Difficulty in delivery of fetal

shoulders
Failure to deliver fetal shoulder
without utilizing facilitating
maneuvers
Prolonged head-to-body delivery
time
>60 seconds

The overall incidence of shoulder dystocia

varies based on fetal weight
Incidence: 0.2-0.3% of all live births;
represents an obstetric emergency
Increase between 5-9 % for infant weighing
between 4000-4500 g
0.6-1.4%: 2500g

Antepartum
Macrosomia

(>4500g)
DM/GDM (increases overall risk by 70%)
Multiparity

Intrapartum
Prolonged

active phase of first-stage labor

Prolonged second-stage labor
Protracted descent
Assisted vaginal delivery (forceps or vacuum)

25-50% have no defined risk factor!

50% of cases occur in infants whose birth
weight is <4000g
84% of patients did not have prenatal dx. of
macrosomia by US
82%of infants with brachial plexus palsy did
not have macrosomia

It should be suspected when the fetal head

retracts into the perineum (ie, turtle sign)
after expulsion due to reverse traction from
the shoulders being impacted at the pelvic
inlet.
The diagnosis is made when the routine
practice of gentle, downward traction of the
fetal head fails to accomplish delivery of the
anterior shoulder.

Maternal
Hemorrhage

because of laceration, episiostomi.

Fetal
Fracture

of humerus or clavicle

Brachial

plexus injury

Fetal

hypoxia

With or without permanent neurologic damage

Offer cesarean section in labor risk

Intrapartum interventions
Immediately ask for help when shoulder
dystosia is known

Diagnostic

Call for adittional assistance

Manuver McRobert

Manuver Rubin

Gave birth to the posterior shoulder

(Manuver wood)

H: Call for Help; Shoulder dystocia is called

if shoulders cannot be delivered with gentle
traction
E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when attempting
intra-vaginal maneuver
L: Legs (McRoberts): Hyperflexion and
abduction of hipsinitial maneuver

This procedure results in a cephalad rotation of

the symphysis pubis and a flattening of the sacral
promontory
These motions push the posterior shoulder over
the sacral promontory, allowing it to fall into
the hollow of the sacrum, and rotate the
symphysis over the impacted shoulder
When this maneuver is successful, the fetus
should be delivered with normal traction
The McRoberts maneuver alone is believed to
relieve more than 40% of all shoulder dystocias
and, when combined with suprapubic pressure,
resolves more than 50% of shoulder dystocias

P (Suprapubic Pressure): No fundal

pressure; combination of McRoberts and
suprapubic pressure resolves most
shoulder dystocias

Enter (Internal Maneuvers):

Rubin:

Push posterior or anterior shoulder

toward fetal chest to adduct shoulders
Woods: Insert hand into posterior vagina and
rotate posterior shoulder clockwise or
counterclockwise

Remove: Delivery posterior arm

Follow posterior arm down to elbow

Usually anterior to fetal chest
Flex arm at the elbow
Sweep forearm across fetal chest
grasping hand directly and pulling outward
may lead to fractures

R = Roll the Patient

Roll patient to all fours position

Increases pelvic diameters
Movement and gravity may also contribute
to dislodging the impaction
Deliver posterior shoulder with gentle
downward traction