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Shoulder Dystocia

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 (Erb’s/Klumpke’s 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 hips—initial 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