Aust N Z J Obstet Gynaecol 2017; 1–8

DOI: 10.1111/ajo.12718

ORIGINAL ARTICLE

Impact of shoulder dystocia, stratified by type

of manoeuvre, on severe neonatal outcome and
maternal morbidity

Flurina Michelotti1, Christopher Flatley2 and Sailesh Kumar1,2,3

1
Mater Mothers’ Hospital, South
Brisbane, Queensland, Australia Background: Shoulder dystocia is an uncommon and unpredictable obstetric
2
Mater Research Institute – University emergency. It is associated with significant neonatal, maternal and medico-­
of Queensland, South Brisbane, legal consequences.
Queensland, Australia
3 Aim: To ascertain the impact shoulder dystocia has on severe neonatal and ma-
School of Medicine, The University of
Queensland, Brisbane, Queensland, ternal outcomes specific to the type of manoeuvre.
Australia
Materials and methods: This was a retrospective study of 48 021 term singleton
Correspondence: Professor Sailesh vaginal deliveries the Mater Mothers’ Hospital in Brisbane between 2007 and
Kumar, Mater Research Institute/
2015. Maternal and neonatal outcomes were compared between deliveries com-
University of Queensland, Level 3,
Aubigny Place, Raymond Terrace, South plicated by shoulder dystocia and those uncomplicated.
Brisbane, Qld 4101, Australia. Email:
Results: Deliveries complicated by shoulder dystocia are associated with low
sailesh.kumar@mater.uq.edu.au
Apgar scores (≤3) at five minutes (odds ratio (OR) 5.25, 95% CI 3.23–8.56, P < 0.001),
Conflicts of Interest: The authors report
no conflicts of interest. acidosis (OR 3.10, 95% CI 2.76–3.50, P < 0.001), postpartum haemorrhage (OR

Received: 21 June 2017;
Accepted: 19 August 2017
2.28, 95% CI 1.90–2.75, P < 0.001) and perineal trauma (OR 1.92, 95% CI 1.54–2.39,
P < 0.001). Compared to McRoberts’ manoeuvre and suprapubic pressure alone,
the odds of serious neonatal outcome are increased with internal rotational ma-
noeuvres (OR 3.82, 95% CI 2.54–5.74, P < 0.001) and delivery of the posterior arm
(OR 4.49, 95% CI 3.54–5.69, P < 0.001). The OR of maternal injury is 2.07 (95% CI
1.77–2.45, P < 0.001), 2.26 (95% CI 1.21–4.21, P < 0.001) and 2.29 (95% CI 1.58–
3.32, P < 0.001) with McRoberts’/suprapubic pressure, internal rotation and pos-
terior arm delivery, respectively. Brachial plexus injuries and fractures complicate
1.4 and 0.9% of deliveries, with the risk of injury increasing when greater than
one manoeuvre is required.
Conclusion: The risk of neonatal and maternal trauma is strongly associated with
the number and types of manoeuvres. Given the associated implications, ade-
quate antenatal counselling, simulation training and enhanced labour surveil-
lance are essential.

KEYWORDS
birth injury, brachial plexus injury, McRoberts’ manoeuvre, shoulder dystocia

INTRODUCTION morbidity.1,2 It occurs when the anterior, or occasionally the

posterior, fetal shoulder impacts the maternal pubic sym-
Shoulder dystocia is an uncommon and unpredictable obstetric physis.1,2 Although there are multiple risk factors for shoul-
emergency with significant impact on neonatal and maternal der dystocia, the most significant ones include macrosomia,

