GUIDED BY HOD AND PROFF. DR. RATNA THAKUR

PRESENTED BY DR. SNEHALATA

DR.TRINA

DR.SONAL

Introduction Shoulder dystocia has emerged as one of the most important clinical and medico legal complication of vaginal delivery.

When shoulder dystocia is anticipated the obstetrician should mentally rehearse the sequence of steps necessary to treat this problem and be ready to act in a logical , step by step fashion.

The reported incidence varies from 0.2 to 1.7% in cephalic vaginal deliveries.

Certain patterns increases the likelihood of shoulder dystocia 1. a protracted or arrested active phase of first stage of

labour is associated with an increased incidence of shoulder dystocia

2. Protracted or arrested descent in the second stage of labour is another marker.

3. Assisted mid pelvic delivery carries a higher risk of shoulder dystocia but it does not occur in 95% of such deliveries.

Defination Shoulder dystocia is defined when the fetal head has

delivered but the shoulder do not deliver spontaneously or with normal amount of gentle downward traction.

Clinical diagnosis is confirmed when the head delivers but external rotation does not occur and the head recoils tightly against the perineum. ( TURTLE SIGN )

When the head to completion of delivery interval of more than 60 secs or need to use additional manoeuvres to deliver the shoulder.

Shoulder dystocia is of two types

Unilateral shoulder dystocia – when anterior or posterior shoulder is impacted.

Bilateral shoulder dystocia – when bilateral shoulders lie above the pelvic brim.

Prediction Following predisposing factors have been identified but, in

general, lack specificity.

Antepartum risk factors 1. Macrosomia 2. Diabetes- this is due to greater shoulder/head

circumference ratio because of the insulin senstivenature of the tissues that contribute to shoulder girth , compared to brain growth which is not affected by hupoglycaemia and hyperinsulinism.

3. Obesity- chances are 0.6% in women less than 90kgs to 5% in women more than 113kgs.

4. Post term pregnancy- incidence of macrosomia is 12% at 40 weeks and 21% at 42 weeks. In later weeks of pregnancy the fetal chest and shoulders continue to grow steadily, whereas the biparietal diameter growth slows , increasing the likelihood of an unfavourable shoulder/head circumference ratio.

5. Previous shoulder dystocia Because macrosomia is the commonest association

with shoulder dystocia and neonatal injury, it has been proposed that elective cs of fetus estimated to weigh more than 4500gm and even 4000gm should be persued.

6.Abnormal pelvic anatomy 7.Short stature (less than 5feet tall) 8.Previous large infant (>4000gms) 9.Anencephaly 10.Multiparity 11.Fetal ascites

Intrapartum risk factors Operative vaginal delivery

Arrest in the late first stage of labour

Arrest of descent in second stage of labour

Precipitous delivery

ACOG guidelines on shoulder dystocia Shoulder dystocia cannot be predicted or prevented

because accurate methods for doing so do not exist.

Elective induction or caesarean delivery for all women with a suspected macrosomic fetus is not appropriate.

When evaluating the risks and benefits of caesarean and vaginal delivery in patients with a history of shoulder dystocia , the obstetrician should consider.

estimated weight

gestational age

maternal glycemic status

previous history of shoulder dystocia.

Complications Fetal – 1. Asphyxia fetus is not hypoxic before

shoulder dystocia occurs there should be 4 to 5 mins before the possibility of permanent hypoxic damage.

2.Brachial plexus injury is the most common and serious complication.

occurs in 5-15% of neonates .

Most common type is Erb-Duchenne involving C5 and C6 nerve roots . The range of permanent palsy in those infants with brachial plexus is 4-32%.

3.Fractures occuring in 15% . Majority of these are clavicular,

with fracture of humerus account for less than 1%.

Maternal complication 1.Genital tract lacerations more common due to the

tight feto pelvic relationship.additional room needed for manoeuverextension of episiotomy and 3rd and 4th degree tears are more common.

Post partum haemorrahage due to combination of -uterine atony, prolonged labour,large infant increased blood loss from lacerations andextensive episiotomy.

Managing shoulder dystocia For managing shoulder dystocia we use term

HELPERR

H – call for help

E – evaluate for episiotomy

L – legs ( MC ROBERTS maneuver )

Mc Roberts Maneuver -symphysis rotates

superiorly which lifts the fetus and flexes the fetal spine toward the anterior shoulder.

P – Suprapubic pressure

E- Enter maneuvers ( Internal rotation ) – manipulates the fetus to rotate the anterior shoulder

into an oblique plane and under maternal symphysis.

R-Rubin 2 maneuver Placing two fingers behind posterior aspect of anterior

shoulder toward the fetal chest . This will adduct fetal shoulder girdle, reducing its diameter.

Wood screw maneuver Two fingers on the anterior aspect of the fetal posterior

shoulder, applying gentle upward pressure 180 degrees ,thus the posterior shoulder which is below the level of pelvic brim is screwed around under the level of pubic arch and then it is delivered from anterior position.

Deliver the posterior arm Flex the elbow and sweep the forearm across the chest.

Grasping of the upper arm should be avoided as there is risk of fracture of humerus.

R- Roll the patient ( Gaskin or all four maneuver )- increases the flexibility of sacroiliac

joint and gravity push the posterior shoulder anteriorly.

Maneuvers of last resort Zavanelli maneuver : Cephalic replacement followed

by cs.

Cliedotomy

Abdominal rescue

Symphysiotomy

ZAVANELLI MANEUVER/cephalic replacement

Summary Shoulder dystocia cannot be reliably predicted in the

antenatal period .

Clinical estimation of macrosomia is as as accurate as ultrasound.

Elective cs is not recommended solely on the grounds of suspected macrosomia.

No consistent patterns of labour and/or delivery reliably predict shoulder dystocia.

Cs for cumulative risk factors in the antenatal and/or intrapartum period may be reasonable on a selective basis.

All personnels involved with the care of the women in labour should be familiar with a logical sequence of manoeuvers to manage shoulder dystocia.

No evidence is available that any one standard manoeuverto deal with shoulderdystocia is superior to another. However rotating the shoulders to the oblique diameter and mc roberts manoeuver are easily performed,logical,often successful , and associated with minimal fetal trauma.

Strong downward traction on the fetal head and neck should be avoided as it is associated with high rate of brachial plexus injury.

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