1. Shoulder Difficulty Max Brinsmead MB BS PhD May 2015

2. Definition When extra steps are required to deliver the shoulders Or a delay of >60 sec between head and shoulders Most commonly involves the anerior shoulder which impacts over the symphysis pubis

3. Incidence 0.58 to ≈1.0% for normal birthweight infants 5 - 7% of those with BW >4500g Although there are many risk factors It is now agreed that the condition is basically Unpredictable

4. Sequelae Maternal trauma Soft tissue e.g. 3rd and 4th degree tears Symptoms from symphyseal separation Femoral neuropathy Postpartum haemorrhage Fetal Brachial Plexus Injury (BPI, about 1:6) Fracture of clavicle or humerus Fetal hypoxia

5. Risk Factors Large baby - Symphysis fundal height >42cm Past history of shoulder difficulty Obese mother (BMI>30) Diabetic mother +/- fetal macrosomia Slow progress in 2nd stage of labour with turtle sign of head between contractions After assisted delivery of the fetal head

6. Prevention Elective CS not recommended for suspected fetal macrosomia UNLESS Associated with maternal diabetes Requires 443 CS to prevent one case of permanent neonatal injury IOL at term for gestational diabetes Recurrence risk after previous shoulder dystocia reaches 25% But any decision about mode of delivery requires patient involvement in the decision

7. Prevention of Brachial Plexus Injury Use AXIAL traction only (avoid lateral and downward traction) Avoid sudden traction Prophylactic McRobert’s for suspected shoulder dystocia is of no help

8. Management – Systematic H E L P E R R Send for Help Legs up (McRobert’s manoeuvre) Pressure suprapubically plus axial traction Consider episiotomy Rotate the shoulders internally Bring down the posterior arm Try moving to all fours position (requires a slim, mobile woman)

9. Manoeuvres of Last Resort Replace the fetal head (Zavanelli) Symphysiotomy Cleidotomy

10. Medicolegal Consequences Neonatal brachial plexus injury (BPI) is the most common litigious consequence of shoulder dystocia And the 3 rd most common obstetric- related subject of claim Fortunately, only 10% of BPI is permanent And be aware that it can occur after elective CS!

11. To Keep You Out of Court Be Prepared… Mental rehearsal Practice drills (RCT’s have been done) Early recognition Work with the mother and the uterus Don’t pull too hard on the fetal head The hollow of the sacrum is your HELPERR Document carefully Debrief parents

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