Shoulder dystocia

Credit: Drs Wu, A. Ogunniyi, R. Pedigo, R. Fleischman on 
OB Sim Day at Harbor-UCLA

Shoulder dystocia

  • Failure of
    the fetal shoulders to clear after the head is delivered

    • Occurs in
      0.6 to 2% of all vaginal deliveries

    • Diagnosed
      in the intrapartum period; may not be predictable based on prenatal

  • Rare
    obstetric emergency, unpredictable

  • Serious
    potential harm for morbidity for mother and baby, esp brachial
    plexus injury, may be exacerbated by inappropriate management

  • Maternal
    and fetal factors leading to this condition:

    • Maternal
      DM, obesity, multiparity, precipitous or protracted

    • Fetal
      : Macrosomia, post-dates

  • Complications

    • Fetal:
      Brachial plexus injuries, humeral/clavicular fractures, aspiration,
      hypoxic brain injury (from cord compression or compression of the

    • Maternal:
      Post-partum hemorrhage, vaginal, perineal or sphincter tears,

  • Diagnosis:
    Clinical – when the shoulder cannot be delivered and delivery

    • Fetus may
      “retract” into the perineum (“turtle sign”).

  • Management:

    • First
      things first – call for help! OB, NICU/PICU team, anesthesia

    • Initial
      steps – increase the AP diameter of the passage

      • Cut an
        episiotomy and drain the bladder with a Foley

    • 1st
      maneuver: McRoberts’ maneuver

      • Flexion/hyperflexion
        of the maternal thighs in the knee to chest position.

      • Successful
        in up to 40% of cases when used alone

    • Next
      step: Suprapubic pressure to push the anterior shoulder under the

      • Not
        fundal pressure

    • If that

      • Rubin’s
        maneuver: push the most accessible shoulder to the fetal chest
        (transabdominal, via the introitus or through the episiotomy)

      • Wood’s
        corkscrew maneuver: rotate the fetus 180 degrees to release the
        impacted shoulder

      • Pull on
        the posterior arm

    • Next??

      • Break
        the clavicle, symphisotomy, Zavanelli maneuver (push the baby back
        in), Gaskin all-fours maneuver

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