Shoulder dystocia

Prepared by Misganaw W.
Moderator- Professor Lukman Yesuf
june 2013

6/14/2013 1
 CONTENTS
• Introduction/Definition
• Epidemiology
• Pathophysiology
• Risk factors
• Diagnosis
• Prevention
• Complications
• Management
• Recommondations
• Video
• Reference
6/14/2013 2
 Shoulder Dystocia
Introduction
 Smellie described this phenomenon first in 1730
Morris in 1955 gave what is now a classic description of
shoulder dystocia.
Defined as the need for additional obstetric maneuvers to
effect delivery of the fetal shoulders at the time of vaginal
delivery.
 Occurs in 0.2 to 3 percent of all births and represents an
obstetric
Head toemergency.
body delivery time of >60 sec.
 ACOG: 0.6 % must
Obstetrician to 1.4%
be prepared to recognize a shoulder
dystocia immediately and proceed through an orderly
 Few shoulder dystocias can be anticipated and prevented
sequence of steps to affect delivery in a timely manner
6/14/2013 3
 DEFINITION cont…
• Use of maneuvers to define shoulder dystocia has
been criticized by different scholars
– When shoulder dystocia is anticipated, 1 or more
maneuvers may be used prophylactically, & the Dx of
shoulder dystocia is therefore not reported
– In other cases, 1 or 2 maneuvers may be used with rapid
resolution of shoulder dystocia & excellent outcome, & the
Dx may not be recorded.
– The lack of a uniformly accepted criteria

6/14/2013 4
 DEFINITION cont…
• Spong and colleagues (1995) proposed defining of shoulder
dystocia objectively
• 250 deliveries were studied .
• The mean head-to-body delivery time in normal births was 24
sec vs. 79 sec in those with shoulder dystocia

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 They proposed defining shoulder dystocia as
• ‘‘prolonged head-to-body delivery time (eg, more than 60
seconds) and/or the necessitated use of ancillary
obstetric maneuvers.’’

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 EPIDEMIOLOGY
 Incidences vary depending on the criteria for diagnosis
 0.15 % to 3% - different literatures
 0.6 % to 1.4% (ACOG)
 0.6% to 1.4% for infants of birth weight 2500 g to 4000
g
 5% to 9% for infant weighing between 4000 g and
4500 g
 Incidence increased in recent years, likely due to
– increasing birth weight
– appropriate documentation

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 Types of Shoulder Dystocia

1- High Shoulder Dystocia

2-Low Shoulder Dystocia

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 1- High Shoulder Dystocia
• Both shoulders fail to engage
(Bilateral Sh.D). (Rare)
• More common with mid -pelvic
assisted delivery
• This presentation often requires a
cephalic replacement.
(The most difficult)

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 2-Low Shoulder Dystocia

A) Failure of engagement of
the anterior shoulder
(Unilateral Sh.D). ,The
commonest:
Usually easily dealt with by
Standard techniques

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 Shoulder Dystocia…
Pathophysiology
 IfShoulder
Normal
descentdystocia
of the fetal head
IfThe
continuesthefetal
fetal
while
biacromial
shoulders
shoulderdiameter
remain
remainsin
impacted,
enters
an anterior-posterior
the pelvis at anposition
oblique
during
angle
Stretching
descent
of the nerves in the
brachial
The
If descend
posterior
plexus
simultaneously
shoulder
result in nerve
ahead
of the anterior
rather
injury. than sequentially
one into the
pelvic
Rotates
Entrapmrnt
inlet
to theof anterior-
cord
posterior
The anterior
Sever brain
position
damage
shoulder
at the
orcan
death
pelvicif
outlet
become
not delivered
with
impacted
external
within
behind
rotation
minutestheof
the fetal head.
symphysis pubis
 The posterior
anterior shoulder
shouldercanmay then
be
slide under by
obstructed thethe
symphysis
sacral pubis
for delivery
promontory.
6/14/2013 11
 Shoulder Dystocia…
Risk Factors

 Few can be anticipated and prevented

 Most occur in the absence of risk factors

 50% have no identifiable risk factors

 Predictive value of combination of risk factor low(<10%)

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Shoulder Dystocia…
Risk Factors
Maternal
Fetal
 Suspected
Abnormal pelvic anatomy
macrosomia
 Diabetes mellitus
 Male Infant
 Post-dates pregnancy
 Previous shoulder dystocia
Labor related
Previous macrosomic infant
 Short stature
 Assisted vaginal delivery (forceps or vacuum)
 Multiparity
 Advanced
Protractedmaternal age of first-stage labor
active phase
 Protracted
High maternal body masslabor
second-stage index
 Excessive weight gain in pregnancy
 Maternal birth weight over 4000 grams

