SHOULDER DYSTOCIA

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPS

Clincal Associate Professor
Section of Urogynecology & Pelvic Reconstructive Surgery
Department of Obstetrics & Gynecology
University of the Philippines -
Philippine General Hospital
 CASE
● Ruby, a 34-year-old G3P1 (1011), consulted for
labor pains.

● She delivered her firstborn vaginally. The baby

weighed 3 kilograms. She had a miscarriage a
year later.

● According to her LMP, she has an AOG of 37

weeks. She was diagnosed with gestational
diabetes mellitus during the 7th month of this
pregnancy.
 CASE
● Her vital signs were normal. She weighed 81
kilograms at a height of 5'2”. Her BMI was 33.

● She had a fundic height of 38 centimeters and

an estimated fetal weight of 3,800 grams

● Pelvic examination revealed a fully effaced

cervix dilated to 7 centimeters. The bag of
waters was intact and the fetal head was at
station -1.
 CASE
● Two hours after admission, Ruby entered the
2nd stage of labor and was brought to the
delivery room. The fetal head was at station +3,
left occiput anterior position.

● After an hour of pushing, the head was

delivered but restitution did not proceed
smoothly. The fetal head remained in left
occiput transverse, with the chin retracted
against the perineum.
 CASE
Question: What is your diagnosis?

Pregnancy uterine, 37 weeks age of gestation,

cephalic, in labor
Shoulder dystocia
Gestational Diabetes Mellitus
Obese
G3 P1 (1011)
 CASE
Question: What signs and symptoms are
consistent with your diagnosis of shoulder
dystocia?

Fetal head was delivered but shoulder did not

(+) Turtle sign
Left occiput transverse position

Pertinent history: (+) GDM, Obese, EFW 3.8 kg

 Shoulder Dystocia
● Occurs when the fetal head is delivered but the
shoulders cannot be spontaneously delivered
with gentle downward traction

● Occurs in 0.6 to 1.4% of deliveries

 Shoulder Dystocia
● Unpredictable and unpreventable;
approximately 50% of cases occur in women
without identifiable risk factors

● Risk factors:
– Fetal macrosomia
– Maternal diabetes mellitus
– Maternal obesity
– Previous shoulder dystocia
 Shoulder Dystocia
●
Diagnosis is made during the 2nd stage of labor

● Signs:
– The fetal head delivers but restitution does not take
place.
– Turtle sign : The fetal head recoils back against
the perineum after it comes out of the vagina.
– The shoulders fail to deliver with maternal pushing
and gentle downward traction from below.
(+) Turtle sign – the chin is retracted against the perineum
(because the head recoils after delivery)
 CASE
● Despite gentle downward traction on the fetal
head but was unable to deliver the shoulder.

Question: What should she do next?

a. Apply fundal pressure
b. Flex the patients' legs against her abdomen
c. Call for help
 Shoulder Dystocia
● Mechanism
– Normal labor:
● The shoulders should enter the pelvis in an oblique
diameter.
● The bisacromial diameter rotate toward the AP diameter
of the pelvis.

– Shoulder dystocia:
● The shoulders attempts to enter the pelvis with the
bisacromial diameter in the AP diameter of the inlet.
 Shoulder Dystocia
● Mechanism
– Shoulder dystocia:
● The shoulders attempts to enter the pelvis with the
bisacromial diameter in the AP diameter of the inlet

>>> Anterior shoulder is wedged against

the symphysis pubis
>>> Posterior shoulder is able to descend
(usually) past the promontory
 Shoulder Dystocia Drill
ACOG mnemonic
● Ask for help
● Lift legs
● Anterior shoulder delivery
● Rotate
● Manual removal of the posterior arm and shoulder
● Episiotomy
● Repeat
 CASE
● Despite gentle downward traction on the fetal
head but was unable to deliver the shoulder.

