SHOULDER DYSTOCIA
Introduction
Shoulder dystocia has emerged as one of the most
important clinical and medico legal complication of
vaginal delivery.
When shoulder dystocia is anticipated the
obstetrician should mentally rehearse the sequence
of steps necessary to treat this problem and be ready
to act in a logical , step by step fashion.
The reported incidence varies from 0.2 to 1.7% in
cephalic vaginal deliveries.
Certain patterns increases the
likelihood of shoulder dystocia
1. a protracted or arrested active phase of first stage of
labour is associated with an increased incidence of
shoulder dystocia
2. Protracted or arrested descent in the second stage
of
labour is another marker.
3. Assisted mid pelvic delivery carries a higher risk of
shoulder dystocia but it does not occur in 95% of
such deliveries.
Defination
Shoulder dystocia is defined when the fetal head has
delivered but the shoulder do not deliver
spontaneously or with normal amount of gentle
downward traction.
Clinical diagnosis is confirmed when the head delivers
but external rotation does not occur and the head
recoils tightly against the perineum. ( TURTLE
SIGN )
When the head to completion of delivery interval of
more than 60 secs or need to use additional
manoeuvres to deliver the shoulder.
Shoulder dystocia is of two types
Unilateral shoulder dystocia – when anterior or
posterior shoulder is impacted.
Bilateral shoulder dystocia – when bilateral
shoulders
lie above the pelvic brim.
Prediction
Following predisposing factors have been identified but, in
general, lack specificity.
Antepartum risk factors
1. Macrosomia
2. Diabetes- this is due to greater shoulder/head
circumference ratio because of the insulin senstive
nature of the tissues that contribute to shoulder
girth , compared to brain growth which is not
affected by hupoglycaemia and hyperinsulinism.
3. Obesity- chances are 0.6% in women less than
90kgs to 5% in women more than 113kgs.
4. Post term pregnancy- incidence of macrosomia is 12%
at 40 weeks and 21% at 42 weeks. In later weeks of
pregnancy the fetal chest and shoulders continue to grow
steadily, whereas the biparietal diameter growth slows ,
increasing the likelihood of an unfavourable shoulder/head
circumference ratio.
5. Previous shoulder dystocia
Because macrosomia is the commonest association
with shoulder dystocia and neonatal injury, it has
been proposed that elective cs of fetus estimated to
weigh more than 4500gm and even 4000gm should be
persued.
6.Abnormal pelvic anatomy
7.Short stature (less than 5feet tall)
8.Previous large infant (>4000gms)
9.Anencephaly
10.Multiparity
11.Fetal ascites
Intrapartum risk factors
Operative vaginal delivery
Arrest in the late first stage of labour
Arrest of descent in second stage of labour
Precipitous delivery
ACOG guidelines on shoulder
dystocia
Shoulder dystocia cannot be predicted or prevented
because accurate methods for doing so do not exist.
Elective induction or caesarean delivery for all women with
a suspected macrosomic fetus is not appropriate.
When evaluating the risks and benefits of caesarean and
vaginal delivery in patients with a history of shoulder
dystocia , the obstetrician should consider.
estimated weight
gestational age
maternal glycemic status
previous history of shoulder dystocia.
Complications
Fetal – 1. Asphyxia fetus is not hypoxic before
shoulder dystocia occurs there should be 4 to 5
mins before the possibility of permanent hypoxic
damage.
2.Brachial plexus injury is the most common and
serious complication.
occurs in 5-15% of neonates .
Most common type is Erb-Duchenne involving C5 and
C6 nerve roots . The range of permanent palsy in those
infants with brachial plexus is 4-32%.
3.Fractures occuring in 15% . Majority of these are
clavicular,
with fracture of humerus account for less than
1%.
Maternal complication
1.Genital tract lacerations more common due to the
tight feto pelvic relationship.
additional room needed for manoeuver
extension of episiotomy and 3rd and 4th degree tears
are more common.
Post partum haemorrahage due to combination of
-
uterine atony,
prolonged labour,
large infant
increased blood loss from lacerations and
extensive episiotomy.
Managing shoulder dystocia
For managing shoulder dystocia we use term
HELPERR
H – call for help
E – evaluate for episiotomy
L – legs ( MC ROBERTS maneuver )
Mc Roberts Maneuver -symphysis rotates
superiorly which lifts the fetus and flexes the fetal spine toward the
anterior shoulder.
P – Suprapubic pressure
E- Enter maneuvers ( Internal
rotation ) – manipulates the fetus to rotate the anterior shoulder
into an oblique plane and under maternal symphysis.
R-Rubin 2 maneuver
Placing two fingers behind posterior aspect of anterior
shoulder toward the fetal chest . This will adduct fetal
shoulder girdle, reducing its diameter.
Wood screw maneuver
Two fingers on the anterior aspect of the fetal
posterior shoulder, applying gentle upward pressure
180 degrees ,thus the posterior shoulder which is
below the level of pelvic brim is screwed around under
the level of pubic arch and then it is delivered from
anterior position.
Deliver the posterior arm
Flex the elbow and sweep the forearm across the
chest. Grasping of the upper arm should be avoided as
there is risk of fracture of humerus.
R- Roll the patient ( Gaskin or all
four maneuver ) increases the flexibility of sacroiliac
-
joint and gravity push the posterior shoulder anteriorly.
Maneuvers of last resort
Zavanelli maneuver : Cephalic replacement followed
by cs.
Cliedotomy
Abdominal rescue
Symphysiotomy
ZAVANELLI MANEUVER/cephalic
replacement
Summary
Shoulder dystocia cannot be reliably predicted in the
antenatal period .
Clinical estimation of macrosomia is as as accurate
as
ultrasound.
Elective cs is not recommended solely on the
grounds
of suspected macrosomia.
No consistent patterns of labour and/or delivery
reliably predict shoulder dystocia.
Cs for cumulative risk factors in the antenatal
and/or intrapartum period may be reasonable on a
All personnels involved with the care of the women in
labour should be familiar with a logical sequence of
manoeuvers to manage shoulder dystocia.
No evidence is available that any one standard manoeuver
to deal with shoulderdystocia is superior to another.
However rotating the shoulders to the oblique diameter
and mc roberts manoeuver are easily
performed,logical,often successful , and associated with
minimal fetal trauma.
Strong downward traction on the fetal head and neck
should be avoided as it is associated with high rate of
brachial plexus injury.
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