Shoulder dystocia occurs when the baby's head has been born but a shoulder becomes stuck behind the mother's pelvic bone, resulting in a delivery that requires additional obstetric manoeuvres to release the shoulder after gentle downward traction has failed. Failure of external rotation of the fetal head and turtle sign, the retraction of the fetal head into the vagina from the perineum, are the key diagnostic signs. First line manoeuvres (SPR) and second line manoeuvres are carried out to manage shoulder dystocia. If facilities for safe and immediate emergency caesarean sections are not available, then clinicians should be trained on symphysiotomy as the main second-line measure. A metal catheter, scalpel handle and blade and suitable local anaesthetic should be made available in birth settings. All staff providing intrapartum care should undergo annual skills and drills training on the management of shoulder dystocia.

This chapter reviews and examines the best evidence available about the nature and scope of shoulder dystocia, including reasonable management options and the challenging ethical and legal aspects surrounding this common obstetric emergency. The range of injuries to the newborn following a shoulder dystocia typically include trauma to the brachial plexus or phrenic nerve, fractures of the clavicle or humerus, neonatal asphyxia, and even death. From a medicolegal perspective, any reasonable method to resolve the impacted anterior shoulder conforms to the level of care expected of the average competent physician. If the physician can articulate a reasonable basis for the clinical judgment, and that information is documented in the medical record, then the physician has the best defense against a medicolegal entanglement. Acute management of dystocia remains a major problem. Some practitioners, on encountering a shoulder dystocia, fail to approach the problem systematically and sometimes panic.

Pregnancy, labor, and delivery are associated with major physiologic changes that can decrease maternal reserves. Consequently, various techniques of analgesia and anesthesia can have profound effects on maternal physiology. Furthermore, obstetric pain management and operative obstetric anesthesia are recognized as secondary causes of neonatal respiratory depression. Improper management of labor is the common claim in obstetrical malpractice cases. Malpresentation and/or dystocia are some of the most fertile areas for medical negligence lawsuits. The clinician must be fully aware of the general predisposing factors to complications in the third stage of labor. Common postpartum complications include urinary tract problems, such as infections, urine retention, or incontinence. Obstetricians have long recognized the excessive perinatal morbidity and mortality associated with the breech-presenting fetus. Multiple gestations often pose intrapartum management problems. Emphasizing the shoulder dystocia was a true obstetric emergency, and greater emphasis was placed on team approach, including neonatal resuscitation.

This chapter discusses pre-term labour, abnormalities at different stages of labour, placenta accreta, and certains emergencies such as cord prolapse and shoulder dystocia. The management of threatened preterm labour is aimed at maximising neonatal survival by prolonging the pregnancy. The administration of corticosteroids 24 to 48 hours prior to delivery significantly improves perinatal morbidity and mortality. Oxytocin is commonly used in abnormal labour and effectively increases uterine activity and causes cervical dilatation. Uterine hyperstimulation is a common side effect of oxytocin administration and this is the reason for the incremental regime used to accelerate or induce labour. Retained placenta is a cause of major obstetric haemorrhage. Abnormal progress in the first and second stages of labour is associated with fetal malpresentations and malpositions. Shoulder dystocia is a very serious obstetric emergency and in current obstetric practice is a significant cause of perinatal morbidity and mortality.