Obstetric Emergencies
Shoulder dystocia occurs when the anterior shoulder is impacted behind the pubic symphysis after head delivery. It is unpredictable, unpreventable, and requires rapid, skilled intervention.
Incidence & Pathophysiology
0.2–3% of vaginal deliveries. Shoulders too wide for pelvic outlet.
Risk Factors
~50% occur without risks — be prepared always.
Maternal
- Obesity
- Diabetes
- Short stature
Fetal/Labour
- Macrosomia
- Instrumental delivery
- Prolonged 2nd stage
Diagnosis: Turtle Sign
- Head retracts against perineum
- No restitution
- No descent with traction
Call for help immediately
Management: Stepwise Maneuvers
Call help, stop pushing, no head traction
- McRoberts: Thighs to abdomen
- Suprapubic pressure: Downward, lateral
- Rubin: Push anterior shoulder to chest
- Woods: Rotate posterior shoulder 180°
- Posterior arm delivery
- All fours (Gaskin)
- Last resort: Zavanelli, symphysiotomy
Never: Fundal pressure, excessive head traction
Complications
Fetus
- Erb’s palsy
- Fractures
- Hypoxia
Mother
- PPH
- Tears
- Rupture
Prevention
- Manage macrosomia/diabetes
- Cesarean if EFW >4.5 kg (diabetic)
- Skilled birth attendants
Key Takeaways
- Turtle sign = diagnostic
- McRoberts + suprapubic = first, most effective
- No head traction
- Systematic maneuvers
- Document time and actions
Conclusion
Shoulder dystocia is a rare but high-stakes emergency. Preparedness and practiced maneuvers save outcomes.
Shoulder dystocia is not preventable — but it is manageable with skill and speed.