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Difficulty in delivery of fetal

shoulders
Failure to deliver fetal shoulder
without utilizing facilitating
maneuvers
Prolonged head-to-body delivery
time
>60 seconds
The overall incidence of shoulder dystocia
varies based on fetal weight
Incidence: 0.2-0.3% of all live births;
represents an obstetric emergency
Increase between 5-9 % for infant weighing
between 4000-4500 g
0.6-1.4%: 2500g
Antepartum
Macrosomia (>4500g)
DM/GDM (increases overall risk by 70%)
Multiparity
Intrapartum
Prolonged active phase of first-stage labor
Prolonged second-stage labor
Protracted descent
Assisted vaginal delivery (forceps or vacuum)
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
Itshould be suspected when the fetal head
retracts into the perineum (ie, turtle sign)
after expulsion due to reverse traction from
the shoulders being impacted at the pelvic
inlet.
The diagnosis is made when the routine
practice of gentle, downward traction of the
fetal head fails to accomplish delivery of the
anterior shoulder.
Maternal
Hemorrhage because of laceration, episiostomi.
Fetal
Fracture of humerus or clavicle
Brachial plexus injury
Fetal hypoxia
With or without permanent neurologic damage
Offer cesarean section in labor risk
Intrapartum interventions
Immediately ask for help when shoulder
dystosia is known
Diagnostic

Call for adittional assistance

Manuver McRobert

Manuver Rubin

Gave birth to the posterior shoulder
(Manuver wood)
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
This procedure results in a cephalad rotation of
the symphysis pubis and a flattening of the
sacral promontory
These motions push the posterior shoulder over
the sacral promontory, allowing it to fall into
the hollow of the sacrum, and rotate the
symphysis over the impacted shoulder
When this maneuver is successful, the fetus
should be delivered with normal traction
The McRoberts maneuver alone is believed to
relieve more than 40% of all shoulder dystocias
and, when combined with suprapubic pressure,
resolves more than 50% of shoulder dystocias
P (Suprapubic Pressure): No fundal
pressure; combination of McRoberts and
suprapubic pressure resolves most
shoulder dystocias
Enter (Internal Maneuvers):
Rubin: Push posterior or anterior shoulder
toward fetal chest to adduct shoulders
Woods: Insert hand into posterior vagina and
rotate posterior shoulder clockwise or
counterclockwise
Remove: Delivery posterior arm
Follow posterior arm down to elbow
Usually anterior to fetal chest
Flex arm at the elbow
Sweep forearm across fetal chest
grasping hand directly and pulling outward
may lead to fractures
R = Roll the Patient
Roll patient to all fours position
Increases pelvic diameters
Movement and gravity may also contribute
to dislodging the impaction
Deliver posterior shoulder with gentle
downward traction