1. SHOULDER DYSTOCIA (Sh.D)
An Evidence Based Approach
Dr.Mohamed El Sherbiny
MD Obstetrics&Gynecology
Senior Consultant
Damietta General Hospital
Damietta Egypt

2. SHOULDER DYSTOCIA Evidence Based Sources:
PubMed
Cochrean library
ACOG Issues Guidelines
National Guideline Clearinghouse

3. Definition:
Shoulder dystocia (Sh. D) is the inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers (ie. other than gentle downward traction on the head) .
Spong et al. 1995; Beal et al 1998 ; Bruner 1998

4. Objective definition : Mean head-to-body delivery time > 60 seconds
Spong et al. 1995; Beal et al 1998 ; Bruner 1998

5. As operative vaginal delivery of malposition and malpreresntation has declined, Sh.D has emerged as one of the more important clinical and medico-legal complications of vaginal delivery
Baskett, 2001

6. Shoulder dystocia will still the obstetric nightmare

7. PATHOPHYSIOLOGY
Shoulder dystocia results from a size discrepancy between the fetal shoulders and the pelvic inlet when:
The bisacromial diameter is large relative to the biparietal diameter
Pelvic prim is flat rather
than gynecoid .

8. Types of Shoulder Dystocia
1- High Shoulder Dystocia
2-Low Shoulder Dystocia

9. 1- High Shoulder Dystocia
Both shoulders fail to engage
(Bilateral Sh.D). (Rare)
More common with mid -pelvic assisted delivery
This presentation often requires a cephalic replacement (The most difficult)

10. 2-Low Shoulder Dystocia
Failure of engagement of the anterior shoulder (Unilateral Sh.D). ,The commonest:
Usually easily dealt with by Standard techniques

11. Incidence Varies according to: Criteria for diagnosis.
Prophylactic manoeuvre done
Subjective: %
Objective: Much lower
ACOG Bulletin,22, Novamber2000

12. Release techniques
Complications of Sh D
Maternal
Fetal

13. Maternal Complications (25%)
Postpartum hemorrhage 11%
Vaginal laceration %
Perineal tears 2nd&3rd %
Cervical laceration %
The largest study (285 cases) Gherman et al Am J Obstet Gynecol176:656, 1997

14. Fetal Complications of Sh D
Release techniques

15. Fetal Complications of Sh D
Injuries are a common outcome associated with shoulder dystocia and may occur despite use of proper standard obstetric manoeuvers
ACOG practice 1997 (B: II-2)

16. Fetal Complications of Sh D
Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported injuries associated with shoulder dystocia
ACOG practice 1997 (A: II-2)

17. Fetal Complications of Sh D
Traction combined with fundal pressure has been associated with a high rate of brachial plexus injuries and fractures
ACOG practice 1997 (B: II-2)

18. Fetal Complications of Sh D
Fewer than 10% of deliveries complicated by shoulder dystocia will result in brachial plexus injury.
a persistent
ACOG practice 1997(A: II-2)

19. Head –shoulder interval > 7min. Brain injury
Fetal Complications
Release techniques
Head –shoulder interval > 7min. Brain injury
With hypoxic fetus it is much shorter
(sensitivity & specificity :70 %)
Quzounian et al Am J Obstet Gynecol 178;S76, 1998

20. Can shoulder dystocia be predicted?

21. RISK FACTORS FOR SHOULDER DYSTOCIA
PRECONCEPTIONAL:
Maternal birth weight
Prior shoulder dystocia 12%
Prior macrosomia
Pre-existing diabetes
Obesity
Multiparity
Prior gestational diabetes
Advanced maternal age
O'Leary &, Leonetti; 1990

22. RISK FACTORS FOR SHOULDER DYSTOCIA
Antenatal:
Excessive maternal weight gain
Macrosomia
G. diabetes
Short stature
Post term
O'Leary &, Leonetti; 1990

23. RISK FACTORS FOR SHOULDER DYSTOCIA
Intrapartum:
Protracted or arrested active phase
Protracted or failure of descent of head
Need for midpelvic assisted delivery
Hopwood,1982 ; Baskett &,Allen, 1995

24. RISK FACTORS FOR SHOULDER DYSTOCIA
Most of the prenatal and antenatal risk factor are interrelated with fetal macrosomia. So the main risk factor is: Fetal
Macrosomia

25. Although macrosomia is clearly the main risk factor,
50-60 % of Shoulder
Dystocia are of < 4 Kg !!
Acker et al, Obst. Gynecol 66:762, Baskett &Allen Obstet Gynecol 86:14, 1995

26. Most cases of shoulder dystocia
Prediction
Most cases of shoulder dystocia
because accurate methods for identifying which fetuses will experience this complication do not exist, .
cannot be predicted
ACOG Practice (B: II-2).

27. Greater shoulder /head circumference:
Macrosomia
Fetal body configuration may be more important than macrosomia per se
Greater shoulder /head circumference:
Infant of diabetic mother
Post term (21% at 42 weeks)

28. Macrosomia And Shoulder Dystocia
Non Diabetic+ vacuum Diabetic or forceps
Wight (Kg)
Diabetic
4 : % % %
4.25: % % %
4.5 : % 19.9% %
4.75: % % %
Nesbitt et al, Am J Obstet Gynecol 179;476, 1998

29. ACOG Issues Guidelines on Fetal Macrosomia 2000(Level :A)
Unfortunately
The diagnosis of fetal macrosomia is imprecise.
For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's manoeuver).
ACOG Issues Guidelines on Fetal Macrosomia 2000(Level :A)

30. Can shoulder dystocia be Prevented?

31. Macrosomia There are 2 controversial prophylactic measures
1-Prophylactic labor induction
2-Elective CS

32. ACOG Issues Guidelines on Fetal Macrosomia 2000(Level B):
Induction of Labor
Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.
ACOG Issues Guidelines on Fetal Macrosomia 2000(Level B): .

