Learning objectives
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List risk factors for shoulder dystocia.
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Recognize shoulder dystocia.
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Describe maneuvers used to relieve shoulder dystocia.
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Apply a team-based approach to shoulder dystocia.
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Identify complications of shoulder dystocia.
Shoulder dystocia is an obstetric emergency. It occurs when, following delivery of the fetal head, routine gentle traction fails to deliver the fetal shoulders.
Risk Factors
Known risk factors for shoulder dystocia include:
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High birth weight
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Diabetes mellitus
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Previous shoulder dystocia
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Postterm pregnancy
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Abnormal labor progress
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Operative vaginal delivery
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Male fetal gender
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Maternal obesity and high gestational weight gain
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Advanced maternal age
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African-American
Most shoulder dystocia cases occur in women with no risk factors. The obstetric team must be prepared for the possibility of shoulder dystocia with every delivery.
Prevention of Shoulder Dystocia
Scheduled cesarean delivery is reasonable in the following cases:
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Prior shoulder dystocia, especially with a severe neonatal injury
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Estimated fetal weight >4500 g in women with diabetes (estimated risk of shoulder dystocia 15%)
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Estimated fetal weight >5000 g in women without diabetes (estimated risk of shoulder dystocia >20%)
In addition, women with estimated fetal weights >4000 g who undergo a trial of labor become high risk for shoulder intrapartum if they have a prolonged second stage or require an operative vaginal delivery.
Diagnosis
Shoulder dystocia is a subjective clinical diagnosis. During delivery of the fetal head, difficulty with birth of the face and chin may be present. When the head of the infant is born, it remains tightly applied to the vulva. In addition, the “turtle sign” or retraction of the fetal head against the maternal perineum may be present.
Difficulty or failure to accomplish external rotation of the head after it has passed the perineum is another sign suggestive of shoulder dystocia. Finally, resistance to the delivery of the anterior shoulder with the usual amount of traction applied to the fetal head should alert the delivering provider of the diagnosis of shoulder dystocia.
Management
Initial Steps
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CALL FOR HELP!! Personnel in the delivery room should include:
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An experienced care provider
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Two labor and delivery nurses
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A neonatologist
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An anesthesiologist
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State clearly “There is a shoulder dystocia.”
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Explain to patient the presence of shoulder dystocia and the need for additional maneuvers
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Position the patient with her buttocks at the edge of the bed, lower the bed, and request a stool to assist with specific maneuvers
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Note the time the head was delivered (START THE CLOCK)
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Evaluate the need for episiotomy. This will not relieve the shoulder dystocia but will allow more room for performing maneuvers
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If the bladder is distended, drain it
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Avoid excessive head and neck traction ( Fig. 9.1 )
Fig. 9.1
Avoid traction on fetal neck during delivery as this can result in brachial plexus injury.
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If a tight nuchal cord is encountered, release the cord if possible; avoid clamping and cutting the cord
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NEVER apply fundal pressure. This can further engage the anterior shoulder under the pubic bone
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Implement maneuvers to alleviate shoulder dystocia. Move quickly between maneuvers and do not persist in any one maneuver if it is not immediately successful
McRoberts’ Maneuver
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Requires two assistants who each support a maternal leg and flex the thigh sharply against the abdomen
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Causes cephalad displacement of the symphysis, flattens the sacral promontory, and improves pushing efficiency
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Often recommended as initial or even prophylactic maneuver due to its low invasiveness
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There is not an order for the other maneuvers. The preference is given to the experience of the operator.
Suprapubic Pressure
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An assistant applies suprapubic pressure with his/her palm or fist. It is crucial that pressure is applied suprapubic, not fundal
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Pressure is applied in a downward (below pubic bone) and lateral direction (toward the baby face or sternum) to decrease the bisacromial diameter and shift this diameter into an oblique position
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This maneuver is performed simultaneously with McRoberts’ maneuver ( Fig. 9.2 )
Fig. 9.2
McRoberts’ maneuver and suprapubic pressure. Hips are flexed to flatten the sacral promontory. Suprapubic pressure decreases the bisacromial diameter. Together, these improve pushing efficiency.
Delivery of the Posterior Arm (Jacquemier’s Maneuver)
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Highly effective maneuver to relieve anterior shoulder impaction
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It is best performed under adequate anesthesia
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The provider passes a hand into the vagina over the chest of the fetus to identify the posterior arm and elbow
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If the fetal chest faces the maternal right, then the operator introduces the left hand and vice versa
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Pressure is applied to the antecubital fossa and the elbow is flexed in front of the body, and/or the posterior hand is grasped to sweep the arm across the chest and deliver the arm. Avoid applying pressure directly to the humeral shaft to reduce the risk of fracture
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The fetus is rotated into the oblique diameter of the pelvis, bringing the anterior shoulder under the symphysis pubis ( Fig. 9.3 )
Fig. 9.3
Jacquemier’s maneuver. The posterior arm is swept over the fetal chest and delivered.
Rubin Maneuver
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The operator places a hand on the back surface of the posterior shoulder (right hand if the fetal chest is facing the maternal right and vice versa)
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If the anterior shoulder is more accessible, the hand can be placed in the back of the anterior shoulder
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Pressure causes adduction of the fetal shoulder and allows displacement of the bisacromial diameter from the anteroposterior position to the oblique position ( Fig. 9.4 )
