Shoulder dystocia

Last updated
Shoulder dystocia
Shoulder dystocia hariadhi.svg
Suprapubic pressure being used in a shoulder dystocia
Specialty Obstetrics
Symptoms Retraction of the baby's head back into the vagina [1]
Complications Baby: Brachial plexus injury, clavicle fracture [2]
Mother: Vaginal or perineal tears, postpartum bleeding [3]
Risk factors Gestational diabetes, previous history of the condition, operative vaginal delivery, obesity in the mother, an overly large baby, epidural anesthesia [2]
Diagnostic method The baby's shoulders fail to deliver despite gentle downward traction on the baby's head, requiring the need of special techniques to safely deliver the baby.
Treatment McRoberts maneuver, suprapubic pressure, Rubin maneuver, episiotomy, all fours, Zavanelli's maneuver followed by cesarean section [3] [2]
Frequency0.2% to 3% of vaginal births

Shoulder dystocia occurs after vaginal delivery of the head, when the baby's anterior shoulder is obstructed by the mother's pubic bone. [3] [1] It is typically diagnosed when the baby's shoulders fail to deliver despite gentle downward traction on the baby's head, requiring the need of special techniques to safely deliver the baby. [2] Retraction of the baby's head back into the vagina, known as "turtle sign" is suggestive of shoulder dystocia. [3] [1] It is a type of obstructed labour. [4]

Contents

Although most instances of shoulder dystocia are relieved without complications to the baby, the most common complications may include brachial plexus injury, or clavicle fracture. [2] [1] Complications for the mother may include increased risk of vaginal or perineal tears, postpartum bleeding, or uterine rupture. [3] [1] Risk factors include gestational diabetes, previous history of the condition, operative vaginal delivery, obesity in the mother, an overly large baby, and epidural anesthesia. [2]

Shoulder dystocia is an obstetric emergency. [3] Initial efforts to release a shoulder typically include: with a woman on her back pushing the legs outward and upward, pushing on the abdomen above the pubic bone. [3] If these are not effective, efforts to manually rotate the baby's shoulders or placing the woman on all fours may be tried. [3] [2] Shoulder dystocia occurs in approximately 0.2% to 3% of vaginal births. [5] Death as a result of shoulder dystocia is very uncommon. [1]

Signs and symptoms

One characteristic of a minority of shoulder dystocia deliveries is the turtle sign, which involves the retraction of the fetal chin back into the vagina after the head is delivered. [6] [7] This occurs when the baby's shoulder is obstructed by the mother's pelvis or is high in the pelvis [8] .

Complications

Brachial Plexus Brachial plexus 2.svg
Brachial Plexus
Fracture of both clavicles as a result of shoulder dystocia (top) - Post healing (bottom) ClavicleFractureSD.jpg
Fracture of both clavicles as a result of shoulder dystocia (top) – Post healing (bottom)

Possible complications include:

Risk factors

Even though there are several known risk factors, shoulder dystocia can happen to anyone and cannot be reliably predicted or stopped from happening. [11] Doctors should know the risk factors to watch for in high-risk deliveries and be ready to handle this complication in any delivery. [11]

Pre- labor risk factors: [3] [11]

During labor risk factors: [3]

For women with a previous shoulder dystocia, the risk of recurrence is at least 10%, therefore, doctors do not recommend C-sections for everyone with a history of it. [11] Instead, they suggest making a careful delivery plan based on medical details, future pregnancy goals, and what the patient prefers. [11]

Prevention

Because shoulder dystocia is more common in cases of larger babies (fetal macrosomia) or mothers with diabetes, researchers have studied whether inducing labor, before the baby reaches a weight that might cause medical concerns, can help lower the risk [11] . However, studies looking at how induction affects shoulder dystocia in full-term pregnancies with suspected larger babies have shown mixed results with studies reporting increased rates cesarian deliveries without reducing the risk of birth injuries [13] , while others reported no effect on cesarian delivery rates and a reduction in rates of shoulder dystocia [14] . The American College of Obstetricians and Gynecologists does not recommend delivery before 39 weeks unless medically indicated, and discourages inducing labor just because macrosomia is suspected, regardless of how far along the pregnancy is [11] .

