SHOULDER DYSTOCIA

•	Definition and aetiology.
•	Predisposing factors for shoulder dystocia. 
•	Shoulder dystocia drill.

Definition and Aetiology

1.	Shoulder dystocia means difficult delivery of the shoulders.

2.	Incidence: 0.2 – 1.2 per cent.

3.	An obstetric emergency.

4.	Delay beyond five minutes leads to hypoxia and ultimately fetal death.

5.	Undue haste and traction leads to damage to the cervical plexus nerve roots of the baby.

Predisposing factors for shoulder dystocia

1.	Macrosomia > 4000g:

a.	Elderly multiparous woman.

b.	Tall and overweight woman.

c.	Excessive weight gain in pregnacny.

d.	Previous macrosomic baby.

2.	Diabetes mellitus with poor control.

3.	Post-date pregnancy.

4.	Vacuum extraction or forceps delivery especially with malposition.

5.	Protracted late first stage / second stage of labor.

6.	When fetal head is delivered at the end of the uterine contraction.

7.	Short and stout patients with android features having large babies and protracted labor. 

Shoulder dystocia drill

1.	Anticipate shoulder dystocia based on the above.

2.	Oxytocin infusion to have contractions of 1 in 2 to 2 ½ min.

3.	Large mediolateral episiostomy.

4.	McRobert’s manouvre:

a.	Slight abduction and maximal flexion of the maternal knees and thighs.

b.	Suprapubic pressure downwards and towards direction of fetal face on the fetal shoulder.

c.	Downward traction of fetal head: the anterior shoulder is delivered if necessary by rotation of the fetal body.

5.	If still difficulty encountered, palpate the posterior shoulder from the dorsal side and with 2 fingers press in a forward direction to reduce the diameter of the shoulders along with suprapubic pressure; then apply light pressure downwards on the fetal head.

6.	Attempt to deliver posterior shoulder:

a.	Palpate posterior shoulder from ventral side with 2 fingers and rotate to an oblique or transverse axis of the pelvis.

b.	Suprapubic pressure and light pressure downward on the fetal head with contraction and bearing down effort.

c.	Deliver posterior shoulder first by manipulation with 2 fingers in the posterior part of the axilla and by delivering the posterior arm.

7.	Zavinalli manouvre:

a.	Clavicle is fractured by pressing in the supraclavicular fossa downward and laterally.

b.	The head is rotated and replaced into the pelvis under uterine tocolysis with bolus dose of terbutaline.

c.	Babt delivered by LSCS under GA.