QuestionSBA
QuestionChoice
Where first and second-line manoeuvres and internal rotation have not been successful, the woman should be prepared for theatre for e.g. symphysiotomy (dividing the anterior symphyseal ligament) or the Zavanelli manoeuvre (replacing the foetal head into the vagina in preparation for a caesarean section).
49986
e
Prepare for theatre
QuestionChoice
Forceps are not used where the foetal head has already been delivered, as overzealous pulling can lead to foetal trauma.
49985
d
Apply forceps to the foetal head to aid traction
QuestionChoice
In cases of shoulder dystocia, the mother should be encouraged to stop pushing, as this can worsen shoulder impaction.
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b
Ask the woman to hold her breath and bear down at least three times with each contraction
QuestionChoice
Also known as McRobert's manoeuvre, the mother can be assisted to hyperflex and abduct her legs. This is the first-line manoeuvre in shoulder dystocia. It serves to increase the relative anterior-posterior diameter of the pelvis and is reported to be successful in up to 90% of cases of shoulder dystocia.
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a
Hyperflexion and abduction of the mother's legs
QuestionChoice
Fundal pressure should not be applied during a shoulder dystocia, as this can precipitate uterine rupture. McRobert's manoeuvre may be augmented by moderate suprapubic pressure.
49984
c
Apply fundal pressure
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Chapter
# Summary

Shoulder dystocia is a specific form of obstructed labour where the foetal anterior shoulder becomes lodged behind the maternal pubic symphysis post-delivery of the foetal head. Key signs include difficulty in delivering the foetal face or chin, retraction of the foetal head, failure of restitution, and descent of the shoulders following head delivery. Management involves immediate help calling, avoiding fundal pressure and maternal pushing, employing various manoeuvres, and monitoring both mother and baby post-delivery for injuries and complications.

# Definition

Shoulder dystocia is a specific type of obstructed labour, where following the delivery of the foetal head the anterior shoulder becomes impacted behind the maternal pubic symphysis.

# Risk factors

- Maternal gestational diabetes
- Macrosomia
- Birthweight >4kg
- Advanced maternal age
- Maternal short stature or small pelvis
- Maternal obesity
- Post-dates pregnancy

# Clinical features

Prompt recognition of shoulder dystocia is important for timely management and thus routine observation should be made for:

- Difficult delivery of the foetal face or chin
- Retraction of the foetal head (turtle-neck sign)
- Failure of restitution
- Failure of descent of the foetal shoulders following delivery of the head

# Management

Once shoulder dystocia has been recognised, management is as follows:

- Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required
- Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction

1. McRoberts manoeuvre

- Hyperflexion and abduction of the mother's legs tightly to the abdomen
- This may be accompanied with applied suprapubic pressure
- Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released.

2. All fours position

3. Internal rotational manoeuvres:

   - Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
   - Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest
   - Note that episiotomy will not relieve shoulder dystocia as it is a bony obstruction, but may be indicated to allow space for internal rotational manoeuvres.

4. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)

5. Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section

Following the delivery of a baby after shoulder dystocia:

- The mother should be examined and monitored for postpartum haemorrhage, severe perineal tears and other genital tract trauma.
- The baby should be examined by a neonatologist for injury including brachial plexus injury, hypoxic brain damage, humeral or clavicular fractures
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A 22-year-old woman is in the second stage of labour and has just delivered the foetal head. The midwife notes that restitution does not occur. She is unable to deliver the anterior shoulder and pulls the emergency buzzer.

What is the most appropriate action?
a