SHOULDER DYSTOCIA

NCM 109 RLE

• Shoulder dystocia is the impaction of the anterior shoulder against the
symphysis pubis after the head has been delivered.
• Occurs when the breadth of the shoulder is greater than the biparietal
diameter of the head. Diagnosed when any of the obstetric maneuver is
needed to release the shoulder after gentle axial traction has failed
• Usually results from a change in the interrelationships among the 4 P’s
that is the factors in labor and delivery.
• One of the most dreaded obstetric complications. It is one of the
primary causes of perinatal mortality and morbidity, maternal
morbidity and a costly source of litigation.
• One must be prepared for the possibility of shoulder dystocia in all
deliveries, and have a prepared plan of management.
• Frequently seen causes include:
1. disproportion between fetal presentation (usually the
head) and the maternal pelvis (CPD)
2. if disproportion is minimal, vaginal birth may be
attempted if fetal injuries can be minimized or
eliminated.
3. cesarean birth needed if disproportion is great.
4. Problems with presentation
1. any presentation unfavorable for delivery (e.g. breech,
shoulder, face,transverse lie)
2. posterior presentation that does not rotate, or cannot
be rotated with ease.
3. cesarean birth is the usual intervention.
5. Problems with maternal soft tissue
Early detection

1. “Head bobbing": the head coming down towards the

introitus with pushing, but retracting back between
contraction.
2. “Turtle sign at delivery": The delivered head becomes tightly
pulled back against the perineum
If all procedures fail…….
• Symphysiotomy – cutting the symphysis pubis to allow delivery of the
anterior shoulder.
• Clavicular fracture (@cleidotomy) – allows further adduction of the
fetal shoulder, reducing the diameter of the shoulders, thus allowing
delivery
• Zavanelli maneuvre – push the baby’s head back into the uterus and
proceed with emergency caesarean