Shoulder dystocia

Question 1

Define shoulder dystocia.

Answer 1

An obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery, or, less commonly, the posterior shoulder becomes impacted against the sacral promontory

Question 2

Give 4 risk factors for shoulder dystocia.

Answer 2

• History of shoulder dystocia
• Fetal macrosomia
• Maternal diabetes mellitus or gestational diabetes
• Maternal obesity
• Prolonged second stage of labor

Question 3

What is the Turtle sign?

Answer 3

Retraction of the partially delivered fetal head against the perineum

Question 3

What the HELPER mnemonic stand for

Answer 3

H: Call for help
E: Evaluate for episiotomy
L: Legs (the McRoberts’ manoeuvre)
P: Suprapubic pressure
E: Enter manoeuvres (internal rotation)
R: Roll the woman to her hands and knees

Question 4

Describe the McRoberts maneuver.

Answer 4

The patient should stop bearing down and lie supine with the buttocks on the edge of the bed.

Abduct, externally rotate, and hyperflex the maternal hips (with the maternal legs pulled towards the head).

Question 5

What is Rubin I maneuver?

Answer 5

External suprapubic pressure, also known as Rubin I, is applied by an assistant, using a CPR-style hand position. Pressure should be applied to the posterior aspect of the anterior shoulder in a downward lateral direction.

The shoulders should adduct (reduce the bisacromial diameter) and rotate under the symphysis pubis.

Question 6

Describe the Rubin II maneuver.

Answer 6

Insert fingers of the right hand into the vagina (at 5 o’clock position) and apply anticlockwise pressure to the posterior aspect of the anterior shoulder. External suprapubic pressure can also be applied by an assistant to provide additional force

Question 7

Describe the Woods’ screw maneuver.

Answer 7

While maintaining the position of the right hand, insert the fingers of the left hand into the vagina (at 7 o’clock position) and apply anticlockwise pressure to the anterior aspect of the posterior shoulder. Both hands should be used to apply anticlockwise pressure simultaneously. External suprapubic pressure can also be applied by an assistant

Question 8

Describe the reverse Woods’ screw maneuver.

Answer 8

Remove the left hand from the vagina (last hand in, first hand out). Keep the right hand in the vagina and slide the fingers down from the posterior aspect of the anterior shoulder to the posterior aspect of the posterior shoulder, and apply clockwise pressure. Do not apply external suprapubic pressure.

Question 9

List the maneuvers of last resort (savage maneuvers).

Answer 9

1. Intentional clavicle fracture
2. Zavanelli maneuver
3. Symphysiotomy

Question 10

What is the Zavanelli maneuver?

Answer 10

The fetal head is pushed back into the pelvis to alleviate pressure on the umbilical cord while the patient is transported to the OR for cesarean delivery.

Question 11

What is a symphysiotomy?

Answer 11

Surgical separation of the anterior fibers of the symphyseal ligament, only performed if all other maneuvers are unsuccessful and cesarean delivery is not available

Question 12

Give 3 fetal complications of shoulder dystocia.

Answer 12

Brachial plexus injury (Erb palsy is more common than Klumpke palsy)

Clavicle or humerus fracture

Perinatal asphyxia and hypoxic-ischemic encephalopathy

Question 13

Give 2 maternal complications of shoulder dystocia.

Answer 13

Perineal lacerations

Postpartum hemorrhage

Vaginal lacerations

Uterine rupture

Pubic symphysis separation