Spong et al (1995) using an objective criteria to determine the presence of shoulder dystocia is the time interval between the birth of the head with the whole body. The normal value of the time interval between delivery head with delivery throughout the body is 24 seconds, 79 seconds on shoulder dystocia. They propose that shoulder dystocia is when the time interval of more than 60 seconds.








American College of Obstetrician and gynecologist (2002) states that the incidence of shoulder dystocia varies between 0.6 - 1.4% of normal deliveries.




This post will discuss how to avoid shoulder dystocia and handle this situation if it occurs. There are a lot of information available on the internet about shoulder dystocia. So, I'll enjoy some blog links for your convenience in order to further understand.Sources: You can download Downloadhttp: / / www.cetl.org.uk / learning / Shoulder_Dystocia / player.html CETL has a learning presentation slides are available online. This resource will give you a comprehensive overview of the incidence, risk factors and the standard approach for shoulder dystocia. There are also other references if you need it.What happens during shoulder dystocia?Basically the baby's shoulders get caught on the edge of the pelvisPathophysiologyAfter the birth of the head, will occur outside the rotation axis causes the head to be normal to the axis of the spine with the shoulder in general will be in a tilted axis (oblique) under the pubic ramus. Encouragement during meneran mother would mislead the front shoulder (anterior) is under the pubic, when the shoulder fails to hold a round of adjusting the tilt axis and remain on the anteroposterior position, the baby will most collision front shoulder against the symphysis so that the shoulders can not be born follow the head.EtiologyShoulder dystocia mainly due to pelvic deformity, failure of the shoulder to "fold" into the pelvis (eg on macrosomia) due to the active phase and a shorter second stage of labor in multiparous so drop the head too quickly causes the shoulder did not fold at the time through the birth canal or the head has been through the middle door of the pelvis after elongation stage II left shoulder successfully folded into the pelvis.Assessment Clinic1. Fetal head has been born but is still tight at the vulva2. Baby's head does not do pivot turns out3. Interested chin and pressing the perineum4. Signs of a turtle's head recalls the head against the perineum so that it looks back into the vagina.5. Withdrawal is not successfully delivered head shoulder trapped behind symphisis.Risk Factors1. Mothers with diabetes, 7% incidence of shoulder dystocia occurred in mothers with gestational diabetes (Keller, et al)2. Large fetus (macrossomia), shoulder dystocia occurs more often in infants with birth weight greater, yet nearly half of all births doistosia shoulder weighs less than 4000 g.3. History obstetrics / labor by big baby4. Mothers with obesity5. Multiparity6. Posterm pregnancy, can cause shoulder dystocia due to fetal continue to grow after the age of 42 mingu.7. Obstetric history with prolonged labor / hard labor or a history of shoulder dystocia, there are cases of recurrent shoulder dystocia in 5 (12%) among 42 women (Smith et al., 1994)8. Cephalopelvic disproportionThe American College of Obstetrician and gynecologist (1997.2000) reviewed studies classified according to evidence-based methods issued by the United States Preventive Task Force sevice, concluded that:1. Most cases of shoulder dystocia can not be foreseen or prevented because there is no accurate method for identifying which fetuses will experience this complication.2. Ultrasonic measurements to predict macrosomia has limited accuracy.3. Elective Caesarean section are based on a suspicion of macrosomia is not a reasonable strategy.4. Elective Caesarean section can be justified on non-diabetic women with an estimated fetal weight over 5000 g or birth weight of diabetic women are estimated to exceed 4500 g.Maternal ComplicationsShoulder dystocia can lead to postpartum hemorrhage due to uterine atony, uterine rupture, or laceration of the vagina and cervix, which is a major risk of maternal death (Benedetti and Gabbe, 1978; Parks and Ziel, 1978)Complications in InfantsShoulder dystocia can be accompanied by fetal morbidity and mortality is significant. Disability is a transient brachial plexus injuries most often, but it can also fracture the clavicle, humerus fracture, and neonatal deathHow to Avoid shoulder dystocia?Many sources of obstetrics and obstetric focuses on how to manage certain complications or problems. But I prefer to avoid this situation rather than managing its complications. Although in some cases of shoulder dystocia can not be avoided, nakun there are a number of ways to reduce the chances of it happening the case:Disturbed Natural Childbirth ProcessWhen a woman can give birth instinctively (no way) and they naturally and without intervention they will go more smoothly during childbirth. I've seen some strange labor positions and movements that make sense after the baby came / come out. And in the case caught his shoulder on the outskirts of the pelvis (shoulder dystocia), an instinctive movement of the pelvis can disconnect and free the shoulder baby without intervention. And that is naturally present in a mother's instinctive. And I had never noticed.PatienceActually, a baby takes time to get into the best position. Position where he could move his body pass