The benefit of elective cesarian delivery has also been studied in cases of suspected fetal macrosomia [11] . The American College of Obstetricians and Gynecologists recommends considering elective C-sections for women without diabetes if their baby is estimated to weigh at least 5,000 g, and for women with diabetes if their baby is estimated to weigh at least 4,500 g [11] .

Management

Preparation

Practicing with obstetric simulations is a helpful way for health care providers to prepare for shoulder dystocia as it is a rare but serious event [11] . Research shows that simulations improve communication, the use of maneuvers, and how events are documented [15] . A training program that included lessons on a specific response plan for shoulder dystocia, along with repeated practice simulations and discussions afterward, led to a significant drop in brachial plexus palsy cases—from 10.1% before training to 4.0% during training, and then to 2.6% after training [16] . The American College of Obstetricians and Gynecologists recommends practicing with simulations and following shoulder dystocia protocols to improve team communication and the use of maneuvers, which could help lower the chances of brachial plexus palsy caused by shoulder dystocia [11] .

Procedures

The steps to treating a shoulder dystocia can be outlined by the mnemonic HELPERR [17] :

*Pushing on the fundus is not recommended as it can make the shoulder more stuck and can lead to tearing of the uterus [1] [11] .

A number of labor positions and maneuvers are sequentially performed in attempt to facilitate delivery. These include:

McRoberts maneuver (1) in combination with suprapubic pressure (2) McRoberts maneuver.svg
McRoberts maneuver (1) in combination with suprapubic pressure (2)

First-line Maneuvers

  • McRoberts maneuver; it is usually the first maneuver performed as it is easy, noninvasive, and effective [11] . It involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine) [18] . This maneuver is usually combined with applying suprapubic pressure or Rubin I by having an assistant apply pressure above the pubic bone with the palm or fist, directing the pressure on the anterior shoulder both downward (to below the pubic bone) and laterally (toward the fetus's face or sternum) [11] . Together, McRoberts maneuver and suprapubic pressure relieves about 58% of shoulder dystocias [19] .

Second-line Maneuvers

  • Rubin II; a rotational maneuver where pressure is applied to the back of the front shoulder to rotate the back shoulder counterclockwise until delivery of the front shoulder [20] [21] [22] .
  • Wood's screw maneuver; another type of rotational maneuver where pressure is applied to the front of the back shoulder to rotate the back shoulder clockwise until delivery of the front shoulder (somewhat the opposite of Rubin II maneuver) [20] [21] [23] .
  • Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled [20] .
  • Gaskin maneuver involves moving the mother to an all fours position with the back arched, widening the pelvic outlet. [24] [25]

Extraordinary Measures

  • Zavanelli's maneuver, which involves pushing the baby's head back in (internal cephalic replacement) followed by a cesarean section. [26]
  • Cleidotomy, which is causing intentional clavicular fractures, thus reducing the diameter of the shoulders to pass through the birth canal. [2]
  • Maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones. [2]
  • Abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates vaginal delivery of the impacted shoulder. [27]

*Before these measures are attempted the above maneuvers should be attempted again [9]

Documentation

The time when shoulder dystocia is diagnosed and when the delivery is completed should be recorded. It is also important to document details about how the shoulder dystocia was managed, including key facts, findings, and any outcomes [18] . The Royal College of Obstetrician and Gynecologist recommends recording [9] :

Epidemiology

Shoulder dystocia occurs in approximately 0.2% to 3% of vaginal births and can happen to anyone. [3] [11] However, research suggest that larger baby size, also known as fetal macrosomia, increases the risk of shoulder dystocia [28] . For babies weighing less than 4 kg, the likelihood of shoulder dystocia is about 1% [29] . This risk rises to approximately 5% for babies weighing between 4 and 4.5 kg and increases further to 10% for babies weighing over 4.5 kg. [29]

Related Research Articles

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In developed countries, most deliveries occur in hospitals, while in developing countries most are home births.

