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 discusses the current practice of cesarean delivery, the indications for the operation, the performance of the surgery, and its potential complications. After forceps and vacuum extraction procedures, symphysiotomy is the principal alternative to the cesarean operation. Epidurals do prolong the second stage of labor and increase the use of oxytocin to maintain progress. As the morbidity associated with cesarean delivery remains low, and the risks associated with elective operations are better appreciated, indications for cesarean operations have progressively increased. The chapter reviews the operative technique for cesarean delivery, cesarean hysterectomy, and the surgical management of acute obstetric hemorrhage. Possible immediate post-operative complications of surgical sterilization include infection, bleeding, intraoperative bowel or bladder injury, thromboembolism, and rarely, death. Sterilization failures are often the result of either mistaken identification of some other intraabdominal structure for the fallopian tube, or of incomplete occlusion of the tubal lumina.