Shoulder dytocia

Question 1

What is shoulder dystocia?

Answer 1

Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

Question 2

Is shoulder dystocia an emergency?

Answer 2

Shoulder dystocia is an obstetric emergency.

It requires additional obstetric manoeuvres to enable delivery of the rest of the body.

Question 3

What is shoulder dystocia commonly caused by?

Answer 3

Macrosomia (large for gestational age baby), occurring secondary to gestational diabetes

Question 4

Presentation of shoulder dystocia?

Answer 4

• Presents with difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head.
• Failure of restitution
• Turtle neck sign

Question 5

What is “failure of restitution” in shoulder dystocia?

Answer 5

Where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head.

Question 6

What is the “turtle neck sign” in shoulder dystocia?

Answer 6

Where the head is delivered but then retracts back into the vagina.

Question 7

First step in management of shoulder dystocia?

Answer 7

Get help, including anaesthetics and paediatrics.

Question 8

What are some of the techniques/manoeuvres that can be used to help delivery of the baby in shoulder dystocia?

Answer 8

Episiotomy
McRoberts manoeuvre
Pressure to anterior shoulder
Zavanelli manoeuvre

Question 9

What is an episiotomy?

Answer 9

Can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary.

Question 10

What is McRoberts Manoeuvre?

Answer 10

Involves hyperflexion of the mother at the hip (bringing her knees to her abdomen).

This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.

Question 11

What is pressure to the anterior shoulder?

Answer 11

Involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.

Question 12

What is Zavanelli manoeuvre?

Answer 12

Involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Question 13

Complications that can occur due to shoulder dytocia?

Answer 13

• Foetal hypoxia (and subsequent cerebral palsy)
• Brachial plexus injury and Erb’s palsy
• Perineal tears
• Postpartum haemorrhage

Question 14

What is the HELPERR mnemonic for shoulder dystocia?

Answer 14

H - call for Help
E - Evaluate for episiotomy
L - Legs: McRobert’s Manoeuvre
P - External pressure: suprapubic
E - Enter: rotational manoeuvres
R - Remove posterior arm
R - Roll patient onto her arms and
knees