to get into his mother's pelvis.But when we try to rush a baby, the baby may not be able to make adjustments or do not have time to adjust naturally. Try to see the normal birth process as the video below, here you will see how naturally the baby trying to turn his shoulders, his head, bowed his head and bending her forehead just to adjust his body to the pelvis and birth canal of the mother (a tremendous effort )But too often we as health workers are not impatient. Always rigid and fixated on HOURS. And we know every birth has its own time.Induction of labor and birth interventions increase the likelihood of shoulder dystocia (Gherman, 2002). Or sometimes, despite being banned but is still often performed by midwives during childbirth to help is by forcibly pressing mendor0ng fundus mother and help push when the mother's pushing. Or by gesturing to the mother to push when in fact a woman who was giving birth and the experts know about when and how did he push / push. We as a midwife or doctor is quite lead him alone. When we force pushing siibu it may also force the baby into the pelvis without letting and giving him time to make adjustments in advance.I also believe (but there should be research back to me, means I have to do minimal research to further ensure this first) by pulling out the babies could increase the incidence of shoulder dystocia.When the baby's head came out first should wait for contractions (can be 5 minutes) so that the shoulder can come out comfortably.But this is very tempting for us to immediately notify siibu so immediately without waiting for the contractions to push there.Though the baby may use this time to make the necessary adjustments so that the shoulder is easy to be born. Because usually so head out he will do the round pivot to adjust the head with his shoulder. Wait and observe it first. If this process is long and we see no signs of asphyxia we just do maneuvers or interventions.Maternity in the position of semi-recumbantIt turns out the delivery with this position increases the likelihood of shoulder dystocia due to pelvic floor can not open.Management of a shoulder dystociaAlthough shoulder dystocia is relatively rare (1:200), but you should know what to do if you find a case like this. First it is important not to make a bad situation worse:ü Do not pull the baby as this will impact the more restrained shoulder. This is the most common mistakes people make as they panic.ü Traction may cause injury to the brachial plexus in infants (see movie above).ü Do not cut the umbilical cord if it is around the baby's neck.Because the cord is intact there is still chance that the baby receives oxygen which gives you more time and help with resuscitation after.ü Communicate with the mother. You always have the time to explain what happened and why you do what you do, or ask him to do something.In the management of shoulder ditosia management must also consider the condition of mother and fetus. The terms that can be taken to deal with shoulder dystocia are:1. Vital condition is sufficient so that mothers can work together to resolve labor2. Still able to push3. Down the birth canal and pelvic door adequate accommodation for the baby's body4. Baby was alive or expected to survive5. Not monstrum or congenital abnormalities that prevent discharge of babiesBecause of shoulder dystocia can not be predicted, the perpetrator must know the correct obstetric practice the principles of management of complications.We are all still in the stages of learning and storing different information. As a midwife, trainer and lecturer I teach two different approaches for different reasons in the handling of shoulder dystocia:HELPERR - STANDARD APPROACHIn the case HELPERR:H Call For HelpE Evaluate For episiotomyL Leg: Robert Mc ManeuverExternal Pressure P suprapubicE Enter: Rotation ManeuverR Remove the Posterior ArmR Roll The Patient To Her Hand and KneesIn this approach the first E is for 'evaluating perform an episiotomy' - but this is rarely done in practice in the field. First, you must be very brave to try to put / put the scissors in such a way in a very narrow space beside the baby's head / face. Second, you really need to put your left hand to protect baby's head and face of scissors. In the management HELPERR there are still some drawbacks.HOLISTIC APPROACHWhen shoulder dystocia occurs one or both of two things need to happen to release or free the shoulder:1. Changing the size and position of (maternal) pelvisThis can be done by encouraging the mother to move and change position. You can ask or help the mother to change her hips with:a. Lifting foot can be accompanied by shaking backwards and forwards from the pelvis.b. McRoberts is easy if the mother has been lying. way is:- With the mother lying position, asking her to pull both knees toward chest as far as possible, ask for two assistants (be the husband or his family members) to help the mother.- Press the baby's head is steady and continuous downward (towards the anus mother) to move the anterior shoulder under the pubic symphisis. Avoid excessive pressure on the baby's head as they may be hurt.- Simultaneously ask one of the assistants to give a little supra-pubic pressure downwards gently. Do not do drive on the pubis, as it will further affect the shoulder and can cause uterine rupturec. Gaskin Maneuver. This by making changes to the current position of mothers in the lying position, the mother immediately asked to spin and turn into a crawl position.

