Shoulder Dystocia

Or,
The heads out; what next?

Christian A. Chisholm, MD
Division of Maternal-Fetal Medicine
 Objectives

At the completion of this presentation, the

participant should be able to:
Define shoulder dystocia (MK)
Name three risk factors for shoulder dystocia
(MK, PC)
List potential complications, both maternal and
fetal, of shoulder dystocia (MK)
Describe the maneuvers used to relieve a
shoulder dystocia (MK, ICS)
Definition

a delivery that requires additional

obstetric maneuvers following failure
of gentle downward traction on the
fetal head to effect delivery of the
shoulders.
ACOG, Practice Bulletin 40 (November 2002)
Definition

Prolonged head-to-body expulsion

time
Objectively defined as 60 seconds
Deliveries with head-to-body interval
of > 60 seconds more commonly have
higher birth weight, shoulder dystocia,
and low 1 minute Apgar scores
Beall et al 1998; Spong et al 1995
Functional Definition

A delivery in which the shoulders do not

follow the head as usual, but rather are
delayed in delivering or require the use of
ancillary obstetric maneuvers to effect
delivery.
The anterior shoulder may be impacted
behind the symphysis pubis, or (less
commonly) the posterior shoulder behind
the sacral promontory
Incidence

Reported to occur in 0.2-2% of births

May recur with a higher frequency, but
this is really unknown
Many women and clinicians will opt for
cesarean in the future, especially if there
has been a fetal injury
Recurrence rates reported 1-17%
Risk Factors

Maternal diabetes mellitus

Fetal macrosomia
Multiparity
Post-term pregnancy
Previous macrosomic infant
Previous shoulder dystocia
Macrosomia

Birth weight in excess of a specific

weight, usually defined as either 4500
grams (1.5% of births) or 4000 grams
(10% of births)
Birth weight > 4500 grams rate of
shoulder dystocia is 10-25%
Birth weight > 4500 grams AND maternal
diabetes rate of shoulder dystocia is 20-
50%
Large for gestational age

Birth weight that exceeds the 90th

centile of a standard growth curve,
regardless of gestational age.
A baby may be LGA without being
macrosomic
Pathophysiology

A mismatch between fetal size and

maternal pelvic capacity
Positional variations vertical rather
than oblique orientation of shoulders
Increased diameter of shoulder girdle
Subcutaneous fat deposition may be
increased in infant of diabetic mother
especially with sub-optimal glucose
control
Anatomy of the Brachial
Plexus
Nerve roots from C5-C8 and T1
Merge into three trunks
Superior (C5, C6)
Middle (C7)
Inferior (C8, T1)
Each splits into anterior and posterior
divisions
Anatomy of the Brachial
Plexus
The six divisions regroup into three
cords
Posterior all 3 posterior trunk divisions
(C5-T1)
Lateral anterior divisions of upper and
middle trunks (C5-C7)
Medial continuation of lower trunk (C8,
T1)
Anatomy of the Brachial
Plexus
Anatomy of the Brachial
Plexus
Brachial Plexus Injuries

Strain or stretch
Partial disruption
Complete avulsion
Brachial Plexus Injuries

Injury primarily to lateral trunk (C5,6,

7) leads to Erbs palsy adducted
shoulder, extended elbow, and flexed
wrist (waiters tip)
Injury primarily to the medial trunk
(C8, T1) leads to Klumpkes palsy
paralyzed hand with good shoulder
and elbow function
Maternal Complications

Post-partum hemorrhage occurs in

11%
4th degree laceration occurs in 3-4%
Into the Delivery Room
Clinical Management

Step One: Recognize the presence of a

shoulder dystocia
Step Two: Be sure enough help is
present
Nursing
Obstetrics
Pediatrics
Anesthesiology
Clinical Management

Step Three: Apply primary maneuvers

Mc Roberts maneuver
Oblique suprapubic pressure
Step Four: Apply secondary
maneuvers; no prescribed order
Rubin; Woods screw; Posterior arm; All-
fours; Clavicular fracture
Clinical Management

Step Five (concurrent):

Repeat steps three and four (different
operator?)
Consider if an episiotomy is needed
(intentional 4th degree?)
Step Six: Apply final (heroic)
maneuvers
Zavanelli; symphysiotomy
Steps One and Two

The operator determines a shoulder

dystocia is present
Personnel needed:
Nursing
At least two to assist with maneuvers
One to serve as recorder, as in a code 12
situation
Pediatrics full resuscitation readiness
Steps One and Two

Personnel (continued)
Anesthesiology
Obstetrics
Attending to supervise and step in as needed
2 residents at minimum
Ideally 2 at perineum
One to assist with maneuvers (suprapubic
pressure) away from perineum
Step Three Primary
Maneuvers
McRoberts maneuver
Patient positioned with hips at edge of
the broken-down birthing bed
Both hips are sharply flexed with knees
remaining flexed (knees to shoulders)
Ideally performed by staff, not family, to
assure it is adequately performed
No benefit to prophylactic McRoberts
McRoberts Maneuver
McRoberts Maneuver

