Shoulder Dystocia

imagesImpaction of the infant shoulders in the pelvic outlet occurring after delivery of the head during a vertex vaginal delivery


imagesManeuvers intended to disimpact the shoulders by adducting the shoulders, either by direct pressure or by rotating the infant’s trunk


imagesFailure of delivery of anterior shoulder with usual downward traction after delivery of infant head

images“Turtle Sign”—Retraction of fetal head back into maternal perineum after initial delivery


imagesImmediate availability of obstetric services for cesarean section


imagesNone. Considered an obstetrical emergency since fetal demise can occur if the procedure is indicated and not performed.

imagesGeneral Basic Steps

   imagesRecognize shoulder dystocia

   imagesCall for help immediately (including emergency department personnel and appropriate consulting services)

   imagesPrepare patient

      imagesIV, oxygen, and maternal and fetal monitor must be available

      imagesCall for assistance and obstetric, anesthesia, and pediatric backup

      imagesDrain bladder if distended

      imagesAvoid maternal pushing while attempts are made to reposition fetus

      imagesAvoid excessive head and neck traction or uterine fundal pressure

   imagesApply maneuvers to facilitate delivery (may need to attempt multiple maneuvers)


imagesMazzanti Maneuver (FIGURE 41.1)

   imagesAdduct shoulders by applying downward or oblique suprapubic pressure to dislodge anterior shoulder from pubic symphysis

   imagesAvoid applying fundal pressure, which may cause further fetal injury


FIGURE 41.1 Mazzanti maneuver.

imagesMcRoberts Maneuver (FIGURE 41.2)

   imagesHyperflex maternal hips to a knee-to-chest position

   imagesThis flattens the lumbar spine and rotates the pelvis toward the head, which frees the impacted anterior shoulder

imagesWoods Screw Maneuver (FIGURE 41.3)

   imagesRotate the fetus 180 degrees by applying pressure to the clavicular surface of the posterior shoulder in an attempt to dislodge anterior shoulder

   imagesDo not twist the head and neck

imagesRubin Maneuver (FIGURE 41.4)

   imagesPlace one hand behind the posterior shoulder and adduct shoulder while rotating it anteriorly

imagesGaskin Maneuver

   imagesMother is repositioned on her hands and knees (on “all fours”) and gentle downward traction is applied to posterior shoulder or upward traction applied to the anterior shoulder

imagesDelivery of the Posterior Arm (FIGURE 41.5)

   imagesLocate the posterior arm in the vagina

   imagesApply pressure to the antecubital fossa to flex the elbow and bring the forearm across chest

   imagesLocate the forearm and hand and pull through the vagina to deliver the posterior shoulder

imagesClavicular Fracture

   imagesFracture the clavicle intentionally to decrease bisacromial diameter by pulling the anterior clavicle outward away from the lung to avoid causing a pneumothorax

imagesZavanelli Maneuver (FIGURE 41.6)

   imagesReverse the cardinal movements of labor and take the patient to the operating room (OR) for cesarean section

   imagesRelax the uterus with terbutaline (0.25 mg SC (subcutaneously)) or nitroglycerin (50–200 µg/min IV)

   imagesRotate fetal head to occiput anterior position

   imagesFlex fetal neck and apply gentle cephalad pressure to fetal head to replace the fetus back into the pelvis

   imagesPrepare for cesarean section


FIGURE 41.2 McRoberts maneuver.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Shoulder Dystocia
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