Ultrasound Obstet Gynecol 2014; 43: 77–82
Published online 27 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.12560
Evaluation of fetal anthropometric measures to predict the
risk for shoulder dystocia
T. BURKHARDT#, M. SCHMIDT#, J. KURMANAVICIUS, R. ZIMMERMANN and L. SCHÄFFER
Department of Obstetrics and Gynecology, University Hospital of Zürich, Zürich, Switzerland
K E Y W O R D S: anthropometry; biometry; prediction; shoulder dystocia
ABSTRACT
Objective To evaluate the quality of anthropometric mea-
sures to improve the prediction of shoulder dystocia by
combining different sonographic biometric parameters.
Methods This was a retrospective cohort study of
12 794 vaginal deliveries with complete sonographic
biometry data obtained within 7 days before deliv-
ery. Receiver–operating characteristics (ROC) curves
of various combinations of the biometric parameters,
namely, biparietal diameter (BPD), occipitofrontal diam-
eter (OFD), head circumference, abdominal diameter
(AD), abdominal circumference (AC) and femur length
were analyzed. The influences of independent risk factors
were calculated and their combination used in a predictive
model.
Results The incidence of shoulder dystocia was 1.14%.
Different combinations of sonographic parameters
showed comparable ROC curves without advantage for a
particular combination. The difference between AD and
BPD (AD – BPD) (area under the curve (AUC) = 0.704)
revealed a significant increase in risk (odds ratio (OR) 7.6
(95% CI 4.2–13.9), sensitivity 8.2%, specificity 98.8%)
at a suggested cut-off ≥ 2.6 cm. However, the positive
predictive value (PPV) was low (7.5%). The AC as a
single parameter (AUC = 0.732) with a cut-off ≥ 35 cm
performed worse (OR 4.6 (95% CI 3.3–6.5), PPV 2.6%).
BPD/OFD (a surrogate for fetal cranial shape) was not
significantly different between those with and those with-
out shoulder dystocia. The combination of estimated fetal
weight, maternal diabetes, gender and AD – BPD pro-
vided a reasonable estimate of the individual risk.
Conclusion Sonographic fetal anthropometric measures
appear not to be a useful tool to screen for the risk
of shoulder dystocia due to a low PPV. However,
AD – BPD appears to be a relevant risk factor. While risk
Correspondence to: Dr L. Schäffer, Division of Obstetrics, University Hospital of Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
(e-mail: leonhard.schaeffer@usz.ch)
#T. Burkhardt and M. Schmidt contributed equally to this study.
Accepted: 27 June 2013
Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd.
stratification including different known risk factors may
aid in counseling, shoulder dystocia cannot effectively be
predicted. Copyright  2013 ISUOG. Published by John
Wiley & Sons Ltd.
INTRODUCTION
Prediction of the risk of shoulder dystocia is rather
poor. Although risk factors such as fetal macrosomia and
maternal diabetes are well established, these parameters
are not sufficient to adequately predict this obstetric
emergency in a clinically useful way. Therefore, attempts
have been made to further characterize circumstances that
may contribute to a better judgment of risk estimation.
Two conditions appear to add valuable additional
information that may be of benefit. First, the proportions
of the fetus which is also subsumed under the term
‘anthropometric measures’; and second, the way the fetus
rotates through the maternal pelvis. Both conditions may
directly influence how the fetal trunk with its shoulders
will overcome the inlet of the maternal pelvis. The notion
that these conditions may be of major relevance is derived
from the fact that the presence of maternal diabetes as an
independent risk factor has been shown to significantly
influence fetal body composition in favor of the trunk.
Likewise, the application of vaginal operative procedures
(an intrapartum risk factor for shoulder dystocia) appears
to influence the physiological method by which the fetus
rotates and descends through the maternal pelvis. As such,
investigators have analyzed sonographic features that may
indicate such unfavorable circumstances. In a small study
of selected cases with maternal diabetes, Cohen et al.1
analyzed the effect and feasibility of sonographically
defined cephalo-abdominal disproportion of the fetus.
They found an abdominal diameter minus biparietal
diameter (AD – BPD) ≥ 26 mm to be highly discriminative
in the detection of shoulder dystocia. This parameter
ORIGINAL PAPER
78 Burkhardt et al.