6/14/2013 13
 Shoulder Dystocia…
Risk Factors…
Fetal macrosomia

A
 1-year
LGA: >90 incidence
th
percentile statewide in California
for a given GA of shoulder
Incidence of Shoulder Dystocia According to Birthweight Grouping in Singleton Neonates
dystocia
 Weighs
Delivered and
more
Vaginally in its associated
than
1994 g risk
4000Hospital
at Parkland factors
or 4500 g
 175,886
Major vaginal
risk factor births
for of infants
shoulder >3500
dystocia g included
(10%).
Birthweight Group Births Shoulder Dystocia (%)
 6238 infants (3%) 2,953
3000 g
had shoulder dystocia. 0
% 50% of of
3001–3500
shoulder dystocia,
g shoulder dystocia 4,309
non diabetic
occur in infants whose birth
14 (0.3)
 5.2%
weight
3501–4000 for infants
gis less than 4000 4000grams
2,839 to 4250 g 28 (1.0)
 It is9.1%
4001–4500 g for those
difficult for the 4250 to 4500
704clinician g
to identify 38the
(5.4) macrosomic
 14.3%
>fetus
4500 g prior for 4500 91
to delivery to 4750 17 (19.0)
 21.1% for those10,896
All weights 4750 to 5000 g 97 (0.9)

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 Shoulder Dystocia…
Risk Factors…
Diabetes mellitus
Incidence of shoulder dystocia by birth weight in
nondiabetic
Macrosomic
Independent infants
andrisk of diabetic
factor
diabetic are characterized
for shoulder
women dystocia by

Birth weight, grams Nondiabetic women, Diabetic women,

Chest-to-head ratios is increased
percent percent
 Risk for shoulder dystocia 2-6x that of the normal
 Shoulder-to-head ratios is increased
population
Less than 4000 0.1 to 1.1 0.6 to 3.7
 Higher
4000With body fat
shoulder dystocia, the risk of adverse neonatal
to 4449 1.1 to 10.0 4.9 to 23.1
outcome
 Larger isshoulder
4500 or more
higher and extremity circumferences
2.7 to 22.6 20.0 to 50.0
 Thicker upper-extremity skin folds
Data from Ecker, JL, Greenberg, JA, Norwitz, ER, et al. Birth weight as a predictor of brachial
plexus injury. Obstet Gynecol 1997; 89:643.
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Shoulder Dystocia…
Risk Factors…
 The presence of both diabetes and macrosomia
accurately predicted 55% of cases of shoulder dystocia

In a classic study, 9864 deliveries were retrospectively

reviewed
 The combination of macrosomia ( BW > 4000 g), PSS,
and midpelvic operative delivery was associated with a 21%
incidence of shoulder dystocia
 When only PSS and midpelvic operative delivery were
present, the risk fell to 4.57%
 0.16% in the absence of these risk
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6/14/2013 17
Shoulder Dystocia…
Risk Factors…
History of shoulder dystocia
A The incidence
retrospective of recurrent
cohort shoulder
study in Norway withdystocia is 1 to 25%
two consecutive
singleton cephalic studies.
in retrospective vaginal deliveries (537,316 women)
 Shoulder
This maydystocia
be an occurred in 2745 first
underestimation as deliveries
many (0.5 %) and
mothers
 85% of these women had a 2nd vaginal delivery
clinicians choose an abdominal delivery in pregnancies
 170 (7.3%) of these deliveries were complicated by recurrent
subsequent to an episode
shoulder dystocia of shoulder
(OR 9.7, 95% dystocia.
CI 8.2-11.3)
 The increased risk of shoulder dystocia in the 2nd delivery was
limited to women who delivered infants ≥3500 g
 Shoulder dystocia also occurred in the 2nd vaginal delivery of 0.8%
of women with no prior history of shoulder dystocia
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 Shoulder Dystocia…
Diagnosis
 Shoulder dystocia is a subjective
clinical diagnosis

 The “Turtle” sign

 The fetal head suddenly retracts
back against the mother's
perineum after it emerges from the
vagina.
 The baby's cheeks bulge out,
resembling a turtle pulling its head
back into its shell.

