Shoulder Dystocia

Abstract

It is a real intrapartum emergency defined as difficulty in delivery of shoulders and trunk after head has come out of introitus with a delay by more than 60 s and further requiring certain maneuvers. The incidence is related to some macrosomic babies of diabetic or nondiabetic mothers weighing 4–4.5 kg or more. Some postmature babies may have it.

The incidence in general is 0.2–1.75 %. In many situations, it has been under or over reported as figures are derived from labor room records. To know its real incidence, standardized criteria for registry have been defined.

The management aim is to reduce head to body delivery time in order to release cord compression early and to avoid fetal and maternal injury due to aggressive manipulations.

No single maneuver is superior to others in releasing impacted shoulder and reducing risk of injury. When diagnosed, shoulder dystocia drill is recommended. McRoberts’ maneuver with suprapubic pressure is a preferred initial approach.

Maternal morbidity is due to lacerations of genital tract, extension of episiotomy, and rupture uterus. There may occur postpartum hemorrhage due to uterine atony, prolonged labor, large infant, and increased blood loss from vaginal tears. Fetal injuries of neuromusculoskeletal type cause morbidity and mortality. About 11 % neonates suffer from serious neonatal trauma.

Mostly shoulder dystocia is neither accurately predicted nor prevented. Elective induction of labor or elective cesarean section for all macrosomic babies is not appropriate. Elective cesarean is indicated for estimated fetal weight 5000 g (4500 g in Indians) in nondiabetic and 4500 g (4000 g in Indians) in diabetes mellitus. Counseling and documentation of events save from the medicolegal problems.