Shoulder dystocia

Jennie Magor
• Anterior shoulder
impacts on
symphysis pubis
• Affects ~1%
vaginal births
• Needs to be managed
efficiently to reduce
neonatal hypoxia and
effectively to reduce
neonatal injury
The problem

Fetal shoulders
too wide for
narrow AP
pelvic
diameter
 Risk factors

• Previous shoulder • Prolonged first stage

dystocia • Prolonged second
• Diabetes mellitus stage
• Fetal macrosomia • Augmentation of
• Maternal obesity labour
• Instrumental delivery
Unpredictable and unpreventable
• Majority of cases of shoulder dystocia occur in
women with no risk factors
• Clinicians should be aware of existing risk factors
and make appropriate recommendations for the
best place for birth
• However, clinicians should be alert to the
possibility of shoulder dystocia with any birth
Warnings in labour –
be prepared and call for help
• Difficult delivery of face and chin
• Head remains tightly applied to vulva
• Chin retraction ‘turtle neck’
• Anterior shoulder fails to deliver with
routine axial traction
Management
• Call for help
• McRoberts’ position
• Suprapubic pressure
• Internal manoeuvres
• Delivery of posterior arm
• Internal rotational manoeuvres
 Shoulder
dystocia
management
algorithm
 Call for help and state the
problem
• Use emergency bell
• Most senior midwifery and obstetric staff
available
• Healthcare assistants
• Neonatologist
• Anaesthetist and theatre team on standby
 McRoberts’ position
• Increases relative AP diameter of pelvic
inlet by tilting the pelvis
• Lie mother flat,
removing any pillows
• Hyperflex mother’s
hips so her knees are
next to her ears
• Apply routine axial
traction to fetal head
 Routine axial traction
•The same degree of traction as applied
during a normal birth in an axial
direction:
• Traction applied in
line with the axis of
the fetal spine
• Routine axial traction
only applied to assess Axial traction

whether each
manoeuvre has been
 Suprapubic pressure
•Aims to reduce diameter of fetal shoulders
and rotate the anterior shoulder into the
wider oblique angle of pelvis

• Apply pressure from

side of fetal back in a
downward lateral
direction
• Apply routine axial
traction to fetal head
• Delivery of the posterior arm and internal
rotational manoeuvres both start with gaining
internal access
• No room anteriorly
• Most spacious part of
pelvis is the sacral
hollow
• Scrunch up hand and
enter vagina
posteriorly
Axial traction
Incorrect vaginal access:
what not to do
 Delivery of the posterior arm
• Reduces diameter of fetal shoulders by the width
of a shoulder
• Locate the posterior fetal hand
• Arms often flexed across chest
• Grasp the fetal wrist
• Gently deliver the posterior arm by pulling the
wrist gently in a straight line
 Internal rotation
• Moves the fetal shoulders out of narrowest
diameter of pelvis

• Apply pressure to the

anterior or posterior
aspect of the posterior
shoulder to rotate the
fetus in the pelvis
• Suprapubic pressure may
help
 All-fours position
• Be guided by individual circumstances whether to
try the ‘all-fours’ technique before or after
attempting internal manoeuvres.
• Sacral hollow is accessed ‘anteriorly’
What not to do
• Nothing more than routine axial
traction
• Don’t pull hard
• Don’t pull down
• Don’t pull quickly or with a
‘jerk’
• Axillary traction
• Fundal pressure
 Complications
• Brachial plexus injury (Erb’s palsy)
• 4–16% SD deliveries
• ~10% injuries permanent
• Incidence of permanent injury is 1/2300 live
births
• Fractures – humerus and clavicle
• Hypoxia and stillbirth
• Maternal trauma
 Documentation
• Head and body delivery times
• Who was there and who was called
• Which manoeuvres were performed and in what
order
• Traction applied
• Anterior shoulder at the time of the dystocia
• Condition of the baby at birth
• Apgars
• Cord pHs
• Signs of neonatal injury
Documentation

pro forma
 After-birth care
• Neonatal review of baby
• Debrief parents
• Information for parents (Erbs Palsy)
• Referral for mode of birth discussion in next
pregnancy