wileyonlinelibrary.com/journal/anzjog © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 1
2 Outcomes following shoulder dystocia
diabetes, obesity, induction of labour (IOL), abnormalities of
1–4
labour and instrumental deliveries. The diagnosis is largely
dependent on subjective recognition, which partly accounts
for the d
­ ifferences seen in incidence rates across maternity
units. Currently, reported institutional rates range from 0.2
4
to 3%. Perinatal consequences of shoulder dystocia can be
­profound and include severe birth asphyxia, ­brachial plexus
injuries (BPI), upper limb fractures, soft tissue trauma and
death. Maternal complications include an i­ncreased incidence
of postpartum haemorrhage (PPH), perineal tears and psycho-
logical trauma.1,2
The management of shoulder dystocia involves a sequence
of manoeuvres to allow dislodgement of the anterior shoulder
from below the symphysis pubis. These include hyperflexion of
the maternal thighs against the abdomen (McRoberts’ manoeu-
vre) while applying lateral suprapubic pressure as a first step
followed by internal rotational manoeuvres (Rubin’s, Wood’s
screw, reverse Wood’s screw), delivery of the posterior arm and
maternal ‘all fours’ position.1,2,4–7 Failure to resolve the shoulder
dystocia may require more extreme measures, including cleido-
tomy, symphysiotomy or the Zavenelli manoeuvre.1,2,5–7 The use
of additional manoeuvres lengthens the delivery interval and po-
tentially also increases the risk of neonatal and maternal trauma.
The aim of this study was thus to ascertain the impact shoulder
dystocia has on severe neonatal outcome and maternal morbidity
specific to the type and number of manoeuvres required to
achieve resolution.
MA TERIALS AND METHODS
This was a retrospective cohort study of all term (≥37 weeks)
singleton vaginal deliveries at the Mater Mothers’ Hospital
in Brisbane, Australia, between January 2007 and December
2015. The Mater Mothers’ Hospital is one of the largest ter-
tiary obstetric hospitals in Australia with an annual birth rate
of approximately 10 000. All cases were first identified from
the institution’s electronic health records database and then
cross-­referenced with both maternal and neonatal records.
Exclusion criteria included multiple pregnancy, preterm births,
malpresentation, known congenital abnormalities and caesar-
ean birth. Shoulder dystocia was defined as any vaginal birth
that required additional manoeuvres beyond that of normal
traction on the fetal head to effect delivery of the shoulders.2
As hospital protocol requires that the McRoberts’ manoeu-
vre and suprapubic pressure be used before any additional
techniques are employed, for the purposes of this study it
was assumed that any extra manoeuvres were used only
after these had failed. The diagnosis of shoulder dystocia was
made contemporaneously and recorded in the medical notes
following the affected delivery. Controls were births with simi-
lar exclusion criteria over the same period not complicated by
­shoulder dystocia.
Maternal demographic information collected included age,
body mass index (BMI), ethnicity, parity and maternal medical
conditions including diabetes and hypertensive disorders. The
number of inductions, instrumental deliveries and delayed
second stage deliveries were also collected. Prolonged sec-
ond stage was defined as labour ≥3 h with epidural and ≥2 h
without epidural for nulliparous women, and in multiparous
women ≥2 h with epidural and ≥1 without.8 Neonatal outcomes
included gestation at birth, birth weight, Apgar score ≤3 at five
minutes, significant acidosis (pH ≤ 7.0 or lactate >6 mmol/L or
base excess <−12 mmol/L), neonatal intensive care unit (NICU)
admission, BPI, fractures and death. Severe neonatal outcome
was defined as a composite of acidosis, Apgar ≤3 at five min-
utes, admission to NICU and death. Maternal complications
assessed included rates of PPH, perineal trauma and length of
hospital stay.
Statistical analysis was performed using Kruskal–Wallis tests
for comparisons of medians where data showed a skewed dis-
tribution and analysis of variance for comparisons of means
between groups where the data was normally distributed.
Proportions were compared using Chi-­square test or Fisher’s
exact test where expected frequencies were <5. Statistics are re-
ported as mean (standard deviation (SD)) or median (inter-­quartile
range (IQR)) for normally and non-­normally distributed variables,
respectively, or as the number of observations with the percent-
age of total. Multivariate analysis was performed by logistic re-
gression and odds ratio (OR) or relative risk ratios (RRR) reported
with 95% confidence intervals (CIs) for the shoulder dystocia
cohort. All statistical analyses were conducted using Stata®,
Release 13 statistical analysis program for Windows (StataCorp
LP, College Station, TX, USA). Ethics approval was granted by
the institution’s Human Research Ethics Committee (Reference
number HREC/13/MHS/104).
Data integrity was assessed using a year by year analysis to
identify inconsistencies of reporting between years. Where data
integrity was questionable with sudden drops in outcomes that
could not be accounted for by change in policy or treatment,
those variables were excluded from any analysis. Efforts were
made to correct missing and data entry errors through searches
of individual patient records. Where data were collected with dif-
ferent degrees of outcomes between years, these variables were
collapsed into dichotomous variables to indicate whether the out-
come occurred or not. Where only the outcomes were recorded,
after discussion with data custodians it was determined that it
was reasonable to assume that missing data indicated that the
outcome had not occurred.
RESULTS
During the study period there were 86 109 births. Of these, 38 088
(44%) did not meet the inclusion criteria, resulting in a total study
cohort of 48 021 births. Shoulder dystocia was recorded as
F. Michelotti et al. 3

