Shoulder Dystocia

Question 1

Define shoulder dystocia

Answer 1

After delivery of the head, the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis, or (less commonly) the posterior shoulder becomes impacted on the sacral promontory

Obstetric emergency

Question 2

What are the complications from shoulder dystocia?

Answer 2

Maternal = 3rd or 4th degree tears (3-4%), post-partum haemorrhage (11%)

Hypoxia of the fetus (head out but cant expand lungs, cord compressed)

Brachial plexus injury (erbs palsey) - from traction on the fetal head

Clavicle/humerus fracture

Question 3

List the RF for shoulder dystocia

Answer 3

• previous shoulder dystocia
• macrosomia
• DM
• maternal BMI >30
• prolonged 1st stage labour
• sec arrest
• assisted vaginal delivery

Question 4

What are the signs of shoulder dystocia?

Answer 4

Difficulty in delivery of the fetal head or chin

Failure of restitution = fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’

‘Turtle Neck‘ sign = fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell.

Question 5

How should shoulder dystocia be managed?

Answer 5

Call for help

Stop pushing

Avoid downward traction on the fetal head (only use axial traction)

Consider episiotomy

McRoberts manoeuvre = hyperflex maternal hips, stop pushing, flatten sacral promontory and increase lumbosacral angle

Suprapubic pressure = applied in either a sustained or rocking fashion to apply pressure behind the anterior shoulder to disimpact it from underneath the maternal symphysis

Woodscrew

Question 6

What are the secondary manoeuvres

Answer 6

Posterior arm = insert hand posteriorly into sacral hollow and grasp posterior arm to deliver

Internal rotation (“corkscrew manoeuvre”) = apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position

Further:

• Cleidotomy – fracturing the fetal clavicle
• Symphysiotomy – cutting the pubic symphysis
• Zavenelli – returning the fetal head to the pelvis for delivery of the baby via caesarean section

Question 7

Outline the management of shoulder dystocia post-delivery

Answer 7

Active management - increased risk of PPH

PR - exclude 3rd degree tear

Physiotherapist - increased risk of pelvic floor weakness/3rd degree tear, musculoskeletal pain and temporary nerve damage

Paeds review - asses brachial plexus injury, humeral fracture or hypoxic brain injury.