internal rotational method. The All fours technique has been described with 83% success
rate in one case series [59]. For the cases resistant to all simple measures, other options like
cleidotomy, symphysiotomy and Zavanelli could be used. These maneuvers are fraught with
complications and must be handled by only those with enough exposure to manage shoulder
dystocia.
Fetal death and hypoxic encephalopathy are the most severe outcomes related shoulder
dystocia. Leung et al from Hong Kong reported in there series, a very low rate of hypoxic is
chaemic injury if the head-to–body delivery time was less than five minutes. Therefore, the
target time for delivery of the trunk should be within 5 minutes [60]. It is clear that risks may
increase as the time to complete delivery increases. It is therefore important to manage the
problem as efficiently as possible to avoid hypoxic acidosis and carefully to avoid
unnecessary trauma.