 Objective definition:
 Head to body delivery time of >60 sec.
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 Management of shoulder Dystocia
Goal
 ATostudy
safelywith
effect
thedelivery
use of aofdata
the set
infant
of litigated
before asphyxia
vaginal deliveries
and cortical
(n =
103
In deliveries)
general,
injury thefrom
occur from operator
umbilicalhas upcompression
1978 through
cord to1999
five that
minutes
andtoimpeded
resulteddeliver a
in permanent
previously
inspiration,
brachial well-oxygenated
plexus
andinjury. termperipheral
without causing infant before an increased
neurologic injuryrisk of
or other
asphyxial
Result: injury occurs
trauma.
 Nine of 89 neonates (10%) had low 5-minute Apgar scores.
 Physical
 Head-to-body
injury (eg,
delivery
boneintervals
fractures,were
maternal
significantly
trauma)longer
are acceptable
in
if needed with
neonates to prevent
5-minute
permanent
Apgar scores
injuryofin<7
the
vschild.
> or =7.
 Conclusion: head-to-body delivery interval was the only significant
factor
 Mostininterventions
the predictionareofintended
5-minutetoApgar score the
disimpact of <7.
anterior shoulder
from
Fetalbehind
blood Ph
theissymphysis
said to decrease
pubis bybyrotating
the ratetheof fetal
0.04 unit
trunkper
or min.
delivering the posterior arm and shoulder

6/14/2013 20
 Head –shoulder interval > 7min.

Brain injury
(sensitivity & specificity :70 %)
• With hypoxic fetus it is much shorter

Quzounian et al Am J Obstet Gynecol 178;S76, 1998

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 Management…
Initial steps
 Have the patient stop pushing
 The patient should be positioned with her buttocks flush
with the edge of the bed to provide optimal access for
executing maneuvers to effect delivery.
 Performing a generous episiotomy
 Useful to facilitate delivery of the posterior shoulder
and other internal procedures
 Does not by itself help to release the anterior shoulder
and increases perineal trauma.
 Assembling necessary personnel
6/14/2013
Draining a distended bladder 22
 Management…
Call for help
 Remain calm
 Stop patient’s pushing efforts
 The obstetrician should ask to have a second obstetrician
called
 Nurses make sure that extra nursing personnel, anesthesia
and pediatrics are available
 Nurses have a to be ready if needed to assist with
Suprapubic pressure
 The obstetrician should also stay informed of the time
that has elapsed since delivery of the head.
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 Management…
Fundal pressure and traction

 Increasing traction traction

Avoid overzealous is
counterproductive
and pressure on the fundus
 This combination of the
will only increase
maneuvers
impaction. can stretch and
injure the brachial plexus.

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 Management…
Which maneuver to use?

 Maneuvers have not been

Steps recommended by WHOcompared
–clinicalinexperience
RCT.
 No single maneuver is  MAPSmore effective than
clearly
 MacRoberts
another; the initial choice and order of progression is at
the
 provider's discretion.
Anterior shoulder
 Posterior shoulder
 Usual suggestion: begin with the least invasive
 Salvageand,
maneuvers P : if-posterior axilary
unsuccessful, slingon
move traction
to more
invasive options. -Zavanelli M.&
-clvicular fracture

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 Management…
McRoberts maneuver
 Needs two assistants
 It is hyperflexion and abduction hips against
maternal abdomen; patient in supine position.

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 Management…
McRoberts maneuver

 Straightens
Suggestedthe as maternal
the initial
approach
lumbosacral lordosis, thus
removing
Less invasive than
the sacral other
promontory
maneuvers.
as an obstruction site
 Brings the pelvic inlet into the
plane
Sharp ventral rotation
perpendicular to the of
both maternal
maximum hips
expulsive brings
force.
the pelvic inlet and outlet
into
Elevates the vertical
a more anterior shoulder
and flexes thefacilitating
alignment, fetal spine toward
the anterior shoulder. This push
delivery of the fetal
the posterior shoulder over the
shoulders.
sacrum
6/14/2013 and through the inlet. 27
 Management…
McRoberts maneuver…
 In a retrospective review of 250 cases of shoulder
dystocia, the McRoberts' position alone successfully
alleviated the shoulder dystocia in 98 cases (42%).
 There is no advantage to performing the maneuver before
diagnosis of shoulder dystocia.

