Definition of "Shoulder dystocia"

Last modified: 18 hours



Shoulder dystocia is a case of obstructed labor, where shortly after the delivery of the head, the anterior shoulder of the infant can't pass below because it is obstructed by the maternal pelvis (pubic symphysis).

Patient information

What is shoulder dystocia? It sounds like something horrible has happened to the shoulder
It's where the baby isn't able to be pushed out of the mother, because their shoulder is stuck!

Wait, which way does the baby pop up? Head or toes first?
Usually head. We call that "cephalic".

So the head has popped out, but the shoulder is stuck - physically?
That's right ! Specifically, the shoulder of bub that faces the pubic symphysis.

What is the pubic symphysis? Is it some sort of bone?
It's a cartilage, that connects the left and right pubic bones.

Dx
  • The shoulders fail to deliver shortly after the fetal head
  • Turtle sign, which is the appearance and retraction of the fetal head, analogous to a turtle withdrawing into its shell
  • Facial flushing (erythematous, puffy face)
  • Need for oxytocics
  • Prolonged 1st or 2nd stage of labor
  • Head bobbing in the 2nd stage
  • Failure to restitute
  • No shoulder rotation or descent
  • Instrumental delivery

Patient information

How do you know bub's shoulder which faces the cartilage that connects the left and right pubic bones, is stuck because of that cartilage?
Well... if it's been some time after the head has popped out, and the shoulders still haven't come out. If bub's head is popping in and out like a turtle retracting into its shell.

Risk factors
  • Fetal macrosomia (>4kg (high maternal birthweight)
  • Diabetes (2-4x increase in risk)
  • Maternal obesity
  • Age>35yo
  • Short in stature
  • Small/abnormal pelvis
  • Post dates (>42 weeks gestation)
  • Previous shoulder dystocia (recurrence is relatively high)

Patient information

I remember a few times as a kid getting my hand stuck after I'd inserted it somewhere! Scary stuff :'(!!! So what is it exactly that causes a baby to become stuck, at the point of birth?
If the baby is big, it's obviously going to get stuck easily. Just think of trying to squeeze through a limited space. The smaller/skinnier you are, the easier!

So anything and everything that's going to make the baby bigger, is going to be a risk factor?
Yep, so the baby actually being big. Or things that likely make the baby big, such as diabetes, or that the mother is obese.

And of course you have the status quo thing...
Yep, if you've previously had it... as they say, history repeats itself!

Mx

Shoulder dystocia may require significant manipulate to pass below:

  • HELPERR mnemonic, which goes from least to most invasive, thereby reucing harm to the mother in the event that the infant delivers with 1 of the earlier maneuvers. It is used in the event the infant delivers with an earlier maneuver. It includes:
    • Ask for help, for an obstetrician, anesthesia, and pediatrics (for subsequent resuscitation of the infant if needed), that may be needed if the methods below fail
    • Evaluate for episiotomy
    • Leg hyperflexion (aka McRoberts maneuver), involving hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine)
    • Suprapubic pressure (aka Rubin I maneuver), where an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled
    • Enter, with rotational maneuvers, including:
      • Rubin II maneuver, which is posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the vagina
      • Woods' screw maneuver, where the anterior shoulder is turned posterior
      • Reverse Woods' screw maneuver, which is the vice versa movement
    • Remove the posterior arm
    • Roll over on all fours (aka Gaskin maneuver), where the mother is rolled on to all fours position with the back arched, widening the pelvic outlet

YouTube video

Patient information

What do we do if bub's shoulder is stuck?
We do this thing called HELPERR. So we ask for help. We check if we want to make a cut to the perineum, to make it easier for bub to pop out. If the shoulder is actually stuck, we get mom to raise her legs to her abdomen, to widen the pelvis. If that doesn't work, we can then try to move bub. We start outside pushing against mom's tummy, against bub's front shoulder. We then move internally, trying the same thing. We can then try assisting that rotation, by pushing against bub's back shoulder. If that doesn't work, we try rotating bub the opposite direction. Now if all of that doesn't work, we get mom to roll on her all 4's. And we start again.

In the event that these maneuvers are unsuccessful, a skilled obstetrician may attempt some of the additional procedures listed above. More drastic maneuvers include:

  • Intentional fracture of the clavicle, reducing the diameter of the shoulder girdle that requires to pass through the birth canal
  • Both of which are considered extraordinary Tx measures:
    • Zavanelli’s maneuver
    • Symphysiotomy
Prognosis
  • Obstetric emergency
Complications
  • Fetal injury, such as upper brachial plexus nerve (i.e. supply sensory/motor to the shoulder, arms and hands) injury, despite appropriate obstetric Mx → manual stretching of the nerves causing injury, tension causing physical tearing of nerve roots from the spinal column (esp ventral/motor as they are anterior)
  • Fetal hypoxia
  • Cerebral palsy
  • Fetal death can occur if the infant is not delivered → compression of the umbilical cord within the birth canal
  • Maternal PPH
  • Unintentional fracture of the clavicle or humerus
  • Birth asphyxia

Patient information

What bad things can happen as a result of bub's front shoulder being stock?
There can be injury to the nerves that supply the shoulder, arms and hands of bub. Bub can be low on oxygen. Bub can have brain damage causing movement problems. It can cause bub to die. Mom can have lots of bleeding. Bub can break the bones of their upper arm or shoulder.

Epidemiology
  • Occurs in 1% of vaginal births
Paperwork
  • Fill in the Date, time Called for help at
  • List of Staff present, Role, and Time arrived
  • Mode of Delivery of Head, including Spontaneous, or Instrumental
  • Times, including Time of Delivery of Head, Time of Delivery of Body, and Head to Body Delivery Interval
  • Fetal Position During Dystocia, either Head Facing Maternal Left/Left Fetal Shoulder Anterior, or Head Facing Maternal Right/Right Fetal Shoulder Anterior
  • Description of Traction, including Routine Axial (As in Normal Vaginal Delivery), or Reason if Not Routine
  • Procedures Used to Assist Delivery, including at 30 Seconds, 2nd Attempt, the Order, and By Whom:
    • ​McRoberts Maneuver (Nipples to Knees)
    • Rubins I (Suprapubic Pressure to Move Anterior Shoulder)
    • Evaluate for Episiotomy
    • Rubins II (Internal Pressure to Move Anterior Shoulder)
    • Wood's Screw (Internal Pressure Anterior and Posterior)
    • Reverse Wood's (As Above in Reverse)
    • Posterior Arm (Removal of Posterior Arm)
    • Gaskin (Hands - Knees Position to Facilitate Birth)
  • Birth Weight in "gms" (grams)
  • APGAR, including at 1 min, 5 mins, 10 mins
  • Cord Gases
  • Arterial pH
  • Arterial BE (base excess)
  • Venous pH
  • Venous BE
  • Baby Assessment After Birth, including Yes/No for whether there are Any signs of arm weakness? Any sign of potential bony fracture? Baby admitted to SCN? If yes to any of these questions for review by Pediatric Registrar
  • EBL (estimate of blood loss)
  • Date IIMS (Incident Information Management System) Attended
  • Authentication including Name, Designation, Signature, Date, and Time
See also
  • Obstructed labour
  • Brachial plexus injury (complication)

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