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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 2 - Symptoms


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:

- Fracture the clavicle to decrease the width of the shoulders and free the shoulder that is anterior;

- Apply traction with a hook in the axilla to extract the arm that is posterior.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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