Obstetric emergency

1. SHOULDER DYSTOCIA
ROSSHINI JAGATHESWARAN

2. DEFINITIONS
• Obstetric emergency
• vaginal cephalic delivery that requires additional
obstetric maneuvers to deliver the fetus after the
head has delivered and gentle traction has failed
• occurs when either the anterior, or less commonly
the posterior fetal shoulder impacts on the
maternal symphysis, or sacral promontory,
respectively
Source : RCOG Guidelines

3. DEFINITIONS
• Impaction of fetal shoulders at the pelvic outlet
after the delivery of the head
Source: Handbook of Obstetrics & Gynaecologic Emergencies
• Difficulty in delivery of the fetal shoulders
Source: Obstetrics by Ten Teachers

4. MECHANISM OF LABOUR

6. Process of delivery during labor normally passes
through these steps:
Engagement  Descend  Flexion  Internal rotation 
Extension  Restitution  External rotation  Delivery of the
body
In shoulder dystocia:
Engagement  Descend  Flexion  Internal rotation 
Extension  Restitution  External rotation  /// /// ///
/// /// ///  Delivery of the body

9. Unilateral Shoulder Dystocia

10. Bilateral shoulder dystocia

11. RISK FACTORS – Pre-labour
• Previous shoulder dystocia
• Induction of labour
• Infants of diabetic mothers
• Fetal macrosomia >4.5kg
- excessive weight gain during pregnancy
- maternal obesity (BMI>30)
- asymmetric accelerated fetal growth in non-diabetic
patients
- post-term pregnancy
- parity

12. RISK FACTORS – Intrapartum
• Prolonged first stage of labour
• Secondary arrest
• Prolonged second stage of labour
• Oxytocin augmentation
• Assisted vaginal delivery

13. PREVENTION
The risk factor assessment and progress of labour may help in
prediction of it but they are insufficient.
But trials include:
A. Management of suspected fetal macrosomia
B. History of previous shoulder dystocia and its sequelae
C. Partograph may signal you the delay of the stages and any
fetal distress

14. Management of
suspected fetal macrosomia
• Early induction of labour
- Doesn’t prevent SD in non-diabetic woman with
suspected macrosomic fetus
- Reduce incidence of SD at term for GDM mothers
• Elective LSCS
- Should be considered if pregnancies complicated
by pre-existing or gestational DM, regardless of
treatment, with an estimated fetal weight of
greater than 4.5 kg.

15. Approach
History
Examination
Investigation:
early
Monitoring
and
Partograph
Delivery of
the head of
the baby
Delivery of
shoulders +
Body
After delivery

16. Preparation for labour
All birth attendants should be aware of the methods
for diagnosing shoulder dystocia and the techniques
required to facilitate delivery.
Birth attendants should routinely look for the signs of
shoulder dystocia.
Timely management of shoulder dystocia requires
prompt recognition.

17. DIAGNOSIS
• Difficulty with delivery of the face and chin
• The head remaining tightly applied to the vulva or
even retracting (turtle-neck sign)
• Failure of restitution of the fetal head
• Failure of the shoulders to descend

18. Turtle-neck sign
Fetal head emerges and
retracts against the
perineum

19. Routine traction in an axial direction can be used to
diagnose shoulder dystocia but any other traction
should be avoided.
Routine traction is defined as ‘that traction required
for delivery of the shoulders in a normal vaginal
delivery where there is no difficulty with the
shoulders’.
Axial traction is traction in line with the fetal spine
i.e. without lateral deviation.

20. Management
First-line
Maneuvers
Second-line
Maneuvers

22. Call for Help, initiate RED ALERT!
• State clearly
• Experienced obstetrician, midwife, nurses,
neonatologist, anesthetist
• Secure IV line
• Lithotomy position, legs in stirrup with buttocks at edge
of bed
• Empty/catheterise the bladder
Time window for brain hypoxia is 5 minutes.
* Fundal pressure should not be used.
* Encourage the mother not to push.

23. Episiotomy
• To create more space for greater access to the
pelvis
• An episiotomy is not always necessary.

24. Legs: McRoberts’ Maneuver

25. External Pressure - suprapubic pressure

26. Enter pelvis: rotational maneuvers
Rubin II +
Woodscrew’s
Maneuver
Reverse
Woodscrew’s
Maneuver

27. Remove the posterior arm

28. Roll the patient to her hands & knees
Gaskin maneuver

30. Third-linemaneuvers
* The baby most likely in hypoxic-acidotic state…
 Cleidotomy
 Zavanelli maneuver (mostly for bilateral dystocia)
Symphysiotomy
Future: Posterior axillary sling

31. Cleidotomy
• Anterior clavicle is pressed against the ramis of the
pubis.
• Avoid puncturing the lung by angling the fracture
anteriorly.
• Theoretically, a fracture of the clavicle is less
serious than a brachial nerve injury and often heals
rapidly.

32. Zavanelli maneuver
Consists of cephalic replacement
+ caesarean delivery.
• Relax uterus with terbutaline
• Rotate head back to OA
(“reverse restitution”)
• Flex neck
• Upward pressure
• To Operation Theatre

33. Symphysiotomy
• Insert Foley catheter
• Use vaginal hand to
laterally displace
urethra to avoid
injury
• Incise symphysis
through mons pubis

34. AFTER DELIVERY

35. MATERNAL COMPLICATIONS
• Postpartum hemorrhage – 11%
• Vaginal lacerations
• Cervical lacerations
• Third and fourth degree tears – 3.8%
• Puerperal infection

36. FETAL COMPLICATIONS
• Brachial plexus injury
• Fetal fractures - humerus or clavicle
• Erb’s palsy
• Perinatal asphyxia
• HIE
• Neonatal death

37. Brachial Plexus Injury
• Most cases resolve
without permanent
disability
• Larger infants at higher
risk
• Due to excess traction,
maternal propulsive
force
• Damage to the
posterior shoulder
plexus is unlikely due
to healthcare
professional

39. Future pregnancy
• Mode of delivery – LSCS or vaginal delivery
• Important to discuss with patient and her husband

40. THANK YOU