Shoulder Dystocia
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Direct answer
Shoulder dystocia is the failure of shoulder delivery with routine axial traction after the head is born — practically flagged when the head-to-body interval crosses 60 seconds or the head retracts against the perineum (turtle-neck sign). It affects roughly one in a hundred vaginal births, five to ten times that in diabetic macrosomia, and over half of cases have no risk factor at all, which is why the answer is a drilled sequence, not prediction: HELPERR — call for help, consider episiotomy, hyperflex the hips (McRoberts) with suprapubic pressure, enter for rotational manoeuvres or posterior arm delivery, and roll to all-fours. Brachial plexus injury, clavicular fracture and birth asphyxia are the foetal toll; haemorrhage and extensive tears the maternal one.
What you must remember
- Definition: failure of shoulder delivery with routine traction; head-body interval more than 60 seconds or turtle-neck retraction of the delivered head.
- Risk factors: foetal macrosomia (especially diabetic, above 4-4.5 kg), previous shoulder dystocia (recurrence about ten-fold), diabetes, prolonged second stage, operative vaginal delivery from mid-cavity, and obesity — yet under half of cases show any of them.
- HELPERR sequence: Help, Episiotomy, Legs (McRoberts), Pressure (suprapubic, continuous then rocking), Enter (Rubin II, Wood's screw, posterior arm), Remove posterior arm, Roll to all-fours (Gaskin).
- McRoberts manoeuvre: hyperflexion of the maternal hips onto the abdomen straightens the lumbosacral angle and rotates the symphysis cephalad; with suprapubic pressure it resolves over half of cases.
- Wood's screw versus Rubin: Wood's rotates the posterior shoulder 180 degrees to the front by pushing its anterior aspect; Rubin presses its posterior surface to adduct and rotate — both bring the posterior shoulder anteriorly.
- Never: fundal pressure (worsens impaction and can rupture the uterus), downward lateral traction on the head and neck (brachial plexus injury), or panic traction before positioning.
- Last resorts: deliberate clavicle fracture, symphysiotomy, the Zavanelli manoeuvre (cephalic replacement then caesarean), and cleidotomy for a dead baby in a referral setting.
- Foetal injuries: Erb-Duchenne palsy of C5-C6 (waiter's tip posture, the commonest), Klumpke's palsy of C8-T1, clavicle and humerus fractures, and birth asphyxia.
Ninety seconds that decide a lifetime
A woman with gestational diabetes delivers the head spontaneously; the chin tightens against the perineum and does not deliver with the next push. The clock starts. Announce "shoulder dystocia" — the room changes. Stop all traction. Legs up in extreme McRoberts while a second person applies suprapubic pressure behind the pubic bone, directing the anterior shoulder into the oblique; rhythmic rocking can shake it free. Most deliver now. If not, an episiotomy widens the space and a hand enters: press the posterior shoulder to rotate it (Rubin II), screw the shoulders through the oblique (Wood's), or flex the posterior arm at the elbow and sweep it across the chest — delivering it resolves most of the remainder. Persistent impaction means rolling the mother onto all fours, which changes every pelvic diameter. Beyond this the options are ugly but real: Zavanelli's cephalic replacement with caesarean, deliberate clavicle fracture, and cleidotomy for a dead baby — a scenario Indian district hospitals still see after hours of transport. Afterwards the paperwork is clinical care: timings, manoeuvres in order, cord gases, examination of the baby's arms over two days, and energetic prevention of postpartum haemorrhage.
The Indian ground truth
Shoulder dystocia is the classic one-minute emergency in Indian vivas and the classic referral disaster in practice — the mother delivered at home, the head born, the body stuck, arrival at the medical college with a dead foetus and a traumatized perineum. Two Indian realities sharpen the topic: gestational diabetes and obesity are rising fast in urban antenatal clinics, so the macrosomic diabetic baby is no longer a teaching-hospital curiosity; and documentation culture is weak, so with litigation rising, FOGSI workshops teach structured recording — times, manoeuvres, personnel — as protection. The viva gold: asked whether shoulder dystocia can be predicted, the model answer is no — antenatal weight estimation errs by 15-20 per cent and most cases have no risk factor; drills, not prediction, save brachial plexes.
Frequently asked questions
What is the single first manoeuvre after recognising shoulder dystocia?
Call for help, stop traction, hyperflex the hips in McRoberts with suprapubic pressure — together they resolve over half of cases.
Why is fundal pressure forbidden in shoulder dystocia?
It impacts the shoulder further behind the symphysis, increases brachial plexus injury and can rupture the uterus; pressure belongs above the pubis, not on the fundus.
Which nerve roots are injured in Erb's palsy, and what is the prognosis?
C5 and C6 — waiter's tip posture; most recover within months, roughly one in ten persist.
When is the Zavanelli manoeuvre used?
After McRoberts, suprapubic pressure, rotation and posterior arm delivery fail — the head is flexed, replaced in the vagina, tocolysis given, and caesarean performed.
Why does cord pH matter so much in the record?
Acidosis deepens steadily from delivery of the head, so cord pH guides neonatal resuscitation and anchors the medicolegal record of the dystocia's length.