1. Vanderbilt High Risk Obstetrics Conference 2017
Shoulder Dystocia
Vanderbilt High Risk Obstetrics Conference 2017

2. Outline Learning Objectives Background Management / Treatment Summary
References

3. Learning Objectives Understand the risk factors for shoulder dystocia
Be able to communicate the critical tasks that should be performed when a shoulder dystocia occurs
Demonstrate the proper technique to relieve a shoulder dystocia
Be able to communication effectively to the team and patient when a shoulder dystocia occurs

4. Background

5. Shoulder Dystocia Occurs in 0.2% - 3% of vaginal deliveries
Variety of risk factors including fetal macrosomia, diabetes, history of shoulder dystocia and prolonged second stage
Other factors that have been associated include post- term pregnancy, multiparity, obesity and operative vaginal delivery
50% of should dystocia have no risk factors identified

6. Definition Head successfully delivered
Shoulder lodged behind pubic bone
Posterior shoulder may be lodged behind sacral promontory
Delivery arrested

7. Anterior Shoulder Impaction

8. Identification of Shoulder Dystocia
Delivery of head with retraction of head against perineum (Turtle Sign)
Delivery of head with arrest of shoulder delivery with usual delivery maneuver (axial traction of fetal head)
Traction should be done in alignment with cervico-thoracic spine at an angle of degree
Should not be done at an angel – increases the risk of brachial plexus injury
Delivery with or arrest of delivery of fetal head and chin

9. Risk Factors Antepartum Intrapartum Fetal macrosomia Obesity
Maternal diabetes
Prior shoulder dystocia
Excessive weight gain
Prior macrosomic infant
Abnormal labor pattern
Operative vaginal delivery

10. Prevention of Shoulder Dystocia
Prevention of shoulder dystocia with Cesarean section prior to labor should only be considered in unusual circumstances:
Estimated fetal weight in diabetic patient ≥ 4500 gms
Estimated fetal weight in non diabetic patient ≥ 5000 gms
Prior shoulder dystocia with injury to infant (brachial plexus, limb fracture or asphyxia)

11. # of CD needed to avoid permanent brachial plexus injury
Elective CD for fetal macrosomia based on ultrasound – Effectiveness/Cost
Non-Diabetic
# of CD needed to avoid permanent brachial plexus injury
Cost ($ millions)
CD if ≥ 4000 gms
2345
$4.9
CD if ≥ 4500 gms
3695
$8.7
Rouse DJ, et al. JAMA 1996;276:1480–1486.

12. # of CD needed to avoid permanent brachial plexus injury
Elective CD for fetal macrosomia based on ultrasound – Effectiveness/Cost
Diabetic
# of CD needed to avoid permanent brachial plexus injury
Cost ($)
CD if ≥ 4000 gms
489
$930,000
CD if ≥ 4500 gms
443
$880,000
Rouse DJ, et al. JAMA 1996;276:1480–1486.

13. Morbidity Maternal Neonatal Increased risk of postpartum hemorrhage
Increased risk of higher degree perineal lacerations
Brachial plexus injury – majority resolve
Fractures of clavicle or humerus
Hypoxemia
Death

14. Management and Treatment

15. Shoulder Dystocia Algorithm
Call for help: RN, Pediatrics, OB
Brief team huddle (clearly state problem, assign roles)
McRobert’s Maneuver (thighs to abdomen)
Suprapubic pressure  routine delivery traction
Episiotomy if necessary to do internal maneuvers
Deliver posterior arm OR
Internal rotational maneuvers
Posterior Axilla Sling Traction (PAST)
All fours position and delivery of posterior shoulder
Cephalic replacement and Cesarean section

16. McRobert’s Maneuver - Before

17. McRobert’s Maneuver - After
Flexion of maternal thighs
Cephalad rotation of symphysis pubis
Flattening of the lumbar lordosis

18. Suprapubic Pressure
Pressure is directed downward and laterally (towards the fetus face and sternum)
Assist in abduction and rotation of the anterior shoulder

19. Suprapubic Pressure

20. Delivery of the Posterior Arm
Move the thumb to palm of hand prior to vaginal insertion

21. Delivery of the Posterior Arm

22. Delivery of Posterior Arm – View from inside

23. Delivery of Posterior Arm

24. Delivery of Posterior Arm

25. Delivery of Posterior Arm
Delivery of posterior arm reduces obstruction from fetal shoulder

26. Rotational Maneuvers Rubin’s Maneuver
Place pressure on fetal back rotating shoulder towards chest

27. Rotational Maneuvers Wood’s Screw
Place pressure on the anterior portion of the shoulder to rotate it towards the back