33. Induction of Labor
Labor induction for suspected fetal macrosomia results in an increased CS delivery rate without improving perinatal outcomes.
Sanchez-Ramos Obstet Gynecol Systemic Review November 2002:100: .

34. Induction For Gestational Diabetes
There is very little evidence to support either elective delivery or expectant management at term.
A single randomized controlled trial suggest that induction of labor in GDM treated with insulin reduces the risk of macrosomia.
Boulvain et al:Cochrane Review,2001. In: The Cochrane Library, Issue Oxford: Update Software.

35. Prevention of Sh. D. : c.s.
Planned cesarean delivery on the basis of suspected macrosomia in the general population is not a reasonable strategy because the number and cost of additional cesarean deliveries required to prevent one permanent injury is excessive
ACOG 1997 (B: II-2).

36. Furthermore 3% of brachial plexus injury
are associated with C.S.

37. When is CS recommended in macrosomia?

38. ACOG Issues Guidelines on Fetal Macrosomia 2000
Prophylactic CS may be considered for suspected fetal macrosomia with estimated fetal weights of:
> 5,000 g in non diabetic women
> 4,500 g in diabetic women
(Level :C) .

39. ACOG Issues Guidelines on Fetal Macrosomia 2000
With an estimated fetal weight more than 4,500 g, with :
A prolonged second stage of labor or
Arrest of descent in the second stage
It is an indication for CS delivery.
Level B .

40. MANAGEMENT
(Within5- 7 minutes) .

41. Management 1-Suprapubic pressure 2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy

42. ACOG Issues Guidelines Recommendation 1991
1-Call for help: assistants, anesthesiologist
2-Initial gentle attempt of traction.
3-Generous episiotomy.
4-Suprapubic pressure.

43. ACOG Issues Guidelines Recommendation 1991
5-The Mc Roberts manoeuvre (Exaggerated hyper flexion of the thighs upon the abdomen.) & Suprapubic pressure in the direction of the Foetal face .

44. McRoberts manoeuvre: X ray pelvimetry study
No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000

45. Mc Roberts manoeuvre IU pressure by 97% (P<0.0001)
U. contraction amplitude by 25% (P<0. 001)
Applied additional 31 Newtons pushing force
Buhimschi et al Lancet 358:470 ,2001

46. ACOG Issues Guidelines Recommendation 1991
If Mc Roberts failed:
6-Woods manoeuvre:
The hand is placed
behind the posterior
shoulder of the fetus.
The shoulder is rotated progressively 180 d in a corkscrew manner so that the impacted anterior shoulder is released. .

47. ACOG Issues Guidelines Recommendation 1991
7-Delivery of the posterior arm : .

48. delivery over the perineum
By inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder
delivery over the perineum

49. ACOG Issues Guidelines Recommendation 1991
8-Other techniques include:
Intentional fracture of the clavicles or the humerus Or
Zavanelli Maneuver. .

50. The Zavanelli Manoeuver
Reversing the mechanism of delivery of the vertex under tocolytic

51. The head first manually rotated to the occipito anterior
(Pre-restitution) position

52. 2.Flexion of the head, Returning it to the vagina with upward constant firm pressure, followed by CS

53. The Zavanelli Manoeuver
Zavanelli maneuver
It would usually only be applicable in those rare cases of bilateral Sh.D.
It involves an emergency procedure that is not without risks of its own .
It has minimal applicability as it needs
Immediate CS

54. The Zavanelli Manoeuver Maternal complication:
Zavanelli maneuver
In an analysis of 92 cases of shoulder dystocia managed by Zavanelli Maneuver:
Success rate : %
Stillbirth: %
Neonatal death : 9%.
Brain damage : %
Maternal complication:
Rupture uterus ,vaginal rupture ,severe infection,
Sanberg; Obstet Gynecol.;93:

55. It consists of placing the patient onto her hands and knees
All- Fours Manoeuver
It consists of placing the patient onto her hands and knees

56. All- Four Manoeuver
It allows rotational movement of the sacroiliac joints resulting in a l-cm to 2-cm increase in the sagittal diameter of the pelvic outlet.
It disimpact the shoulders, and allowing it to slide over the sacral promontory.
Effective also for bilateral Sh.D.

57. All- Fours Manoeuver
In an analysis of 82 cases of shoulder dystocia managed by all-four manoeuver :
Success rate : 83%
Maternal complications 1.2%
Neonatal complications : 4.9%,
Time for complete delivery : 2 to 3 Ms.
Drummond et al. J Reprod Med. ;43:439; 1998.

58. ACOG Issues Guidelines 1997
Release techniques
There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury.
(B: II-2).

59. ACOG Issues Guidelines 1997
Release techniques
However, the Mc Roberts maneuver is easily facilitated and has a high success rate without an associated increased risk of injury to the newborn
(B: II-2).

60. Bilateral Shoulder Impactions
All- Fours Manoeuver:
Used at all circumstances except if the patient has received epidural analgesia, heavy analgesia or anesthesia
Zavanelli Manoeuver:
Used if the patient has received epidural analgesia or heavy analgesia
with obstetric facilities for emergency CS

61. Prophylactic Procedures
When shoulder dystocia is anticipated , prophylactic McRobert position is recommended

62. Shoulder Dystocia Drill
Shoulder dystocia drill should be as important as CPR for the mother and neonate.
This should be taught and practiced regularly, by all staff involved with delivery

63. Thank You