 In rare cases, excessive force or prolonged placement of

the patient's legs in a hyperflexed position has led to
maternal complications such as symphyseal separation,
sacroiliac joint dislocation, and transient lateral femoral
cutaneous neuropathy

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 Management…
Supra Pubic pressure

 An assistant applies
pressure suprapubically with
the palm or fist
 Directing the pressure on
the anterior shoulder both
downward and laterally.
 In conjunction with the
McRoberts maneuver

 This tends to nudge the

shoulder into a more oblique
orientation.
6/14/2013 29
 Management…
Mazzanti technique

 Gentle
Suprapubic pressure
downward with
traction
downward traction
on the fetal
 Straight head in
downward
combination with suprapubic
pressure to disimpact the
fetal shoulder.
pressure, maternal pushing
efforts and McRobert's
position may relieve the
obstruction.
 If not, stop the pushing and
pulling efforts, and try
another maneuver.
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Management…
Rubin maneuver

• Involves inserting one hand posterioly or anteriorly in

the birth canal on the dorsal aspect of the fetal
shoulder and rotating it inward(adduction) about 30
degree so that it come to lie in the oblique
dimension.
• Advantages…reduces bisacromial diameter
…..enables to know orientationand to
avoid more than 90 degree rotation

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 Management…
Rubin maneuver

 Other
Causesapproaches
adduction of shoulders
 The
 shoulders
Combine displaced
the Rubin from
maneuver
the
on theAP posterior
diameter shoulder
of the inlet
with
external
Under adequate
abdominalanesthesia
pressure on
the
Anterior orshoulder
anterior posteriorinshoulder
the
opposite direction
 Rubin with the McRoberts
maneuver.
 Woods and Rubin procedures
can be combined.
6/14/2013 32
Management…
Rubin maneuver
 A study done using laboratory birthing simulator

 Rubin's maneuvers were found to require less traction force than

McRoberts’
 Brachial plexus extension was significantly lower after anterior
Rubin's maneuver compared with McRoberts' or posterior Rubin's
maneuvers.
 Conclusion: anterior Rubin's maneuver requires the least traction
for delivery and produces the least amount of brachial plexus
tension.
 Further study is needed to validate these results clinically.

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 Management…
Barnum maneuver
 Delivery of the posterior arm

 The operator inserts a hand into the

vagina and delivered the posterior arm
by sweeping it across the fetal chest,
and thus delivered the posterior
shoulder as well.

 A 13-cm bisacromial diameter

becomes an 11-cm axillo-acromial
diameter upon delivery of the arm.
6/14/2013 34
Management…
Barnum maneuver…
 Delivery of the posterior arm almost always relieves
impaction of the anterior shoulder.
 It is an appropriate 3rd maneuver if the less technically
demanding and often successful McRoberts maneuver and
suprapubic pressure fail

 A similar procedure is followed if the arm is trapped

behind the fetus.
 Manipulation of the forearm may involve deliberate or
inadvertent fracture of the humerus.
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 Management…
Woods Screw Maneuver
 Rotates the fetus by exerting
pressure on the anterior, clavicular
surface of the posterior shoulder
 The fetal head and neck should
not be twisted

(A) The posterior shoulder is

rotated counterclockwise until
(B) it becomes anterior. The anterior
shoulder rotates out from under the
symphysis pubis and descends
during this process.
6/14/2013 36
 Management…
Gaskin’s Maneuver
 Get the woman into a hands and
knees position.
 This will also change the diameters
of her pelvis.

 Delivery effected with

 By gentle downward traction on
the posterior shoulder or
 Upward traction on the anterior
shoulder (the shoulder against the
maternal symphysis)
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Management…
Clavicular fracture

 The clavicle can be intentionally fractured to shorten the

biacromial diameter.
 This is done by pulling the anterior clavicle outward.

However, intentional clavicular fracture can be difficult to

perform and can lead to injury of underlying vascular and
pulmonary structures.

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Management…
Zavanelli maneuver
 Replacement of the fetal head in the pelvis, followed by
cesarean delivery.
 When conventional maneuvers have failed to alleviate
shoulder dystocia.
 Steps:
MEDLINE
ACOG: “thereview
Zavanelliofmaneuver
93 casesis(1985
 Prepare for abdominal delivery.
through
associated with a1997)
significantly
increased risk of fetal morbidity and mortality and of maternal
 Administer terbutaline or nitroglycerin
morbidity
The andoverall
that it should only be performed in cases of severe

 Place a92%
fetal scalp success
electrode. rate
shoulder dystocia unresponsive to more commonly used maneuvers”.
Rotate
 Was theusedheadonly after
back to conventional
an occiput maneuvers had failed.
anterior position
 Flex the head from its extended position
 Push it as far cephalad as possible using firm pressure with the palm of one
hand.
 Insert a catheter into the bladder and proceed with cesarean delivery.

