Shoulder Dystocia

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

PROCEDURAL DEFINITION

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

INDICATIONS

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

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

CONTRAINDICATIONS

Immediate availability of obstetric services for cesarean section

CONSENT

None. Considered an obstetrical emergency since fetal demise can occur if the procedure is indicated and not performed.

General Basic Steps

Recognize shoulder dystocia

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

Prepare patient

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

Call for assistance and obstetric, anesthesia, and pediatric backup

Drain bladder if distended

Avoid maternal pushing while attempts are made to reposition fetus

Avoid excessive head and neck traction or uterine fundal pressure

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

TECHNIQUES

Mazzanti Maneuver (FIGURE 41.1)

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

Avoid applying fundal pressure, which may cause further fetal injury

FIGURE 41.1 Mazzanti maneuver.

McRoberts Maneuver (FIGURE 41.2)

Hyperflex maternal hips to a knee-to-chest position

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

Woods Screw Maneuver (FIGURE 41.3)

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

Do not twist the head and neck

Rubin Maneuver (FIGURE 41.4)

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

Gaskin Maneuver

Mother 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

Delivery of the Posterior Arm (FIGURE 41.5)

Locate the posterior arm in the vagina

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

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

Clavicular Fracture

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