New Born OB

Shoulder Dystocia Quick Facts                   PB178


Shoulder dystocia = failure to deliver the fetal shoulder/s with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery (occurs in 0.2-3% of deliveries) *turtle sign is predictive but not diagnostic                                                                                                         

*can be anterior shoulder impacted by symphysis or posterior shoulder impacted by sacral promontory

-          Complications:

o   Maternal: PPH, perineal lacerations and anal sphincter injuries, symphyseal separation, lateral femoral cutaneous neuropathy related to extreme hyperflexion

o   Fetal: brachial plexus injuries, clavicle/humerus fractures, very rarely hypoxic-ischemic encephalopathy and death

  • It should be noted that a significant % of brachial plexus injuries are not associated with dystocia, occurring either during uncomplicated vaginal delivery or cesarean delivery.

-          Risk Factors: increased birth weight, maternal diabetes, h/o shoulder dystocia (NOT obesity, excessive maternal weight gain, oxytocin use, operative delivery, epidural use, precipitous or 

            prolonged 2nd stage, multiparity, fetal AC:BPD)

-          Recurrence: ~10% (underestimated as some women will have elective C/S next pregnancy)

-          Management:

o   Note the time when shoulder dystocia was diagnosed

o   Request additional nursing, providers and anesthesia

o   Instruct patient not to push, position patient appropriately for optimal access

o   If traction is used, it should be axial, in alignment with the fetal cervico-thoracic spine…typically has a downward component 25-45 degrees below the horizontal plane when patient is in the dorsal lithotomy position.

o   Attempt McRobert’s maneuver first = sharp flexion of maternal thighs against the abdomen to rotate the symphysis cephalad and flatten the lumbar lordosis. Can be done in conjunction with suprapubic pressure = pressure above the maternal pubic bone to direct the fetal anterior shoulder downward and medially towards its face.

o   Attempt posterior arm delivery next (will relieve 95% of dystocias within 4 minutes, less force required and fewer branchial plexus injuries compared to other maneuvers)

o   Attempt “rotational maneuvers” next

  • Rubin = hand on back surface (scapula) of fetal posterior shoulder, rotate anteriorly toward fetal face -> decreases bisacromial diameter and rotates

  • Wood Screw = hand on front surface (clavicle) of fetal posterior shoulder, rotate posteriorly toward fetal spine -> only rotates

o   Other methods include…

  • Gaskins – patient on all-fours, try all of the above maneuvers in this position

  • Posterior axilla sling – soft catheter around posterior arm, steady traction

  • Zavenelli – cephalic replacement followed by C/S

  • Abdominal rescue – laparotomy and hysterotomy to manually dislodge anterior shoulder and effect vaginal delivery

  • Clavicular fracture – may decrease bisacromial diameter

-          Documentation: critical for informing patient and their future providers, should include counseling re: future risks

-          Simulation: increases evidence-based management and decreases branchial plexus injury