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 Management…
Symphysiotomy

The skin over

Splitting the symphysis
the symphysis pubispubis and fibrocartilaginous
is effective in opening the
area is infiltrated
maternal with
pelvis and local anesthetic.
relieving the obstruction
Has
Thehigh
urethra is displaced
maternal laterally using the index and
morbidity
middle fingers placed against the posterior aspect of the
symphysis
 Avoiding symphysiotomy unless all other maneuvers have
failed
rarely used
and exceptdelivery
cesarean in remote areas
is not where no OR setup
possible.
recommended to avoid it unless all other maneuvers have
failed and cesarean delivery is not possible.

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 Complications
Infant Complications

 In a series
In series including
including overcases
over 100 2000 of cases of shoulder dystocia,
shoulder
approximately
dystocia, reported5neonatal
percentoutcomes
were complicated
included by neonatal
injury
 Transient brachial plexus palsy (3.0 to 16.8%)
 Clavicular fracture (1.7 to 9.5%)
 Humerus fracture (0.1 to 4.2%)
 Permanent brachial plexus palsy (0.5 to 1.6%)
 Hypoxic-ischemic encephalopathy (0.3%)
 Death (0 to 0.35%)

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 Brachial Plexus Injuries
• Strain or stretch
• Partial disruption
• Complete avulsion

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6/14/2013 43
 Brachial Plexus Injuries…
• Injury primarily to lateral trunk (C5,6, 7) leads
to Erb’s palsy – adducted shoulder, extended
elbow, and flexed wrist (“waiter’s tip”)
• Injury primarily to the medial trunk (C8, T1)
leads to Klumpke’s palsy – paralyzed hand
with good shoulder and elbow function

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 Mx of plexus injury
• Erbs palsy has better prognosis
• Usually resolves between two weeks and
twelve months ….average three months
 physiotherapy
 nerve graft or muscle trasposition…controversial

6/14/2013 45
 Complications…
Maternal Complications

 Potential maternal complications include

 Hemorrhage (11 %)
 Fourth degree lacerations (3.8 %)
 Lower genital tract lacerations
 Uterine atony
 Uterine rupture

6/14/2013 46
 HELPER Algorithm(ACOG)
• H: Call for Help; Shoulder dystocia is called if
shoulders cannot be delivered with gentle
traction
• E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when attempting
intra-vaginal maneuver
• L: Legs (McRoberts): Hyperflexion and
abduction of hips—initial maneuver

6/14/2013 47
 HELPER Algorithm cont.
• P (Suprapubic Pressure): No fundal pressure;
combination of McRoberts and suprapubic pressure
resolves most shoulder dystocias
• Enter (Internal Maneuvers):
– Woods: Insert hand into posterior vagina and rotate
posterior shoulder clockwise or counterclockwise
– Rubin: Push posterior or anterior shoulder toward fetal
chest to adduct shoulders
• Remove: Delivery posterior arm

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 Prophylactic Cesarean?
 Not recommended by ACOG
 Exceptions:
 Consider if…
 >5000g in mother without DM
 >4500g in mother with DM

6/14/2013 49
 Recommondation
• There should be shoulder dystocia drill to be
taught and practiced regularly by the staff
• Document clearly & legibly
• Review with family what happened
exactly;soon after delivery
• Send cord blood for gas analysis

6/14/2013 50
 Recommond…

6/14/2013 51
 References
1. Williams Obstetrics, Twenty-Third Edition
2. Gabbe: Obstetrics: Normal and Problem Pregnancies, 5th ed
3. Medscape reference, 1994-2011 by WebMD LLC
4. Uptodate 19.3
5. ACOG practice bulletin clinical management guidelines for obstetrician-
gynecologists. Shoulder dystocia. Number 40, November 2002. Obstet
Gynecol 2002; 100:1045.
6. Allen RH et al.Correlating head-to-body delivery intervals with neonatal
depression in vaginal births that result in permanent brachial plexus
injury. Am J Obstet Gynecol 2002 Oct;187(4):839-42. Abstract
7. SHOULDER DYSTOCIA – Facts, Evidence and Conclusions
-website-http://shoulderdystociainfo.com/index.htm
copyright@ 2004 Dr. Henry Lerner

6/14/2013 52
 Misganaw worku
OBGY-R1
june 2013

• Thank you!!!!!!

6/14/2013 53