<span class="mw-page-title-main">Brachial plexus</span> Network of nerves

The brachial plexus is a network of nerves formed by the anterior rami of the lower four cervical nerves and first thoracic nerve. This plexus extends from the spinal cord, through the cervicoaxillary canal in the neck, over the first rib, and into the armpit, it supplies afferent and efferent nerve fibers to the chest, shoulder, arm, forearm, and hand.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

<span class="mw-page-title-main">Umbilical cord prolapse</span> Complication of pregnancy where the umbilical cord slips out of the uterus prior to birth

Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur anytime after the rupture of membranes.

<span class="mw-page-title-main">Erb's palsy</span> Paralysis of the arm usually caused during birth

Erb's palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves. These form part of the brachial plexus, comprising the ventral rami of spinal nerves C5–C8 and thoracic nerve T1. These injuries arise most commonly, but not exclusively, from shoulder dystocia during a difficult birth. Depending on the nature of the damage, the paralysis can either resolve on its own over a period of months, necessitate rehabilitative therapy, or require surgery.

<span class="mw-page-title-main">Large for gestational age</span> Medical condition

Large for gestational age (LGA) is a term used to describe infants that are born with an abnormally high weight, specifically in the 90th percentile or above, compared to other babies of the same developmental age. Macrosomia is a similar term that describes excessive birth weight, but refers to an absolute measurement, regardless of gestational age. Typically the threshold for diagnosing macrosomia is a body weight between 4,000 and 4,500 grams, or more, measured at birth, but there are difficulties reaching a universal agreement of this definition.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Breakage of the amniotic sac before the onset of labour

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labour. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Brachial plexus injury</span> Medical condition

A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. These nerves originate in the fifth, sixth, seventh and eighth cervical (C5–C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand.

Postterm pregnancy is when a woman has not yet delivered her baby after 42 weeks of gestation, two weeks beyond the typical 40-week duration of pregnancy. Postmature births carry risks for both the mother and the baby, including fetal malnutrition, meconium aspiration syndrome, and stillbirths. After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail. Postterm pregnancy is a reason to induce labor.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

In obstetrics, asynclitic birth, or asynclitism, refers to the malposition of the fetal head in the uterus relative to the birth canal. Many babies enter the pelvis in an asynclitic presentation, but in most cases, the issue is corrected during labor. Asynclitic presentation is not the same as shoulder presentation, where the shoulder enters first.

<span class="mw-page-title-main">McRoberts maneuver</span> Obstetrical maneuver used to assist in childbirth

The McRoberts maneuver is an obstetrical maneuver used to assist in childbirth. It is named after William A. McRoberts, Jr. It is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. It is effective due to the increased mobility at the sacroiliac joint during pregnancy, allowing rotation of the pelvis and facilitating the release of the fetal shoulder. If this maneuver does not succeed, an assistant applies pressure on the lower abdomen. Current guidelines strongly recommend against pulling on the infants head, as this could lead to brachial plexus injury. Instead, support while keeping the neck straight is indicated. The technique is effective in about 42% of cases. Note that suprapubic pressure and McRobert's maneuver together will resolve 90% of cases.

An obstetric labor complication is a difficulty or abnormality that arises during the process of labor or delivery.

<span class="mw-page-title-main">Birth trauma (physical)</span> Medical condition

Birth trauma refers to damage of the tissues and organs of a newly delivered child, often as a result of physical pressure or trauma during childbirth. It encompasses the long term consequences, often of cognitive nature, of damage to the brain or cranium. Medical study of birth trauma dates to the 16th century, and the morphological consequences of mishandled delivery are described in Renaissance-era medical literature. Birth injury occupies a unique area of concern and study in the medical canon. In ICD-10 "birth trauma" occupied 49 individual codes (P10–Р15).