28. Posterior Axilla Sling Traction (PAST)
Suction catheter or firm urinary catheter is formed into a loop
Loop is fed behind the posterior shoulder
The loop is grabbed and brought anterior to create a sling around the posterior axilla
Traction applied to sling to deliver posterior shoulder

29. Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling  Catherine Anne Cluver, MD, G. Justus Hofmeyr, DSc
American Journal of Obstetrics & Gynecology  , 784.e1-784.e7DOI: ( /j.ajog )
Copyright © 2015 Elsevier Inc. Terms and Conditions

30. Gaskin Maneuver – Hands and Knees
Woman placed on hands and knees
Delivery is effected by downward traction on the posterior shoulder or upward traction on the anterior shoulder

31. Cephalic Replacement

32. Documentation Following a Shoulder Dystocia
Identification of complication as shoulder dystocia
Pediatrician called/present at delivery
Identification of anterior shoulder
Quantification of traction
Duration of shoulder dystocia
Maneuvers used to resolve dystocia
Cord blood gases sent or values noted
Moro reflex
Communication with patient about events of delivery
Implementation of a standardized checklist may be necessary to achieve complete documentation

33. Simulation Training and Shoulder Dystocia

34. Simulation Training
Effective because high acuity and low frequency event
Studies have demonstrated improved outcomes following simulation training
Increase use of evidence based techniques
Lower incidence of brachial plexus injury
Simulation and team training is recommended to improve team communication and maneuver use leading to reduction in injuries

35. Fetal outcome before and after simulation training
Crofts & Draycott. Ob Gyn 2008;112:14–20.
Pre-training
15,908
Post-training
13,117
p value
Shoulder Dystocia
324 (2.04%)
262 (2.00%)
0.813
Neonatal Injury
30 (9.3%)
6 (2.3%)
RR 0.25
McRoberts
95 (29.3%)
229 (87.4%)
<0.001
Suprapubic pressure
90 (27.8%)
119 (45.4%)
Internal rotation
22 (6.8%)
29 (11.1%)
0.02
Delivery of posterior arm
24 (7.4%)
52 (19.8%)

36. Fetal outcome after sustained simulation training
Pre-training
15,908
Early Post-training
13,117
Late Post-Training
17,037
Shoulder Dystocia
324 (2.04%)
262 (2.00%)
562 (3.03%)
Neonatal Injury
30 (9.3%)
8 (3.1%)
8 (1.4%)
Sustained Improvements were maintained overtime with training program
Crofts JF et al. BJOG 2016;123:111–118

37. Summary
Shoulder dystocia unpredictable and most occur in patients with no risk factors
Permanent fetal injury may be prevented by
limiting non-axial traction on fetal head
simulation training
Documentation and debriefing after shoulder dystocia essential part of good patient care

38. References
Ouounian JG, Gherman RB. Shoulder dystocia: are historic risk factors reliable predictors? Am J Obstet Gynecol 2005; 192:
Smith RB, Lane C, Pearson JF, Should dystocia: what happens at the next delivery? Br J Obstet Gynaecol 1994; 101:713-5.
Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998; 179:
Bahar AM. Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight. Br J Obstet Gynaecol 1996; 103:
Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk. Am J Obstet Gynecol 1987; 156:
Rouse DJ, Owen J. Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography – A Faustian bargain? Am J Obstet Gynecol 1999; 181:332-8.
Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage labor with midpelvic delivery. Obstet Gynecol 1978; 52:526-9.
Sandmire HF, O’Halloin TJ. Shoulder dystocia: its incidence and associated risk factors. Int J Gynaecol Obstet 1988; 26:65-73.
Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005; 112:
Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998; 43:

39. References
Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol 1985; 152:
Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008; 112:
Draycott TJ, Crofts JF, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20.
 Grobman WA, Miller D, Burke C, et al. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol 2011; 205:
Crofts JF, Lenguerrand E, et al. Prevention of brachial plexus injury – 12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2015; doi: /
Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011; 204:322.e1-6.
Deering SH, Weeks L, Benedetti TJ. Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation. Am J Obstet Gynecol 2011; 204:234.e1-5.
Cluver CA, Hofmeyr GJ. Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling. Am J Obstet Gynecol 2015; 212:
Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, Fox R, Draycott TJ. Prevention of brachial plexus injury—12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016;123:111–118
ACOG Emergency in Clinical Obstetrics Simulation Course. Shoulder Dystocia