complicating 5.3% (2540/48 021) of the study cohort. The majority
(77%, 1957/2540) of cases resolved with McRoberts’ and suprapu-
bic pressure alone. A further 4.6% (118/2540) required additional
internal rotational manoeuvres and in 13% (329/2540) of women,
delivery of the posterior arm was required. In 5.4% (136/2540) of
cases ‘other’ manoeuvres including the ‘all fours’ position were re-
quired. There were no cases requiring cleidotomy, Zavanelli ma-
noeuvre or symphysiotomy.
Maternal demographic information is displayed in Table 1.
Women whose births were complicated by shoulder dystocia
were more likely to be younger, nulliparous, have diabetes mel-
litus and a higher BMI. Compared to the control group, the in-
cidence of shoulder dystocia significantly increased with rising
maternal BMI ≥ 25 kg/m2 and increasing gestation. Prolonged
second stage (OR 2.87, 95% CI 2.59–3.18, P < 0.001), IOL (OR
1.38, 95% CI 1.27–1.49, P < 0.001) and instrumental birth (OR
2.72, 95% CI 2.51.2.96, P < 0.001) were all significant predispos-
ing factors.
The odds for shoulder dystocia related to birth weight and in-
trapartum risk factors is presented in Table 2. Birth weight >90th
centile for gestation was associated with an OR of 4.16 (95% CI
3.77–4.58, P < 0.001) for shoulder dystocia while birth weight
>5000 g had an OR of 14.36 (95% CI 8.62–23.84, P < 0.001). IOL,
prolonged second stage and instrumental deliveries all predis-
pose to shoulder dystocia, but only become significant with birth
weight ≥3000 g.

TABLE 1 Demographics
Shoulder dystocia

Demographics No Yes P value

Maternal age 30.6 ± 5.3 30.2 ± 5.4 <0.001

(mean, SD)
Ethnicity
Caucasian 70.2% (31 884/45 439) 69.8% (1770/2536) 0.67
ATSI 1.9% (878/45 439) 1.6% (40/2536) 0.28
Asian 15.2% (6891/45 439) 14.5% (359/2536) 0.34
Other 12.7% (5786/45 439) 14.2% (359/2536) 0.03
Nulliparous 46.6% (21 192/45 474) 51.3% (1302/2539) <0.001
Diabetes mellitus 10.1% (4602/45 481) 15% (382/2540) <0.001
Maternal BMI 22.4 (20.2–25.6) 23.5 (21.0–27.6) <0.001
2
WHO BMI category (kg/m )
<18.5 8.1% (3649/44 881) 5.2% (131/2512) <0.001
18.5–24.9 63.4% (28 456/44 881) 56.2% (1412/2512) <0.001
25.0–29.9 18.2% (8167/44 881) 22.3% (559/2512) <0.001
30.0–34.9 6.7% (2983/44 881) 9.4% (236/2512) <0.001
35.0–39.9 2.4% (1073/44 881) 4.0% (100/2512) <0.001
>40 1.2% (553/44 881) 3.0% (74/2512) <0.001
Gestation at birth
37 weeks 6.5% (2940/45 481) 3.5% (89/2540) <0.001
38 weeks 17.1% (13 484/45 481) 12.9% (327/2540) <0.001
39 weeks 29.7% (13 484/45 481) 25.4% (644/2540) <0.001
40 weeks 32.3% (14 688/45 481) 34.3% (871/2540) 0.04
>41 weeks 14.5% (6572/45 481) 24.0% (609/2540) <0.001
Induction of 33.6% (15 287/45 478) 41.1% (1043/2540) <0.001
labour
Delayed second 8.3% (3785/45 481) 20.7% (525/2540) <0.001
stage
Instrumental 19.7% (8936/45 481) 40.0% (1015/2540) <0.001
delivery
Gender
Male 50.0% (22 740/45 480) 55.1% (1400/2539) <0.001
Female 50.0% (22 740/45 480) 44.9% (1139/2539) <0.001