Question: What should she do next?

a. Apply fundal pressure
b. Flex the patients' legs against her abdomen
c. Call for help
 Shoulder Dystocia Drill
● Ask for help
– Assistants
– Anesthesiologist
– Pediatrician

– The objective is to deliver the baby with the least fetal

or maternal morbidity.
– DO NOT PANIC, PUSH OR PULL!
 Shoulder Dystocia Drill
● Lift legs
– McRoberts maneuver
–

● Anterior shoulder delivery

– Suprapubic pressure
 Shoulder Dystocia Drill
● McRoberts maneuver
– Involves flexing the legs sharply against the
maternal abdomen
– Rotates the symphysis pubis cephalad and
straightens the sacrum
>>> Allows the shoulder to slide out beneath
the pubic bone
 Shoulder Dystocia Drill
● McRoberts maneuver
 Shoulder Dystocia Drill
● Suprapubic pressure
– Apply oblique pressure just above the pubic
bone with the heel of clasped hands (directed)
against the posterior aspect of the fetal shoulder
to dislodge it
 Shoulder Dystocia Drill
● Suprapubic pressure
– Also, Mazzanti maneuver
 Shoulder Dystocia Drill
● Lift legs (McRoberts maneuver)
● Anterior shoulder delivery (Suprapubic pressure)

– Performed simultaneously
– Resolves 50-60% of cases
 Shoulder Dystocia Drill
● Rotate
– Woods' corkscrew
maneuver
– Rubin maneuver
 Shoulder Dystocia Drill
● Woods' corkscrew maneuver
– Aims to progressively rotate the posterior
shoulder to release the impacted anterior
shoulder
– Apply pressure on anterior surface of the
posterior shoulder, rotating it 180 degrees
 Shoulder Dystocia Drill
● Rubin maneuver
– Reverse Woods' corkscrew maneuver
– The pressure is applied on the posterior
surface of the posterior shoulder
 Shoulder Dystocia Drill
● Rotate
– Woods' corkscrew
maneuver
– Rubin maneuver

– Will only work if the posterior

shoulder is accessible, i.e.
descended below the
promontory
 Shoulder Dystocia Drill
● Manual removal of the
posterior arm and shoulder

1. Following the curvature of the

sacrum, the operator hand in
placed deep in the vagina and
behind the posterior shoulder
 Shoulder Dystocia Drill
● Manual removal of the
posterior arm and shoulder

2. The antecubital fossa is

located and pressure of a
finger is applied in order to flex
the arm.
 Shoulder Dystocia Drill
● Manual removal of the
posterior arm and shoulder

3. The forearm is swept across

the chest and face. The hand
is then grasped, to extend
along the fetal face, and
delivered.
 Shoulder Dystocia Drill
● Manual removal of the
posterior arm and shoulder

4. The anterior shoulder is

deliverd in most cases. If not,
the fetus (body) is rotated to
180 degrees to bring the
anterior shoulder to the
posterior. Steps 1-3 repeated.
 Shoulder Dystocia Drill
● Manual removal of the
posterior arm and shoulder
– Major risk for humeral
fracture
 Shoulder Dystocia Drill
● Episiotomy
– A generous episiotomy may be done at anytime

● Repeat
 Shoulder Dystocia Drill
● Other manuevers
– Fetal clavicle fracture
– Rolling to “all fours” position
– Zavanelli
– Symphysiotomy
 Shoulder Dystocia Drill
● Fetal clavicle fracture
– Often described but rarely performed
– Fracture decreases the bisacromial diameter to
effect delivery of the shoulder
– Causes major damage to lungs ang major blood
vessels
 Shoulder Dystocia Drill
● Rolling over to 'all fours' position
– Gaskin maneuver
– Increases pelvic dimensions and may allow fetal
position to shift, freeing the impacted shoulder
 Shoulder Dystocia Drill
● Zavanelli maneuver
– Cephalic replacement by
reversing cardinal movements
of labor
– Fetal head is rotated to occiput
anterior position, flexed,
rotated and pushed back up to
the uterus
 Shoulder Dystocia Drill
● Symphysiotiomy
– Involves dividing the ligaments between the
right and left pubic symphyseal bones
>>> Increase of the transverse diameter of the
pubis adds 3 cms to the pelvic circumference
– Potential injury to bladder and urethra
 Shoulder Dystocia Sequelae
● Fetal
– Birth Asphyxia
– Brachial plexus injury
– Fetal fractures and Bruising

● Maternal
– Hemorrhage from genital lacerations, uterine atony
– Urinary retention
 References
●
Oxorn & Foote: Human and Birth, 6th ed.
● Pictures:
– http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm
– http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?31/62/32739
– https://www.superteachertools.net/speedmatch/speedmatchfromj.php?gamefile=1412180487
– http://emedicine.medscape.com/article/1602970-overview