appeared to correlate well with incidence and severity2 .
Others confirmed this cut-off in small non-diabetic
populations3,4 . A new approach has been introduced
recently by Belfort et al.5 who hypothesized that a rounder
form of the fetal head may alter fetal transit through
the pelvis by altered velocity and rotational properties.
Our aim was to analyze different fetal anthropometric
properties and combinations in a large, unselected
population with routine ultrasound biometric data close
to delivery for their quality to contribute to the risk
assessment for shoulder dystocia in a clinically useful way.
quality of different biometry parameters was analyzed by
receiver–operating characteristics (ROC) curves and the
area under the curve (AUC). For selected cut-offs, odds
ratios (ORs) with 95% CIs, sensitivity, specificity, and
positive and negative predictive values (PPV, NPV) were
calculated. The influence of independent risk factors was
tested by logistic regression analysis. Based on these data,
a hypothetical model was applied to estimate the percent
risk for the occurrence of shoulder dystocia comprising
different risk factors.

RESULTS
METHODS
Among the 12 794 deliveries that fulfilled the inclusion
A retrospective cohort study was conducted obtaining
criteria, shoulder dystocia occurred in 146 (1.14%).
data from our electronic database ‘Perinat’, which
Women in the study group were slightly older (30.8 ± 5.7
contains all diagnoses and clinical data about the
vs 29.3 ± 5.5 years, P = 0.002), heavier (body mass
course of pregnancy, delivery, maternal and infant
index (BMI) 24.0 ± 4.4 vs 22.9 ± 4.0, P = 0.006) and
outcome, as well as sonographic biometric data. In the
gestation at delivery was slightly later (280.8 ± 8.1 vs
study period from January 1995 to June 2011, 27 318
278.4 ± 8.3 days, P < 0.001). Although small in clinical
singleton infants in vertex presentation were born at term
terms, these differences were statistically significant.
(37 + 0 to 42 + 0 weeks of gestation) in our institution.
Infants with shoulder dystocia were more likely to
To be included in the analysis, subjects had to have
be male and were significantly heavier than were
full sonographic biometry within 7 days of delivery,
measuring biparietal diameter (BPD), occipitofrontal control infants (3948 ± 412 vs 3404 ± 444 g, P < 0.001).
diameter (OFD), abdominal transverse diameter (ATD), Basic maternal and infant characteristics are given in
abdominal anterioroposterior diameter (AAP) and femur Table 1.
length (FL). The head circumference was calculated from Estimated fetal weight (EFW) calculated by ultrasound
BPD and OFD (calipers were set at the outer edges of the biometry within 7 days of delivery likewise was signifi-
fetal skull skin) in our electronic database as described cantly greater in the shoulder dystocia group compared
by Kurmanavicius et al.6 . Abdominal circumference (AC) with the control group (3592 ± 402 vs 3254 ± 421 g,
was calculated from the abdominal diameters ATD and P < 0.001). Evaluation of the mean percentage error
AAP (calipers were set at the outer edges of the fetal of weight estimation revealed an underestimation of
abdominal wall) using the ellipse formula and abdominal −8.8% and −4% in the shoulder dystocia and con-
diameter (AD) and was defined as the mean of ATD trol groups. While fetal head measurements (BPD, OFD
and AAP7 . Fetal biometry at admission to the delivery and BPD/OFD) were not significantly different, abdom-
room is a routine procedure in our clinic. Incomplete inal parameters were significantly larger in the shoulder
data or biometry performed > 7 days before delivery dystocia group (Table 2).
(7744 deliveries (28.3%)) and Cesarean sections (6780
(24.8%)) were excluded from our analysis, resulting in
12 794 term vaginal deliveries with complete sonographic Table 1 Maternal and fetal baseline characteristics of shoulder
dystocia and control groups
biometry data. Fetal weight was estimated according to
the Hadlock three-parameter formula8 , which has been Shoulder
shown to be a reliable model at term9 . dystocia Controls
The presence of shoulder dystocia was defined accord- Variable (n = 146) (n = 12 648) P*
ing to the American College of Obstetricians and Gyne- Maternal age (years) 30.8 ± 5.7 29.3 ± 5.5 0.002
cologists’ (ACOG) practice bulletin10 as ‘the requirement Multiparous (%) 58.2 51.7 0.119
of additional obstetric maneuvers to release the shoulders Body mass index prior to 24.0 ± 4.4 22.9 ± 4.0 0.006
after gentle downward traction has failed’. No prophylac- pregnancy (kg/m2 )
tic maneuvers are performed in our institution. The diag- Gestational diabetes 7.5 2.7 < 0.001
mellitus (%)
nosis of shoulder dystocia was obtained from the Interna-
Gestational age (days) 280.8 ± 8.1 278.4 ± 8.3 < 0.001
tional Classification of Disease codes and all cases were Birth weight (g) 3948 ± 412 3404 ± 444 < 0.001
verified for additional maneuvers to release the shoulders. Birth weight percentile 79.9 ± 21.1 52.4 ± 28.5 < 0.001
Statistical analysis was conducted using STATA Male infant sex (%) 61.6 50.7 0.009
11.0 (Stata Corporation, College Station, TX, USA). Operative vaginal 34.3 17.1 < 0.001
delivery (%)
Continuous variables were compared using the Student’s
Umbilical artery pH 7.21 ± 0.08 7.24 ± 0.08 < 0.001
t-test for different sample sizes. Nominal and categorical 5-min Apgar score 8.4 ± 1.3 8.9 ± 0.6 < 0.001
variables were compared using the χ2 -test. The level of
statistical significance was set at P < 0.05. The diagnostic Results are given as mean ± SD or %. *Student’s t-test.

Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 43: 77–82.
Prediction of shoulder dystocia 79

Table 2 Ultrasound biometric parameters of shoulder dystocia and control groups

Shoulder dystocia Controls

Variable (n = 146) (n = 12 648) P*

Interval between last ultrasound and delivery (days) 2.4 ± 2.5 1.4 ± 1.8 < 0.001
Estimated fetal weight (g) 3592 ± 402 3254 ± 421 < 0.001
Biparietal diameter (BPD) (mm) 97.4 ± 4.0 97.0 ± 4.1 0.211
Occiptofrontal diameter (OFD) (mm) 114.5 ± 6.1 114.0 ± 5.6 0.319
BPD/OFD 0.85 ± 0.04 0.85 ± 0.04 0.978
Head circumference (mm) 333.9 ± 13.8 332.4 ± 13.1 0.201
Abdominal diameter (mm) 112.8 ± 6.5 107.3 ± 6.6 < 0.001
Abdominal circumference (mm) 354.4 ± 20.0 337.0 ± 20.7 < 0.001
Abdominal diameter – biparietal diameter (AD – BPD) (mm) 15.3 ± 6.7 10.3 ± 6.4 < 0.001
Abdominal circumference – head circumference (AC – HC) (mm) 20.5 ± 20.8 4.6 ± 19.8 < 0.001
Abdominal circumference/head circumference (AC/HC) 1.1 ± 0.06 1.0 ± 0.06 < 0.001
Abdominal circumference × femur length (AC × FL) 26 112 ± 3029 24 584 ± 2560 < 0.001

Results are given as mean ± SD. *Student’s t-test.

1.00 40

0.75
20
AD – BPD (mm)
Sensitivity

0.50

0
0.25

−20
0.00
0.00 0.25 0.50 0.75 1.00
1000 2000 3000 4000 5000
1 – Specificity
Estimated fetal weight (g)

Figure 1 Receiver–operating characteristics curves and areas under

Figure 2 Abdominal diameter minus biparietal diameter
the curves (AUC) for different sonographic anthropometric
(AD – BPD) values in shoulder dystocia ( ) and control ( ) infants
measures in the prediction of shoulder dystocia: estimated fetal
plotted against estimated fetal weight. Dashed lines indicate means.
weight ( ; AUC, 0.70); abdominal circumference (AC, ;
AUC, 0.71); abdominal diameter minus biparietal diameter ( ;
AUC, 0.71); AC minus head circumference (HC) ( ; AUC, 0.71);
AC/HC ( ; AUC, 0.71); AC × femur length ( ; AUC, 0.72).