ATSI, Aboriginal or Torres Strait Islander; BMI, body mass index; WHO, World Health Organization.
The denominators vary because of the number of non-­recorded data.
4 Outcomes following shoulder dystocia

Table 3 compares the odds of adverse neonatal and mater-

nal outcomes as predicted by shoulder dystocia. Neonates whose

P-­value

0.001
<0.001
<0.001
<0.001
<0.001

<0.001
0.92

0.47
births were complicated by shoulder dystocia were more likely to
have a very low Apgar score (≤3) at five minutes (OR 5.25, 95% CI
3.23–8.56, P < 0.001), significant acidosis (OR 3.10, 95% CI 2.76–
Instrumental delivery 3.50, P < 0.001) and be admitted to the NICU (OR 3.17, 95% CI

2.00 (0.31–12.92)
0.89 (0.10–8.07)
2.33 (1.43–3.82)
4.33 (3.60–5.22)
2.96 (2.60–3.37)
2.77 (2.34–3.29)
2.37 (1.57–3.60)

2.72 (2.25–3.29)
(95% CI) 2.80–3.58). The composite for both serious neonatal outcome (OR
3.23, 95% CI 2.93–3.55, P < 0.001) and maternal outcome (OR 2.08,
95% CI 1.79–2.40, P < 0.001) was significantly higher after shoul-
der dystocia. A total of 1.4% (36/2540) had BPI, 0.9% (25/2540) had
fractures of the clavicle and humerus, 7.6% (193/2540) had head
and neck trauma (mainly cephalohaematoma) and 0.9% (24/2540)
suffered significant cutaneous trauma (mainly bruising).
P-­value

The risk of severe neonatal and maternal complications strati-

0.052
<0.001
<0.001
<0.001
0.001

<0.001
0.81
fied by type of manoeuvre required for resolution is presented in
Intrapartum risk factors

Table 4. Both neonatal and maternal outcomes were significantly

worse with the use of internal rotational manoeuvres and delivery
of the posterior arm. Compared to McRoberts’ and suprapubic
Prolonged second stage

pressure the OR for serious neonatal injury as expressed by the

2.02 (0.995–4.10)
3.63 (2.91–4.52)
2.61 (2.22–3.07)
2.75 (2.24–3.38)
2.47 (1.47–4.17)
1.28 (0.17–9.73)
2.82 (2.45–3.54)

composite is 3.82 (95% CI 2.54–5.74, P < 0.001) and 4.49 (95% CI

(95% CI)

3.54–5.69, P < 0.001) for internal rotational manoeuvres and de-

NA

livery of the posterior arm. This trend of worsening injury with

increasing number of manoeuvres is also observed with maternal
outcomes. The odds of specific fetal trauma according to manoeu-
vre used is also shown in Table 4. Compared to McRoberts’ and
suprapubic pressure, the odds of fracture were highest with de-
TABLE 2 Odds ratios for shoulder dystocia related to birth weight and intrapartum risk factors

P-­value

livery of the posterior arm (OR 6.83, 95% CI 2.88–16.22, P < 0.001).

