3-95
Follow-up Actions
Return evaluation: Follow weekly to assess for recurrent symptoms and risk factors for PTL.
Evacuation/Consultation Criteria: Evacuate after initial PTL symptoms if possible. Avoid emergent evacua-
tion if possible. Consult expert if available.
Symptom: OB Problems: Relief of Shoulder Dystocia
MAJ Marvin Williams, MC, USAWhat: Shoulder dystocia is a labor complication caused by difficulty delivering the fetal shoulders. Although
this is more common among women with gestational diabetes and those with very large fetuses, it can occur
with babies of any size. Unfortunately, it cannot be predicted or prevented. Improperly relieving the dystocia
can result in unilateral or bilateral clavicular fractures.
When: After delivery of the head, the fetus seems to try to withdraw back into the birth canal (the “Turtle
Sign”). Further expulsion of the infant is prevented by impaction of the fetal shoulders within the maternal
pelvis. Digital exam reveals that the anterior shoulder is stuck behind the pubic symphysis. In more severe
cases, the posterior shoulder may be stuck at the level of the sacral promontory.
What To Do:
- Check for nuchal cord (the umbilicus wrapped around the baby's neck) and relieve it.
- Suction the infant’s mouth to clear the airway of amniotic fluid and other debris.
- Do not apply excessive downward traction on the head to get the baby out. This action can injure the
nerves in the neck and shoulder (brachial plexus palsy) and must be avoided. While most of these nerve
injuries heal spontaneously and completely, some do not. - Otherwise cut a generous episiotomy following proper technique (see Episiotomy Procedure in this
chapter) unless a spontaneous perineal laceration has occurred, or if the perineum is very stretchy and
offers no obstruction. - Initially apply gentle downward traction on the chest and back initially to try to free the shoulder. If this has
no effect, do not exert increasing pressure. Try some alternative maneuvers to free the shoulder. - Place the mother in the MacRobert’s position, and apply gentle downward traction on the baby again.
Maneuver involves flexing the mother’s thighs tightly against her abdomen. This can be done by the
woman herself or by assistants. By performing this maneuver, the axis of the birth canal is straightened,
allowing a little more room for the shoulders to slip through. - If the MacRobert’s maneuver fails have an assistant apply downward, suprapubic (above the bony pubic
arch) pressure to drive the fetal shoulder downward, to clear the pubic bone. Again apply coordinated,
gentle downward traction on the baby. - If pressure straight down is ineffective, have the assistant apply it in a more lateral direction. This tends to
nudge the shoulder into a more oblique orientation, which usually provides more room for the shoulder.
Again apply coordinated, gentle downward traction on the baby. - Often, the baby’s posterior arm has entered the hollow of the sacrum. Reach in posteriorly, identify the
posterior shoulder, follow the humerus down to the elbow and identify the forearm. Grasping the fetal
wrist, draw the arm gently across the chest and then sweep the arm up and out of the birth canal, freeing
additional space and allowing the anterior shoulder to clear the pubic bone. Once again apply
coordinated, gentle downward traction on the baby. - An electric light bulb cannot be removed by simply pulling it out- it must be unscrewed. This concept can
be applied to shoulder dystocia problems. Rotate the posterior shoulder, allowing it to come up outside of
the subpubic arch. At the same time, bring the stuck anterior shoulder into the hollow of the sacrum.
Continue rotating the baby a full 360 degrees to rotate (unscrew) both shoulders out of the birth canal.
Two variations on the unscrewing maneuver include:
· Rotating/shoving the shoulder towards the fetal chest (“shoving scapulas saves shoulders”), which
compresses the shoulder-to-shoulder diameter, and
· Rotating the anterior shoulder first rather than the posterior shoulder. The anterior shoulder may be