SHOULDER

DYSCTOCIA
Definition
A vaginal cephalic delivery that requires additional
obstetric maneuvers to deliver the fetus after the
head has delivered and gentle traction has failed.
It occurs when either the anterior, or less commonly
the posterior, fetal shoulder impacts on the maternal
symphysis, or sacral promontory, respectively
Risk Factors
Be prepared for
shoulder Note:
Have several
dystocia at all Shoulder
persons
deliveries, dystocia cannot
available to
especially if a be predicted
help.
large baby is
anticipated.
Diagnosis
1. The fetal head is delivered but remains tightly applied to
the vulva.
2. The chin retracts and depresses the perineum.
3. Traction on the head fails to deliver the shoulder (caught
behind the symphysis pubis).
4. Usually head-to-body delivery time is >60 seconds.
Management
• Shout for help.
• Make an adequate episiotomy (to reduce soft tissue
obstruction and to allow space for manipulation).
• With the woman on her back, ask her to flex both thighs,
bringing her knees as far up as possible towards her
chest.
• Ask two assistants to push her flexed knees firmly up
onto her chest.
 is flexion and abduction of the
maternal hips, positioning the
maternal thighs on her abdomen.

It straightens the lumbosacral

angle, rotates the maternal pelvis
The McRoberts’ towards the mother’s head and
Maneuvere increases the relative anterior-
posterior diameter of the pelvis.

The McRoberts’ maneuver is an effective intervention, with

reported success rates as high as 90%.
If the shoulder still is not delivered:
• Wear sterile gloves.
• Apply firm, continuous traction downwards on the
fetal head to move the shoulder that is anterior
under the symphysis pubis.
Note: Avoid excessive traction on the fetal head as this
may result in brachial plexus injury.

• Have an assistant simultaneously apply

suprapubic pressure downwards to
assist delivery of the shoulder.
Note: Do not apply fundal pressure. This will further impact the
shoulder and can result in uterine rupture.
If the shoulder still is not delivered:
• Insert a hand into the vagina along the baby’s
back.
• Apply pressure to the shoulder that is anterior
in the direction of the baby’s sternum to rotate
the shoulder and decrease the diameter of the
shoulders.
• If needed, apply pressure to the shoulder that is
posterior in the direction of the sternum.
If the shoulder still is not delivered
despite the above measures:
• Insert a hand into the vagina.
• Grasp the humerus of the arm that
is posterior and, keeping the arm
flexed at the elbow, sweep the arm
across the chest.
• This will provide room for the
shoulder that is anterior to move
under the symphysis pubis.
If all of the above measures fail to deliver the
shoulder, other options include:
• All maneuveres can be repeated on all fours.
• Often the change of position already frees the
shoulder and there will be more space for all the
posterior intra-vaginal manoeuvres.
• Be prepared for PPH after shoulder dystocia.
 COMPLICATIONS

FETAL:
- Brachial plexus injury
(2.3% to 16%)
- Other reported fetal injuries
MATERNAL: include fractures of the
- postpartum haemorrhage humerus and clavicle,
(11%) pneumothoraces and
- third and fourth-degree hypoxic brain damage.
perineal tears (3.8%)
 BPI

• Most cases resolve without permanent

disability, with fewer than 10% resulting
in permanent neurological dysfunction.
• Review of 33 international studies
reported an incidence of BPI of 1.4 in
1000 births, with a permanent injury rate
of 0.2 per 1000 births
• Larger infants are more likely to suffer a
permanent BPI after shoulder dystocia
 THAN
REFERENC KS
•
ES
World Health Organization. Regional
Office for South-East
Asia. (2017). Pocket book of hospital
care for mothers. World Health
Organization. Regional Office for South-
East Asia. https://
apps.who.int/iris/handle/10665/258716
• Shoulder Dystocia (Green-top Guideline
CREDITS: This presentation template was created
No. 42) [Internet]. Royal College of by Slidesgo, including icons by Flaticon, and
Obstetricians & Gynaecologists. infographics & images by Freepik
2022 [cited 28 February 2022].
Available from:
https://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg42/