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
    data

• 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
    factors: DM, obesity, multiparity, precipitous or protracted
    labor

  • Fetal
    factors: Macrosomia, post-dates

• Complications
  include

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

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

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

  • 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

  • 1^st
    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
    pubis

    • Not
      fundal pressure

• • If that
    fails:

    • 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