<0.001
<0.001
0.002
0.75
0.62

0.66
0.38
0.24

Likewise, the risk of BPI was greater with both internal rotation
(OR 3.40, 95% CI 1.14–10.11, P = 0.03) and posterior arm delivery
(OR 3.35, 95% CI 1.59–7.06, P = 0.001).
0.75 (0.12–4.52)
1.13 (0.69–1.86)
1.50 (1.24–1.81)
1.26 (1.11–1.43)
1.28 (1.10–1.50)
1.08 (0.77–1.51)
1.63 (0.55–4.87)
1.11 (0.93–1.32)
IOL (95% CI)

DISCUSSION

Main findings
The results of this large Australian study demonstrate a rela-
tively high shoulder dystocia rate compared to other published
research.4 This may be reflective of the high rates of maternal
P-­value

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

obesity which now affects almost 60% of pregnant women in

Shoulder dystocia

Australia.9 Accurate shoulder dystocia rates can sometimes be

CI, confidence intervals; IOL, induction of labour.

difficult to estimate because the diagnosis is often subjective in

mild cases and may be influenced by the use of ‘prophylactic’
Odds ratio (95% CI)

8.60 (7.24–10.22)
14.36 (8.65–23.84)
0.14 (0.06–0.34)
0.17 (0.13–0.22)
0.33 (0.29–0.36)
1.32 (1.22–1.43)
4.09 (3.73–4.47)

4.16 (3.77–4.58)

McRoberts’ manoeuvre. In this study, when McRoberts’ manoeu-

vre and suprapubic pressure were excluded, the incidence of
shoulder dystocia reduced to approximately 1.4%, which is closer
to the prevalence reported in other large publications.10
Consistent with other studies our data shows an increas-
ing risk of developing shoulder dystocia with rising maternal
BMI, maternal diabetes mellitus, IOL, prolonged second stage
≥90th Centile

and instrumental delivery.2,4,10–15 We also show that the risk of

2500–2999
3000–3499
3500–3999
4000–4499
4500–4999
Weight (g)

shoulder dystocia only becomes significant once birth weight is

<2500

≥5000

≥3000 g. In contrast to other studies we have calculated the odds

of shoulder dystocia according to birth weight and intrapartum
F. Michelotti et al. 5

TABLE 3 Neonatal and maternal outcomes predicted by shoulder dystocia

Shoulder dystocia

Outcomes No Yes Odds ratio (95% CI) P-­value

Apgar ≤3 at five minutes 0.2% (72/45 292) 0.8% (21/2531) 5.25 (3.23–8.56) <0.001
Acidosis† 5.0% (2290/45 481) 14.1% (359/2540) 3.10 (2.76–3.50) <0.001
NICU 4.6% (2109/45 481) 13.4% (339/2540) 3.17 (2.80–3.58) <0.001
Neonatal death 0.05% (23/45 421) 0.08% (2/2534) 1.56 (0.37–6.62) 0.55
Composite neonatal outcome 8.9% (4035/45 481) 23.9% (607/2540) 3.23 (2.93–3.55) <0.001
Brachial plexus injury 0% 1.4% (36/2540) NA NA
Fracture 0% 0.9% (25/2540) NA NA
Head and neck trauma 0% 7.6% (193/2540) NA NA
Other cutaneous trauma 0% 0.9% (24/2540) NA NA
Perineal trauma
3rd/4th degree 1.9% (872/45 470) 3.6% (92/2540) 1.92 (1.54–2.39) <0.001
Episiotomy 9.3% (4227/45 470) 16.9% (429/2540) 1.98 (1.78–2.21) <0.001
Other 18.8% (8563/45 470) 25.1% (638/2540) 1.45 (1.32–1.59) <0.001
PPH (≥1000 mL) 2.4% (1073/45 391) 5.2% (133/2538) 2.28 (1.90–2.75) <0.001
Admission >7 days 9.3% (3360/36 304) 13.6% (287/2109) 1.54 (1.36–1.76) <0.001
Maternal composite outcome 4.4% (1977/45 481) 8.6% (219/2540) 2.08 (1.79–2.40) <0.001

NICU, neonatal intensive care unit; PPH, post-­partum haemorrhage.

