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Shoulder Dystocia

A head-to-body delivery time exceeding 60 sec is used to define shoulder dystocia.

  1. Risk factors include D, O, P, E.
    D = diabetes mellitus
    O = obesity
    P = postdatism
    E = excessive weight gain during pregnancy (mother or fetus)
  2. Postpartum hemorrhage, usually from uterine atony, but also from vaginal and cervical lacerations, is the major maternal risk, following shoulder dystocia.
  3. Shoulder dystocia may be associated with significant fetal morbidity and even mortality.
  4. Transient Erb or Duchenne brachial plexus palsies are the most common injury, followed by clavicular fractures and humeral fractures.

As per ACOG guidelines, planned cesarean delivery is to be considered for the nondiabetic woman carrying a fetus with an estimated fetal weight exceeding 5000 g or the diabetic woman whose fetus is estimated to weigh more than 4500 g to avoid the risk of shoulder dystocia.

Management of Shoulder Dystocia

  1. Extend the episiotomy, remove the lithotomy position. Never give fundal pressure. Moderate suprapubic pressure can be applied by an assistant while downward traction is applied to the fetal head.
  2. Check if it is a unilateral shoulder dystocia (posterior shoulder is in hollow of sacrum, anterior is above pelvic brim) or a bilateral shoulder dystocia (both shoulders above pelvic brim).
  3. If it is bilateral shoulder dystocia, directly proceed to perform LSCS after doing the Zavanelli maneuver (cephalic replacement into the pelvis and then cesarean delivery).
  4. The rest of the maneuvers can be tried for unilateral shoulder dystocia, and if they fail, then proceed for Zavanelli maneuver (cephalic replacement into the pelvis) and LSCS.
  5. The McRoberts maneuver: The maneuver consists of removing the legs from the stirrups and sharply flexing them up onto the abdomen. This procedure causes straightening of the sacrum relative to the lumbar vertebrae, rotation of the symphysis pubis toward the maternal head, and a decrease in the angle of pelvic inclination.
  6. Woods reported that, by progressively rotating the posterior shoulder 1800 in a corkscrew fashion, the impacted anterior shoulder could be released. This is frequently referred to as the Woods corkscrew maneuver.
  7. Delivery of the posterior shoulder.
  8. Rubin maneuver.
  9. Cleidotomy consists of cutting the clavicle with scissors or other sharp instruments and is usually used for a dead fetus. Symphysiotomy has also been applied successfully.
  10. Hibbard maneuver is not used, as it is associated with fetal orthopedic and neurological damage.

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