To analyze the capacity of anthropometric discrep-

ancies to predict shoulder dystocia, ROC curves of 450
different combinations of cephalo-abdominal parameters
Abdominal circumference (mm)

(AD – BPD, AC – HC, AC/HC and AC × FL) and of single

400
parameters (EFW, AC) were generated and the AUC was
compared. While all curves showed an AUC ≥ 0.7, none
of the curves revealed a significant advantage (Figure 1). 350
Thus, the two proposed parameters, AD – BPD and AC,
were further analyzed. First, we plotted all AD – BPD 300
and AC of cases and controls against the estimated
fetal weight (Figures 2 and 3). While both shoulder 250
dystocia and control groups showed an increase in mean
AD – BPD values with increasing fetal weight, shoulder
200
dystocia cases had slightly increased mean AD – BPD 1000 2000 3000 4000 5000
values compared to controls. However, cases were well Estimated fetal weight (g)
incorporated into the general population indicating a
poor discrimination (Figure 2). Accordingly, the positive Figure 3 Abdominal circumference values in shoulder dystocia ( )
predictive value, when applying the proposed cut-off for and control ( ) infants plotted against estimated fetal weight.
AD – BPD of 26 mm, was low (PPV, 7.6%; NPV, 98.9%; Dashed lines indicate means.

Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 43: 77–82.
80 Burkhardt et al.

Table 3 Diagnostic test characteristics for different cut-off values for abdominal diameter – biparietal diameter difference (AD – BPD),
abdominal circumference (AC) and estimated fetal weight (EFW)

Variable Cut-off Sensitivity (%) Specificity (%) PPV (%) NPV (%) OR (95% CI) LR
AD – BPD 15 mm 53.4 76.2 2.52 99.3 3.7 (2.7–5.1) 2.2
20 mm 19.9 93.2 3.28 99.0 3.4 (2.3–5.2) 2.9
24 mm 11.0 98.0 5.97 99.0 6.0 (3.6–10.3) 5.5
26 mm* 8.22 98.8 7.55 98.9 7.6 (4.2–13.9) 7.1
28 mm 4.79 99.3 7.14 98.9 7.0 (3.2–15.0) 6.7
AC 350 mm* 63.7 72.5 2.6 99.4 4.6 (3.3–6.5) 2.3
370 mm 16.4 95.1 3.8 99.0 3.9 (2.47–6.0) 3.4
390 mm 4.8 99.6 11.7 98.9 12.0 (5.5–26.3) 11.4
EFW 3000 g 91.1 26.6 1.4 99.6 3.7 (2.1–6.5) 1.2
3500 g 62.3 71.6 2.47 99.4 4.2 (3.0–5.8) 2.2
4000 g* 15.1 95.3 3.5 99.0 3.6 (2.3–5.7) 3.2
4500 g 4.11 98.8 3.92 98.9 3.6 (1.6–8.2) 3.5

*Cut-off values used for calculations in the study. LR, likelihood ratio; NPV, negative predictive value; OR, odds ratio; PPV, positive
predictive value.

Table 4 Multivariate logistic regression analysis of the influence of Table 5 Regression analysis of the impact of gestational diabetes
gestational diabetes, estimated fetal weight, gender and mellitus (GDM), different estimated fetal weights (EFW), gender
abdominal – biparietal diameter difference (AD – BPD) on the risk and abdominal diameter – biparietal diameter (AD – BPD) on
for shoulder dystocia shoulder dystocia risk

Shoulder dystocia Risk of shoulder dystocia (%)