This maneuver assists delivery by:

Straightening maternal lumbar lordosis
Rotates symphysis superiorly and
anteriorly
Improving angle between pelvic inlet and
direction of maximal expulsive force
Elevates anterior shoulder allowing
posterior shoulder to descend
McRoberts Maneuver
Oblique suprapubic pressure

Usually applied in concert with

McRoberts maneuver
Directed downward and laterally in
order to effect rotation of the fetal
anterior shoulder under the symphysis
Should be applied from the fetal
posterior
Oblique suprapubic
pressure
Step Four Secondary
Maneuvers
There is no conclusive evidence that one
maneuver is superior to another
In each patient, the operator must decide
which maneuver will be most effective
This is a good time to decide about an
episiotomy is there room to get your hand
in?
Time to initiate perinatal code (4-2012)
Woods screw maneuver

Apply pressure on the clavicle to effect

rotation of the shoulders out of the vertical
orientation
As fetus rotates, anterior shoulder should
pass under symphysis
May be a good choice for a right-handed
operator when the fetal occiput is oriented
to the maternal right
Woods screw maneuver
Woods screw maneuver

Potential complication:
Fetal clavicular fracture IN DIRECTION
OF APEX OF LUNG
Rubins maneuver

Apply pressure to the fetal scapula to

effect rotation of the shoulders out of
the vertical orientation
As fetus rotates, anterior shoulder
should pass under symphysis
May be a good first choice for a right-
handed operator when the fetal
occiput is directed to the maternal left
Rubins maneuver

May result in need for less traction and

less brachial plexus strain than
McRoberts maneuver
Gurewitsch, 2005
Delivery of Posterior Arm

The operator inserts a hand into the

vagina and locates the posterior arm.
The operator applies pressure in the
antecubital fossa to flex the elbow
across the chest
The operator grasps the forearm or
hand and pulls it out of the vagina
Delivery of Posterior Arm

The anterior shoulder should pass

under the symphysis
Rotation maneuvers (Woods or
Rubins) can be applied if needed
This maneuver will tend to be more
difficult with ones non-dominant hand
Delivery of Posterior Arm
Delivery of Posterior Arm

Potential complications
Fracture of humerus
Fracture of clavicle
Gaskin All Fours Maneuver

Attributed to midwife Ina May Gaskin

An option for a patient without
anesthesia
Traction is applied in the opposite
direction (still toward the floor, but
now directed towards delivery of the
posterior shoulder first)
Intentional clavicular
fracture
Apply pressure over mid-clavicle in a
vector AWAY from the lung
May be difficult to perform
If successful, may reduce the diameter
of the shoulder girdle
Potential complication:
Lung injury
Still not out?!
What now???
Step Five Regroup and
Repeat
Considerations:
Time passed so far?
Episiotomy?
Different operator?
Make OR preparations!
Step Six Final Steps

Zavanelli maneuver (cephalic

replacement)
Relax uterus with terbutaline
Rotate head back to OA (reverse
restitution)
Flex neck
Upward pressure
To OR
Step Six Final Steps

Symphysiotomy
Not commonly done when cesarean is
available
Last ditch effort
Insert Foley catheter
Use vaginal hand to laterally displace urethra
to avoid injury
Incise symphysis through mons pubis
Do not:

Panic
Apply any more lateral traction than would
be applied in an uncomplicated delivery
Apply fundal pressure may worsen the
shoulder impaction or even rupture the
uterus
Cut a nuchal cord until after the shoulders
are released
Do:

Remain calm
Communicate well
Mark time of head delivery
Consider calling out time in one minute
increments
Call for help
Document clearly and legibly
Do:

Be sure to debrief as a team after

the delivery is completed
Opportunity to analyze situation and
critique team performance
Opportunity to be sure documentation is
consistent
Who did what becomes very important
Send cord gases
Do:

Review with the family exactly what

happened and answer questions
soon after delivery, but probably not
immediately
Follow the babys course in the
nursery
Notify Risk Management
References
Shoulder Dystocia (Practice Bulletin 40). American College of
Obstetricians and Gynecologists. November 2002.
Rodis, JF. Management of fetal macrosomia and shoulder dystocia.
Up to date, v 14.1; last updated October 12, 2005.
Brachial Plexus. Wikipedia, the online encyclopedia.
http://en.wikipedia.org/wiki/Brachial_plexus Accessed March 21,
2006.
Beall, MH, et al. Objective definition of shoulder dystocia: a
prospective evaluation. Am J Obstet Gynecol 1998;179:934.
Spong CY, et al. An objective definition of shoulder dystocia:
prolonged head-to-body interval and/or the use of ancillary obstetric
maneuvers. Obstet Gynecol 1995;86:433
Gurewitsch ED et al. Comparing McRoberts and Rubins maneuvers
for initial management of shoulder dystocia: an objective evaluation.
Am J Obstet Gynecol 2005;192:153.