manoevres (Persistent failure of first/second line manoeuvres; although rarely required)
Cleidotomy: bending the clavicle with a finger/surgical incision Symphysiotomy: dividing the symphyseal ligament (BUT high incidence of maternal M&M and poor neonatal outcome) Zavanelli manoevre: cephalic replacement of the head and delivery by LSCS
May be appropriate for rare bilateral shoulder dystocia

Additional slides
1) Brachial Plexus Injury/Palsy 2) McRoberts Manoeuvre 3) Suprapubic pressure 4) 2nd line manoeuvres

BPI/BPP
Types:
Erbs palsy: C5/6 Upper middle trunk palsy: C5-7 Klumpkes palsy: C8/T1 Total BPP: C5-T1 Bilateral BPP: bilateral involvement

NOTE: Not all BPI are due to excess traction by obstetric staff - There is now significant evidence to suggest maternal propulsive forces may contribute AND some BPI not associated with clinically evident shoulder dystocia. - NOTE: In cases of Erbs palsy caused by posterior shoulder dystocia NOT cause by obstetric staff

McRoberts Manoeuvre
Flexion and abduction of maternal hips
Positioning maternal thighs on abdomen

Function:
Straightens the lumbosacral angle Rotates the maternal pelvis cephalad Associated with an increase in uterine pressure and amplitude of contractions

Suprapubic Pressure
Suprapubic pressure can be employed with McRoberts manoeuvre to improve success rates Suprapubic pressure:
Reduces the bisacromial diameter Rotates the anterior shoulder into the oblique pelvic diameter. Should be applied for 30 seconds
No clear difference in efficacy b/w continuous pressure or rocking; movement

The shoulder is then free to slip underneath the symphysis pubis with the aid of routine traction.

 Clinical judgement should be used to determine order of manoevres: delivery of posterior arm and internal rotation
No advantages between the two

nd 2

line manoeuvres

Internal rotation
Delivery of shoulders may be assisted by rotation into an oblique diameter OR by a full 180 rotation of the foetal trunk

Delivery of posterior arm

High complication rate e.g. humeral fractures Some authors favour delivery of posterior arm in mothers of larger habitus