EFW AD – BPD
Adjusted OR† (g) (mm) Female Male
Parameter OR (95% CI) (95% CI)
GDM 3500 15 2.9 4.5
Gestational diabetes mellitus 4000 20 7.5 11.4
No* 1 1
4000 26 11.8 18.1
Yes 2.91 (1.56–5.42) 2.91 (1.55–5.48)
No GDM 3500 15 1.1 1.7
Estimated fetal weight
4000 20 2.8 4.3
< 3500 g* 1 1
3500–3999 g 3.79 (2.65–5.41) 3.54 (2.47–5.07) 4000 26 4.5 6.9
≥ 4000 g 6.06 (3.67–10.0) 4.73 (2.79–8.00)
AD – BPD
< 26 mm* 1 1
≥ 26 mm 7.62 (4.13–14.05) 4.49 (2.36–8.57)
Fetal gender and before delivery values (OR, 0.76 (95% CI, 0.53–1.08)
Female* 1 1 and OR, 1.13 (95% CI, 0.80–1.63), respectively).
Male 1.56 (1.12–2.18) 1.42 (1.01–1.99) In an attempt to optimize risk estimation, the
*Baseline category. †Odds ratios with adjustment for all variables most important risk factors were combined. First, the
in the multivariate logistic regression model. well-established antenatal risk factors of fetal weight
and maternal diabetes were further characterized to
sensitivity, 8.5%; specificity, 98.8%). However, risk confirm their role in our study population. Sonographic
estimation using this cut-off revealed an OR of 7.6 weight ≥ 4000 g (cut-off) revealed an OR of 3.6 (95%
(95% CI, 4.2–13.9) (Table 3). The number needed CI, 2.3–5.7) (sensitivity, 15.1%; specificity, 95.3%;
to prevent (by primary Cesarean section) one case of PPV, 3.5%; NPV, 99%). Gestational diabetes was an
shoulder dystocia for AD – BPD ≥ 26 mm was 14.2, and independent risk factor (OR 2.91 (95% CI, 1.56–5.42);
when combined with estimated birth weight ≥ 3500 g it sensitivity, 7.5%; specificity, 97.3%; PPV, 3.1%; NPV,
was 9.5. 98.9%). Male gender was a mild risk factor (OR, 1.56
When analyzing AC as a single parameter, the suggested (95% CI, 1.12–2.18); sensitivity, 61.6%; specificity,
cut-off of 350 mm11 resulted in an even lower PPV 49.3%; PPV, 1.38%; NPV, 99.1%). These parameters
of 2.6% (94/3581) (NPV, 99.4%; sensitivity, 63.7%; were then combined with the parameters AD – BPD for
specificity, 72.5%; OR, 4.6 (95% CI 3.3–6.5)). The optimal shoulder dystocia prediction using continuous
diagnostic test characteristics for lower and higher cut-offs variables, resulting in the following model of probability:
for AD – BPD, AC and for the EFW are given in Table 3. risk for shoulder dystocia = exp(−10.4822 + 0.0011 ×
A multivariate logistic regression analysis including the EFW + 0.9693 × GDM + 0.07654 × AD – BPD + 0.4213
main a priori risk factors, estimated fetal weight, gesta- × gender) (gender code: female = 1, male = 2, GDM
tional diabetes, fetal gender and AD – BPD is given in code: no GDM = 1, GDM = 2, where GDM is ges-
Table 4. While maternal BMI was significantly higher in tational diabetes mellitus). Hypothetical scenarios to
the study group, BMI was not shown to be an independent demonstrate the impact of anthropometry are given in
risk factor for a cut-off of BMI 30 at both prepregnancy Table 5.

Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2014; 43: 77–82.
Prediction of shoulder dystocia
DISCUSSION
The proportion of the fetal head to thorax/abdomen
appears to be an important factor in the development of
shoulder dystocia, beyond macrosomia itself. In fact, we
were able to show that for the parameter AD – BPD, a
cut-off of 26 mm is associated with a significant increase
in risk (OR, 7.6) which confirms, in our large unselected
population, the results of previous small studies1,3,4 .
However, this parameter is not applicable as a screening
tool for shoulder dystocia since the positive predictive
value is very low (7.55%). Indeed, when analyzing the
distribution of shoulder dystocia within the population,
as shown in Figure 2, this finding becomes quite clear.
We analyzed a variety of other putative combinations of
biometric parameters which did not perform better.
Though fetal macrosomia is a well-established risk
factor12 , the majority of shoulder dystocias occur in non-
macrosomic fetuses13 (56% (82/146) in our study). The
fact that maternal diabetes has been shown to be an inde-
pendent risk factor in addition to fetal macrosomia13 has
resulted in the hypothesis that the typical disproportion
in these fetuses in favor of the trunk may be the key14,15 .
Cohen et al.1 tried to obtain a simple measure to identify
fetuses of diabetic mothers at risk for shoulder dystocia
at a borderline birth weight of 3800–4200 g. In a highly
selected cohort of 31 infants, six were identified as having
shoulder dystocia. The only difference that could be
found was a significantly increased AD – BPD difference.
ROC curve analysis revealed a cut-off of 26 mm to be
most predictive, reaching a sensitivity of 100% at a
specificity of 46% with a PPV of 30%. Miller et al. later
confirmed a cut-off value of 26 mm in a slightly larger
population of 332 subjects, in which each weighed more
than 3400 g, including 23 cases with shoulder dystocia3 .
In fact, this parameter performed significantly better than
parameters such as estimated fetal weight or abdominal
circumference in that study. Furthermore, they found that
cut-off to be optimal for diabetic and for non-diabetic
pregnancies, suggesting that it really is the anthropometry
contributing to the development of shoulder dystocia.
Finally, Rajan et al. were able to show similar results in
a non-diabetic population of 159 subjects including 27
cases with shoulder dystocia and suspected macrosomia
(estimated fetal weight ≥ 4000 g)4 .
Regarding a putative influence of the shape of the fetal
head on rotation through the maternal pelvis, we did
not find a significant difference in OFD or BPD/OFD
in our study group, in contrast to the suggestion of
Belfort et al.5 . While these authors had to interpolate
OFD values from HC and BPD measurements in a highly
selected population, direct routine sonographic OFD
measurements were available in our study. Furthermore,
the differences in their study were rather small (0.5 cm)
and measurements of OFD near term are rather inaccu-
rate. Thus, even though we believe that rotation might
be a highly relevant factor, antepartal fetal cranial shape,
as approximated by BPD and OFD, appeared not to
contribute significantly to the risk for shoulder dystocia
in our population. Indeed, these cranial parameters are at
Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd.
81
best a weak sonographic surrogate for cranial shape. Even
more importantly, forces during active labor resulting in
deformation, molding and caput may influence consider-
ably fetal head shape, thus making the interpretation of
this parameter prior to labor rather difficult.
Prior studies have been hampered by their rather small
numbers and selectivity leading to a disproportionally
high incidence of shoulder dystocia, which is caused by
the lack of routine fetal biometry close to delivery or
to the fact that birth weight was used as the selection
criterion due to a lack of cross-linking of ultrasound
and delivery data. Furthermore, when sonographic
weight estimation shortly before delivery is not routinely
performed, the study cases obtained may carry a bias, as
there must have been a clinical suspicion of some kind of
pathologic condition.
In our institution, sonographic estimation of fetal
weight close to term is a routine procedure and these data
are cross-linked with the corresponding pregnancy and
delivery data. Calculating the absolute percentage error
of estimation (−4% vs –8.8% for controls and cases,
respectively) confirmed the accuracy of the measurements
as well as the typical increase in underestimation at larger
weight ranges9 .
Since the degree of fetal asymmetry measured by