Neonatal composite outcome: acidosis, NICU admission, death, Apgar score ≤3 at five minutes.
Maternal composite outcome: 3/4th degree perineal tear, admission > 7 days, PPH.
The denominators vary because of the number of non-­recorded data.
†Defined as pH ≤ 7.0 or lactate >6 mmol/L or base excess <−12 mmol/L.

risk factors (IOL, prolonged second stage and instrumental

­delivery) and demonstrate the risk is highest if an instrumental
delivery is required.
We correlated shoulder dystocia with severe neonatal out-
comes and again demonstrate that the risk of birth in very poor
condition was not only significantly increased overall (OR 3.23, 95%
CI 2.93–3.55, P < 0.001) but have also categorised the increased
odds with the type of manoeuvre required. Similar risk calcula-
tions have also been presented for maternal morbidity. Our study
differs from other publications in that we have investigated the
risk of severe neonatal outcome expressed as a composite mea-
sure, which is more likely to be correlated with adverse long-­term
complications such as cerebral palsy. Similar to other published
studies, our results indicate that when additional manoeuvres to
McRoberts’ are used, there is a significant risk of maternal and/or
neonatal complications.5,6,10,12
The reported incidence of BPI in other studies is 2.3–16%,1,4
which is significantly higher than that noted in our study (1.4%).
The rates of fractures and soft tissue injury are also lower in our
study.4 We specifically describe the odds of injury according to the
type of manoeuvres used and show that the risk of injury is higher
with internal rotational manoeuvres and delivery of the posterior
arm compared to McRoberts’. This is in contrast to results pre-
sented by Gurewitsch et al.,7 which found that the least amount
of brachial plexus tension and traction occurred with internal
­rotational manoeuvres.
Strengths and limitations
The strengths of our study are the large cohort from a single
centre with consistent intrapartum guidelines, regular training
of obstetric caregivers to deal with this complication, and the
specific calculation of risks according to the type and number
of manoeuvres required. There are also several potential limita-
tions in our study. This was a retrospective study using previous
prospectively collected data, which has its inherent limitations.
First, errors in coding are a potential source of bias with some
data entered incorrectly or inconsistently. We were also unable
to stratify outcomes according to the method of, or the indica-
tion for, induction. Our assumption that if additional manoeuvres
were used, this was always after McRoberts’ with suprapubic
pressure had failed, although reasonable, may not necessarily
always be correct. We are also assuming that only those ma-
noeuvres documented were used, when in actual fact multiple
attempts could have been used and thus increasing the risk of
injury. We also accept that a combination of manoeuvres over
and above McRoberts’/suprapubic pressure may have been used
but are unable to accurately ascertain this. Furthermore, we were
also unable to report on head-­to-­body-­delivery time and which
actual internal manoeuvres were used due to inconsistent re-
porting. Analysing the type of internal manoeuvres used and its
correlation between number and outcome may be an area for
future consideration.
 6

TABLE 4 Maternal and neonatal outcomes predicted by type of manoeuvre

McRoberts’/suprapubic
Outcomes pressure P-­value Internal rotation P-­value Posterior arm P-­value Other P value

