Shoulder Dystocia - Internal maneuvers
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In this film the internal maneuvers performed for a shoulder dystocia will be demonstrated. The maneuvers are shown in order from less to more invasive for mother and baby.
In the event of shoulder dystocia prior to performing internal maneuvers, external maneuvers may be performed in an to attempt to resolve the shoulder dystocia. For a more detailed elaboration of this refer to the course shoulder dystocia external maneuvers.
The maneuvers that have to be performed will be shown on a model and are alternated with images of a second baby doll placed on the mother’s abdomen on which the same maneuvers will be performed. In this way insight will be provided into what happens internally whilst performing the maneuver.
Shoulder dystocia occurs during childbirth when the anterior shoulder of the fetus seen here becomes impacted behind the symphysis of the mother.
Take note that during labor a slow progress in dilatation or expulsion of the baby, head bobbing and a turtle sign might indicate a shoulder dystocia.
With head bobbing a jerking movement of the fetal head is seen as the head appears and retracts during each push.
During the course of a turtle sign the head may be only delivered partially or suddenly retract back against the mother’s perineum after it is born.
In case the head of the baby is not delivered completely, the caregiver may assist by placing the thumb and index finger on the perineum of the mother and slide it off over the head of the baby while looking at the perineum of the mother.
Emptying the bladder of the mother with a catheter is considered to create more space in the pelvis if a shoulder dystocia is expected but may not always be performed.
After the birth of the head, the neck is palpated with two fingers to check whether the umbilical cord is wrapped around the neck. Take note that if the fetal neck is tightly encircled by the umbilical cord and it cannot be freed without cutting the cord, the umbilical cord is cut only after the shoulder dystocia is resolved to prevent oxygen deprivation.
During a normal delivery, when the fetal head is born an external rotation of the head of about 90 degrees is visible, due to the internal rotation of the shoulders.
If there is no spontaneous rotation of the neonatal head, the mother is encouraged to push to see if a rotation takes place.
If rotation does not take place, the head is grasped with the fingers of both hands interlocking over the occiput of the fetal head and continuous downward traction is applied on the head towards the sacrum of the mother.
In an alternative technique, the index and middle finger of the dominant hand are placed on both sides of the fetal neck. The non-dominant hand is placed on top. Then continuous downward traction is applied towards the sacrum of the mother.
Take care not to put too much traction on the head in. The head should also not be rocked from side to side. This may lead to irreversible injury to the brachial plexus of the baby and should be avoided in all births.
Also take care not to apply fundal pressure in an attempt to resolve the shoulder dystocia, since this is associated with a high neonatal complication rate and could cause a uterine rupture.
If the aforementioned techniques are unsuccessful, it is advised to call for additional help if available, since this is now a complicated delivery. Additional maneuvers to free the shoulders will need to be performed.
In this film, the internal maneuvers will be shown. For a detailed elaboration of this refer to the course shoulder dystocia external maneuvers.