AD – BPD appears to directly correlate with the incidence
of shoulder dystocia2 but this factor alone is not able
to predict reliably shoulder dystocia, we attempted to
combine the most important risk factors using a model of
probability based on our retrospective data. This model
provides some support for clinical advice that has to be
tested prospectively.
One factor which influences all studies, including ours,
is the high rate of Cesarean sections performed for various
reasons in pregnancies with suspected macrosomia. How-
ever, in our collective, rates of Cesarean sections were
quite similar up to an estimated fetal weight of 4500 g
at which rates significantly increased (< 3500 g, 29%;
3500–4000 g, 29%; 4000–4500 g, 33% vs > 4500 g,
48%), which may be the reason for the low incidence
in this high weight range. Accordingly, post hoc analysis
revealed that the rate of Cesarean delivery in fetuses with
an AD – BPD ≥ 26 mm was significantly higher (46%)
compared to a measured AD – BPD < 26 mm (33%).
Thus a significant proportion of these fetuses with an
unfavorable asymmetry were not included in the study.
Nevertheless, hypothetical inclusion of these cases would
have further increased the risk.
A second highly relevant factor for the dilemma
of predicting and advising about the risk of shoulder
dystocia is the problem of adequate sonographic weight
prediction, especially in larger fetuses. Nevertheless,
within normal weight ranges, at which the majority of
shoulder dystocias occur, accuracy is quite acceptable9 .
In conclusion, adequate prediction of shoulder dystocia
remains an unsolved problem. Anthropometric dispro-
portion as represented by an increased abdominocephalic
diameter is a risk factor and can contribute to the risk
assessment for shoulder dystocia.
Ultrasound Obstet Gynecol 2014; 43: 77–82.
82
REFERENCES
1. Cohen BF, Penning S, Major C, Ansley D, Porto M, Garite
T. Sonographic prediction of shoulder dystocia in infants of
diabetic mothers. Obstet Gynecol 1996; 88: 10–13.
2. Cohen BF, Penning S, Ansley D, Porto M, Garite T. The
incidence and severity of shoulder dystocia correlates with
a sonographic measurement of asymmetry in patients with
diabetes. Am J Perinatol 1999; 16: 197–201.
3. Miller RS, Devine PC, Johnson EB. Sonographic fetal
asymmetry predicts shoulder dystocia. J Ultrasound Med 2007;
26: 1523–1528.
4. Rajan PV, Chung JH, Porto M, Wing DA. Correlation
of increased fetal asymmetry with shoulder dystocia in the
nondiabetic woman with suspected macrosomia. J Reprod Med
2009; 54: 478–482.
5. Belfort MA, White GL, Vermeulen FM. Association of fetal
cranial shape with shoulder dystocia. Ultrasound Obstet
Gynecol 2012; 39: 304–309.
6. Kurmanavicius J, Wright EM, Royston P, Wisser J, Huch R,
Huch A, Zimmermann R. Fetal ultrasound biometry: 1. Head
reference values. Br J Obstet Gynaecol 1999; 106: 126–135.
7. Kurmanavicius J, Wright EM, Royston P, Zimmermann R,
Huch R, Huch A, Wisser J. Fetal ultrasound biometry: 2.
Abdomen and femur length reference values. Br J Obstet
Gynaecol 1999; 106: 136–143.
8. Hadlock FP, Harrist RB, Sharman RS, Deter RL, Park SK.
Estimation of fetal weight with the use of head, body, and femur
Copyright  2013 ISUOG. Published by John Wiley & Sons Ltd.
Burkhardt et al.
measurements – a prospective study. Am J Obstet Gynecol
1985; 151: 333–337.
9. Kurmanavicius J, Burkhardt T, Wisser J, Huch R. Ultrasono-
graphic fetal weight estimation: accuracy of formulas and
accuracy of examiners by birth weight from 500 to 5000 g.
J Perinat Med 2004; 32: 155–161.
10. Sokol RJ, Blackwell SC. ACOG practice bulletin: Shoulder
dystocia. Number 40, November 2002. (Replaces practice
pattern number 7, October 1997). Int J Gynaecol Obstet 2003;
80: 87–92.
11. Jazayeri A, Heffron JA, Phillips R, Spellacy WN. Macrosomia
prediction using ultrasound fetal abdominal circumference
of 35 centimeters or more. Obstet Gynecol 1999; 93:
523–526.
12. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia
and associated risk factors with macrosomic infants born in
California. Am J Obstet Gynecol 1998; 179: 476–480.
13. Langer O, Berkus MD, Huff RW, Samueloff A. Shoulder
dystocia: should the fetus weighing greater than or equal to
4000 grams be delivered by cesarean section? Am J Obstet
Gynecol 1991; 165(4 Pt 1): 831–837.
14. McFarland MB, Trylovich CG, Langer O. Anthropometric
differences in macrosomic infants of diabetic and nondiabetic
mothers. J Matern Fetal Med 1998; 7: 292–295.
15. Modanlou HD, Komatsu G, Dorchester W, Freeman RK,
Bosu SK. Large-for-gestational-age neonates: anthropometric
reasons for shoulder dystocia. Obstet Gynecol 1982; 60:
417–423.
Ultrasound Obstet Gynecol 2014; 43: 77–82.