Birth injury refers to damage or injury to the child before, during, or just after the birthing process. "Birth trauma" refers specifically to mechanical damage sustained during delivery.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is a pregnancy where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

<span class="mw-page-title-main">Operative vaginal delivery</span> Medical intervention

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. 1 2 3 4 5 6 7 Gherman, Robert B.; Gonik, Bernard (2009). "Shoulder Dystocia". The Global Library of Women's Medicine. doi:10.3843/GLOWM.10137.
  2. 1 2 3 4 5 6 7 8 9 Dahlke, JD; Bhalwal, A; Chauhan, SP (June 2017). "Obstetric Emergencies: Shoulder Dystocia and Postpartum Hemorrhage". Obstetrics and Gynecology Clinics of North America. 44 (2): 231–243. doi:10.1016/j.ogc.2017.02.003. PMID   28499533.
  3. 1 2 3 4 5 6 7 8 9 10 11 "Shoulder dystocia" (PDF). Royal College of Obstetricians and Gynaecologists. 2013. Retrieved 3 October 2018.
  4. ↑ Buck, Carol J. (2016). 2017 ICD-10-CM Standard Edition - E-Book. Elsevier Health Sciences. p. 108. ISBN   9780323484572.
  5. 1 2 3 4 5 "Executive Summary: Neonatal Brachial Plexus Palsy". Obstetrics & Gynecology. 123 (4): 902–904. April 2014. doi:10.1097/01.AOG.0000445582.43112.9a. ISSN   0029-7844. PMID   24785634.
  6. ↑ Bennett, Barbara B. (September 1999). "Shoulder Dystocia: An Obstetric Emergency". Obstetrics and Gynecology Clinics of North America. 26 (3): 445–458. doi:10.1016/S0889-8545(05)70089-9. PMID   10472064.
  7. ↑ Floyd, Randall C.; Smeltzer, James S. (2012), "Shoulder dystocia", Clinical Maternal-Fetal Medicine (2 ed.), CRC Press, doi: 10.1201/9781003222590-11 , ISBN   978-1-003-22259-0
  8. ↑ Gherman, Robert B.; Chauhan, Suneet; Ouzounian, Joseph G.; Lerner, Henry; Gonik, Bernard; Goodwin, T. Murphy (September 2006). "Shoulder dystocia: The unpreventable obstetric emergency with empiric management guidelines". American Journal of Obstetrics and Gynecology. 195 (3): 657–672. doi:10.1016/j.ajog.2005.09.007.
  9. 1 2 3 4 5 "Shoulder Dystocia (Green-top Guideline No. 42)" (PDF). RCOG. Retrieved 2024-05-24.
  10. 1 2 Gherman, Robert B.; Ouzounian, Joseph G.; Goodwin, T.Murphy (May 1999). "Brachial plexus palsy: An in utero injury?". American Journal of Obstetrics and Gynecology. 180 (5): 1303–1307. doi:10.1016/S0002-9378(99)70633-2.
  11. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 "Practice Bulletin No. 178 Summary: Shoulder Dystocia". Obstetrics & Gynecology. 129 (5): 961–962. 2017-05-01. doi:10.1097/AOG.0000000000002039. ISSN   0029-7844. PMID   28426613.
  12. ↑ Thayer, Sydney Marie; Owens, Sarah N.; Skeith, Ashley; Valent, Amy; Caughey, Aaron B. (May 2019). "Prevalence of Shoulder Dystocia by Maternal Height and Diabetes Status [5T]". Obstetrics & Gynecology. 133 (1): 214S. doi:10.1097/01.AOG.0000559106.44163.fd. ISSN   0029-7844.
  13. ↑ Sanchez-Ramos, Luis; Bernstein, Sara; Kaunitz, Andrew M. (November 2002). "Expectant Management Versus Labor Induction for Suspected Fetal Macrosomia". Obstetrics & Gynecology. 100 (5, Part 1): 997–1002. doi:10.1097/00006250-200211000-00030. ISSN   0029-7844.
  14. ↑ Boulvain, Michel; Thornton, Jim G (2023-03-08). Cochrane Pregnancy and Childbirth Group (ed.). "Induction of labour at or near term for suspected fetal macrosomia". Cochrane Database of Systematic Reviews. 2023 (3). doi:10.1002/14651858.CD000938.pub3.
