Shoulder Dystocia & Uterine Rupture

Question 1

What is shoulder dystocia (SD)?

Answer 1

An obstetric emergency where additional manoeuvres are needed to deliver the shoulders after failure of gentle downward traction.

Question 2

How is SD objectively defined by Spong et al.?

Answer 2

Prolonged head-to-body delivery time (>60 seconds) and/or the use of ancillary manoeuvres.

Question 3

What is the incidence of SD?

Answer 3

0.6–1.4% of vaginal deliveries.

Question 4

What is the recurrence risk of SD?

Answer 4

13–25%.

Question 5

Name four antepartum risk factors for SD.

Answer 5

Macrosomia, diabetes, maternal obesity, previous SD.

Question 6

Name four intrapartum risk factors for SD.

Answer 6

Prolonged labour, assisted vaginal delivery, induction or augmentation with oxytocin, epidural anaesthesia.

Question 7

What are two hallmark clinical signs of SD?

Answer 7

Turtle sign and failure of restitution of the foetal head.

Question 8

List three maternal complications of SD.

Answer 8

4th-degree perineal tear, uterine rupture, postpartum haemorrhage.

Question 9

List four foetal complications of SD.

Answer 9

Brachial plexus injury, fractures, perinatal asphyxia, death.

Question 10

What manoeuvre is considered the most effective for SD?

Answer 10

McRoberts’ manoeuvre.

Question 11

What is the purpose of suprapubic pressure in SD?

Answer 11

To rotate the anterior shoulder into the oblique pelvic diameter and reduce the bisacromial diameter.

Question 12

What is Rubin II manoeuvre?

Answer 12

Digital pressure on the posterior aspect of the anterior shoulder to rotate it toward the chest.

Question 13

What is the Woods’ corkscrew manoeuvre?

Answer 13

Pressure on the posterior shoulder to rotate it forward into the pelvis.

Question 14

What is the Jacquimier manoeuvre?

Answer 14

Removal of the posterior arm to reduce shoulder diameter.

Question 15

What is the Gaskin manoeuvre?

Answer 15

Roll patient onto all fours to use gravity and open the pelvis.

Question 16

List three “rescue” manoeuvres used in SD.

Answer 16

Zavanelli manoeuvre, symphysiotomy, deliberate clavicle fracture.

Question 17

What are two preventive strategies for SD?

Answer 17

Induction of labour in diabetic women; elective C-section if foetal weight ≥ 4.5 kg.

Question 18

What is uterine rupture?

Answer 18

A full-thickness separation of the uterine wall requiring immediate surgical intervention.

Question 19

What is the difference between scar dehiscence and complete rupture?

Answer 19

Dehiscence: partial, asymptomatic separation; Complete: symptomatic rupture with foetal/maternal compromise.

Question 20

What is the incidence of rupture in unscarred vs scarred uteri?

Answer 20

Unscarred: 6.1/10,000; Scarred (VBAC): 22–74/10,000.

Question 21

List four risk factors for uterine rupture.

Answer 21

Prior C-section, myomectomy, overdistension, obstructed labour.

Question 22

What is the most common cause of uterine rupture?

Answer 22

Previous caesarean section.

Question 23

What uterine incisions carry higher risk?

Answer 23

Classical vertical and T-shaped incisions.

Question 24

What are three signs of uterine rupture during labour?

Answer 24

Sudden tearing pain, cessation of contractions, vaginal bleeding.

Question 25

What are additional clinical features of uterine rupture?

Answer 25

Tender scar, foetal parts outside uterus, bradycardia, maternal hypotension or shock.

Question 26

What is the general management approach for uterine rupture?

Answer 26

Resuscitate, stop oxytocin, administer oxygen, prepare for laparotomy.

Question 27

What are the two main surgical options at laparotomy?

Answer 27

Hysterectomy or uterine repair ± bilateral tubal ligation (BTL).

Question 28

When is hysterectomy preferred?

Answer 28

If repair is difficult or bleeding persists.

Question 29

What is the recurrence risk without tubal ligation after uterine rupture?

Answer 29

Approximately 20%.