SHOULDER

DYSTOCIA
Lecture:
dr. Rully P. Adhie, Sp.OG

Created by
GILANG ARIA SANTOSA
INDA YANTI
DEDE TRI PIRMANDI
 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
• 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
 Risk Factors
• 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)
 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
 Diagnostic
• It should 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.
 Complications
• Maternal
• Hemorrhage because of laceration, episiostomi.
• Fetal
• Fracture of humerus or clavicle

• Brachial plexus injury

• Fetal hypoxia

• With or without permanent neurologic damage

 Prevention
• Offer cesarean section in labor risk
• Intrapartum interventions
• Immediately ask for help when shoulder dystosia is known
HELPER Algorithm
• H: Call for Help; Shoulder dystocia is called if shoulders
cannot be delivered with gentle traction
• E: Evaluate for Episiotomy:
• L: Legs (McRoberts): Hyperflexion and abduction of
hips—initial maneuver
McRoberts 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 McRobert’s 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
HELPER Algorithm cont.
• P (Suprapubic Pressure)
• Enter (Internal Maneuvers):
• Push posterior or anterior shoulder toward fetal chest to
adduct shoulders
• 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
Thank you