  15. ↑ Crofts, Joanna F.; Fox, Robert; Ellis, Denise; Winter, Catherine; Hinshaw, Kim; Draycott, Timothy J. (October 2008). "Observations From 450 Shoulder Dystocia Simulations: Lessons for Skills Training". Obstetrics & Gynecology. 112 (4): 906–912. doi:10.1097/AOG.0b013e3181865f55. ISSN   0029-7844.
  16. ↑ Grobman, William A.; Miller, Deborah; Burke, Carol; Hornbogen, Abby; Tam, Karen; Costello, Robert (December 2011). "Outcomes associated with introduction of a shoulder dystocia protocol". American Journal of Obstetrics and Gynecology. 205 (6): 513–517. doi:10.1016/j.ajog.2011.05.002.
  17. 1 2 Stitely, Michael L.; Gherman, Robert B. (June 2014). "Shoulder dystocia: Management and documentation". Seminars in Perinatology. 38 (4): 194–200. doi:10.1053/j.semperi.2014.04.004.
  18. 1 2 Stitely, Michael L.; Gherman, Robert B. (2014-06-01). "Shoulder dystocia: Management and documentation". Seminars in Perinatology. Shoulder dystocia and neonatal brachial plexus palsy. 38 (4): 194–200. doi:10.1053/j.semperi.2014.04.004. ISSN   0146-0005.
  19. ↑ McFarland, M.b.; Langer, O.; Piper, J.m.; Berkus, M.d. (1996). "Perinatal outcome and the type and number of maneuvers in shoulder dystocia". International Journal of Gynecology & Obstetrics. 55 (3): 219–224. doi:10.1016/S0020-7292(96)02766-X. ISSN   1879-3479.
  20. 1 2 3 Gherman, Robert B.; Gonik, Bernard (2009). "Shoulder Dystocia". The Global Library of Women's Medicine. doi:10.3843/GLOWM.10137. ISSN   1756-2228.
  21. 1 2 Stitely, Michael L.; Gherman, Robert B. (2014-06-01). "Shoulder dystocia: Management and documentation". Seminars in Perinatology. Shoulder dystocia and neonatal brachial plexus palsy. 38 (4): 194–200. doi:10.1053/j.semperi.2014.04.004. ISSN   0146-0005.
  22. ↑ Baxley EG, Gobbo RW (April 2004). "Shoulder dystocia". Am Fam Physician. 69 (7): 1707–14. PMID   15086043.
  23. ↑ "Fetal Dystocia: Abnormalities and Complications of Labor and Delivery: Merck Manual Professional" . Retrieved 2007-11-28.
  24. ↑ Murray, Michelle; Huelsmann, Gayle (2008-12-15). Labor and Delivery Nursing: Guide to Evidence-Based Practice . Springer Publishing Company. pp.  143–144. ISBN   978-0-8261-1803-5.
  25. ↑ Murray, Michelle; Huelsmann, Gayle (2008-12-15). Labor and Delivery Nursing. Springer Publishing. ISBN   978-0-8261-1803-5 . Retrieved 2009-02-01.{{cite book}}: |work= ignored (help)
  26. ↑ Fernandez H, Papiernik E (1990). "Manoeuvre de Zavanelli : application à la rétention de tête dernière au détroit supérieur : à propos d'une observation" [The Zavanelli maneuver: use during breech retention of the head in the birth canal. Apropos of a case]. J Gynecol Obstet Biol Reprod (Paris) (in French). 19 (4): 483–5. PMID   2380511.
  27. ↑ O'Shaughnessy MJ (October 1998). "Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia". Obstet Gynecol. 92 (4 Pt 2): 693–5. doi:10.1016/S0029-7844(98)00153-7. PMID   9764668. S2CID   42443502.
  28. ↑ Davis, Donald D.; Roshan, Afghani; Varacallo, Matthew A. (2025), "Shoulder Dystocia", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29261950 , retrieved 2025-01-29
  29. 1 2 Menticoglou, Savas (November 2018). "Shoulder dystocia: incidence, mechanisms, and management strategies". International Journal of Women's Health. 10: 723–732. doi: 10.2147/ijwh.s175088 . ISSN   1179-1411. PMC   6233701 . PMID   30519118.
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