Shoulder dystocia (Stuck shoulders)

PROBLEM

• The fetal head has been delivered but the shoulders are stuck and cannot be delivered.

GENERAL MANAGEMENT

• Be prepared for shoulder dystocia at all deliveries, especially if a large baby is anticipated.

• Have several persons available to help.

Shoulder dystocia cannot be predicted. 

DIAGNOSIS

• The fetal head is delivered but remains tightly applied to the vulva.

• The chin retracts and depresses the perineum. 

• Traction on the head fails to deliver the shoulder, which is caught behind the symphysis pubis.

MANAGEMENT

• Make an adequate episiotomy to reduce soft tissue obstruction and to allow space for manipulation.

• With the woman on her back, ask her to flex both thighs, bringing her knees as far up as possible towards her chest (Fig S-26). Ask two assistants to push her flexed knees firmly up onto her chest.

Figure S-26 

Assistant pushing flexed knees firmly towards chest 

• Wearing high-level disinfected gloves:

- Apply firm, continuous traction downwards on the fetal head to move the shoulder that is anterior under the symphysis pubis;

Note: Avoid excessive traction on the head as this may result in brachial plexus injury;

- Have an assistant simultaneously apply suprapubic pressure downwards to assist delivery of the shoulder;

Note: Do not apply fundal pressure. This will further impact the shoulder and can result in uterine rupture.

• If the shoulder still is not delivered:

- Wearing high-level disinfected gloves, insert a hand into the vagina; 

- Apply pressure to the shoulder that is anterior in the direction of the baby’s sternum to rotate the shoulder and decrease the shoulder diameter;

- If needed, apply pressure to the shoulder that is posterior in the direction of the sternum.

• If the shoulder still is not delivered despite the above measures:

- Insert a hand into the vagina; 

- Grasp the humerus of the arm that is posterior and, keeping the arm flexed at the elbow, sweep the arm across the chest. This will provide room for the shoulder that is anterior
to move under the symphysis pubis (Fig S-27).

FIGURE S-27

Grasping the humerus of the arm that is posterior and sweeping the arm across the chest 

• If all of the above measures fail to deliver the shoulder, other options include: