SHOULDER DYSTOCIA
DEFINITION
Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric
manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed.
Time delay between head and shoulder delivery > 60 seconds
DO NOT
Panic
Give excessive traction over fetal head
Apply fundal pressure
Routine traction in an axial direction can be used to diagnose shoulder dystocia but any other
traction should be avoided.
Factors associated with shoulder dystocia
Pre-labour
Previous shoulder dystocia
Diabetes mellitus
30kg/m2
Induction of labour
ALARMER:
A-Ask for assistance
L-Lift up the buttocks
A-Anterior disimpactation of shoulder
R-Rotation of posterior arm
M-Manual removal of posterior arm
E- Episiotomy
R-Roll over
Baby should be delivered within 7 minutes
Intrapartum
Prolonged first stage of labour
Secondary arrest
Prolonged second stage of labour
Oxytocin augmentation
Assisted vaginal delivery
First line – Mc Roberts and suprapubic pressure
Second line – rotational
Thirdline – symphysiotomy, cleidotomy and zavenelli
McRoberts maneuver
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Flex and abduct the maternal hips, position the maternal thighs up on to the maternal
abdomen.
This position flattens the sacral promontory and results in cephalad rotation of the
pubic symphysis.this straightens the lumbosacral angle and results in disimpaction of
anterior shoulder
Success rate -90%
Rubin’s maneuver (Disimpaction of the shoulder)
Suprapubic pressure
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Assistant places the hand suprapubically over the posterior aspect of fetal anterior
shoulder, applying pressure in downward and lateral direction
Continue the downward traction
Do not apply fundal pressure.
Initially apply the pressure continuously , but if delivery is not accomplished apply
rocky motion which dislodges the shoulder from behind the pubic symphysis
If this is not successful 
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Insert two fingers of right hand vaginally behind the posterior aspect of the approachable
shoulder of the fetus and rotate the shoulder towards the fetal chest (adduction)
This reduces the diameter of fetal shoulder girdle
Bisacromial diameter occupies the larger oblique diameter
Not possible to deliver
Follow one of the following 3 manouvres
Manual removal of Posterior arm :
Most commonly followed when Mc Robert fails
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Done by the obstetrician
Give liberal episiotomy
Place right hand in the vagina
Locate the posterior fetal arm, flex the fetal elbow and deliver the forearm by sweeping
it across the fetal chest
WOODS CROK SCREW MANEUVER
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Insert two fingers of right hand vaginally , place them on the anterior aspect of fetal
posterior shoulder rotate the shoulder away from the fetal chest through 180
degrees bring it under the pubic symphysis and deliver

Deliver the shoulder which is in the sacral hollow. If not possible rotate it by 180
degrees bring it under pubic symphysis and deliver.
COMBINATION OF RUBINS AND WOODS CORK SCREW
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The Rubin and Woods cork screw maneuver may be combined .
Downward traction should be continued during these rotational maneuvers,
stimulating the rotation of the screw being removed .
ROLL OVER- ALL FOURS OR GASKIN MANOUVRE
Roll the patient onto her hands and knees .
Provide gentle downward traction to deliver the posterior shoulder with aid of
gravity.
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This maneuver increases pelvic diameter – inlet AP diameter increases as much as 1
cm and the outlet AP diameter increases upto 2 cms
But it is not evidence based
Success rate 83%
Zavanelli maneuver:
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For bilateral shoulder dystocia
Done under GA
Rotate the head to undo the restitution and flex to undo the extension and then replace in
the vagina maintaining a constant firm pressure. Caeserean is performed immediately
Destructive procedures
-Cleidotomy
-Symphysiotomy
ABDOMINAL RESCUE
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For bilateral shoulder dystocia unresponsive to cephalic replacement
LSCS is performed
Elevate the anterior shoulder and rotate it to oblique position-posterior shoulder descends
beneath the promontory where it can be delivered directly
Then rotate the fetal body so that the impacted anterior shoulder enters the pelvis and it can
be delivered
There is significant maternal morbidity associated with shoulder dystocia, particularly
postpartum
haemorrhage (11%) and third and fourth degree perineal tears (3.8%).11 Other reported
complications include vaginal lacerations,80 cervical tears, bladder rupture, uterine rupture,
symphyseal separation, sacroiliac joint dislocation and lateral femoral cutaneous neuropathy