Step of the Gaskin maneuver is often called flipflop
Flip = plays the mother of lying down to a crawl
flop =
F flips Over Mom (mother turned from lying position to a crawl). After the mother's inverted position using the Gaskin Maneuver most babies will be born spontaneously. However, if the baby is not bornsoon, midwife or assistant directing the next step is done when the next contraction occurs or before any contractions.
L Elevator Legs, With the auxiliary midwife, ask the mother liftedone leg, point forward position is exactly the position ketiaka runnerwould get ready to start the race run. So the position as shownbelow:

Please note the position of the feet, so the knee is not too far from his body.Now begins to curve or curl the anterior shoulder of the baby's pubic bone to move in addition to the symphysis pubis. pubis shift from movement to put the foot into the position of "Running Start" as above as if this is like half the McRoberts maneuver performed with the mother in the supine position. Half of the pubic bone is rolled or shifted when the foot is lifted. If the arm can not be rotated, moved to the next maneuver more quickly.O Oblique (Rotete Shoulder To Oblique) è rotate the shoulder toward the oblique. if the baby is not born when the contractions immediately after the change of position into the position of "Running Start" button, insert the hands of midwives to mothers ssampai he found the back of the baby's posterior shoulder. rotate the posterior shoulder into the chest to the oblique diameter of the mother's pelvis. There is a room that most in the oblique diameter (diameter oblique) pelvic. Thus the baby will be easier than rotating the posterior shoulder into the oblique diameter. If it still fails Continue efforts.P Posterior Arm To Get it. This is done by looking for the baby's arms and hands swept him out toward the chest. so that these arms will flex, which means it will make a bend. Now midwives can capture your baby's wrist, then the entire arm and then shake gently. This will reduce the diameter of the baby's body about 2 cm.Jika was not enough, baby rotated 180 degrees so that the arm is now before the anterior and posterior arm taken out. Now the mother can push and the baby will come out.Gaskin Maneuver is its success rate is high at 80-90%
2. Changing the size and position (the baby) shoulderThis action will create a smaller diameter of the baby's shoulders.Rotate the shoulders into oblique diameter of the pelvis will be available extra space.Several maneuvers are performed to reduce the diameter shoulder baby among others:a. Maneuver Rubin (1964)- First with the rocking of the shoulders of the fetus from one side to the other by bringing pressure on the abdomen.- If not successful, hands in the flank shoulder grab the most easily accessed, then pushing it to the anterior surface of the shoulder.This will usually cause the abduction of both shoulders and then will generate inter-shoulder diameter and shift the front shoulder from behind the symphysis pubisb. Woods Corkscrew Maneuver (1943)- Put one hand into the vagina and applying pressure on the anterior shoulder, toward the baby's sternum, to rotate the baby's shoulders and reduce the diameter of the shoulder- If necessary, apply pressure on the posterior shoulder to the sternum.c. Rear Shoulder Delivery Techniques- Put one hand into the vagina and hold the upper arm bone and positioned at the posterior- Fleksikan baby's arm at the elbow and place the arms across his chestIn the handling of shoulder dystocia no particular order where the first action that you can try. This will depend on how well the mother could move, position the patient, and you have access to the hips.how and where you can get your finger on (if needed). For example, Rubins maneuvers will be easier to do than suprapubic pressure in women who are leaning forward position.A holistic approach means taking and using a movement or action is appropriate at the time.Drastic APPROACHIf other options fail that usually involve damage to the baby or mother. The next step is to use this maneuver but mustinya Zanvanelli conducted in large hospitals with the preparation of the SC because the steps are as follows:Maneuver Zavanelli (Sandberg, 1985)- Return the head to occiput anterior or posterior position when the fetal head was spinning from that position- Memfleksikan head and slowly push it back into the vagina followed by a cesarean delivery.- Provides 250 mg of subcutaneous terbutaline to produce uterine relaxation