Apgar score ≤3 at five 3.56 (1.88–6.72) <0.001 10.83 (2.63–44.66) 0.001 11.81 (5.10–27.37) <0.001 9.44 (2.29–38.89) 0.002
minutes†
Acidosis† 3.24 (2.84–3.70) <0.001 2.34 (1.31–4.16) 0.004 3.38 (2.49–4.58) <0.001 1.34 (0.68–2.63) 0.40
NICU† 2.77 (2.40–3.19) <0.001 4.71 (2.96–7.51) <0.001 5.36 (4.09–7.02) <0.001 2.94 (1.76–4.89) <0.001
Neonatal death† 1.01 (0.14–7.48) 0.99 NA NA 14.62 (1.96–109.04) 0.009
Composite neonatal 3.06 (2.74–3.41) <0.001 3.82 (2.54–5.74) <0.001 4.49 (3.54–5.69) <0.001 2.43 (1.58–3.72) <0.001
outcome†
Brachial plexus injury‡ 3.40 (1.14–10.11) 0.03 3.35 (1.59–7.06) 0.001 0.72 (0.10–5.39) 0.75
Fracture‡ 1.68 (0.21–13.20) 0.62 6.83 (2.88–16.22) <0.001 7.99 (2.15–29.64) 0.002
Head and neck 1.52 (0.84–2.78) 0.17 1.01 (0.65–1.57) 0.96 0.77 (0.37–1.60) 0.48
trauma‡
Perineal trauma
3rd/4th degree† 2.92 (2.23–3.83) <0.001 3.43 (1.25–9.39) 0.02 2.38 (1.3–4.35) 0.01 0.67 (0.16–2.78) 0.58
Episiotomy† 2.99 (2.54–3.51) <0.001 1.98 (0.97–4.06) 0.06 1.96 (1.35–2.85) <0.001 0.34 (0.13–0.88) 0.03
Other† 2.15 (1.85–2.50) <0.001 2.24 (1.23–4.08) 0.01 1.36 (0.97–1.92) 0.08 0.34 (0.17–0.69) 0.003
PPH ≥1000 mL§ 2.30 (1.87–2.83) <0.001 2.60 (1.21–5.60) 0.01 2.39 (1.48–3.86) <0.001 1.59 (0.65–3.89) 0.31
Admission > 7 days§ 1.51 (1.31–1.74) <0.001 1.63 (0.91–2.94) 0.10 1.96 (1.42–2.72) <0.001 0.79 (0.32–1.97) 0.61
Composite maternal 2.07 (1.77–2.45) <0.001 2.26 (1.21–4.21) 0.01 2.29 (1.58–3.32) <0.001 1.38 (0.67–2.81) 0.39
outcome†

†Reported as relative risk ratio.

‡Comparator: McRoberts’ manoeuvre.
§Reported as odds ratio.
NICU, neonatal intensive care unit; PPH, post-­partum haemorrhage.
Outcomes following shoulder dystocia
F. Michelotti et al.
Interpretation
Complications secondary to shoulder dystocia make up to
11% of all obstetric claims.16 According to the National Health
Service Litigation Authority in the United Kingdom (UK) al-
most 250 shoulder dystocia claims were made between 2000
and 2010 with an estimated value of over £100 million.17 The
recent landmark UK Supreme Court judgment (Montgomery
vs Lanarkshire) of a case of shoulder dystocia has resulted in
18
changes to UK medical practice. Doctors are now legally re-
quired to inform patients of all associated risks, regardless of
their significance, and of any reasonable alternative treatment
options18 which in the case of shoulder dystocia would generally
be elective caesarean section.
Given the potential for severe neonatal and maternal mor-
bidity as well as the significant medico-­legal implications, it is
essential to recognise high-­risk patients, although this remains a
challenge due to the poor predictive value of antenatal and in-
trapartum risk factors. Fetal weight is often used as a measure
of risk stratification. However, as up to 70–90% of macrosomic
infants deliver with no complications,4,19 the use of macrosomia
as a predictor is somewhat limited and further compounded by
the inherent limitation of late pregnancy ultrasound fetal weight
estimation.1,12,16 Therefore, considering the relatively poor predic-
tive value of antenatal and intrapartum risk factors, complete pre-
vention of shoulder dystocia is probably not realistic. Instead, the
focus should be on appropriate counselling of high-­risk women,
enhancing surveillance during the second stage, ensuring the
availability of well-­trained staff at delivery and minimising exces-
sive traction on the fetal neck. Counselling, especially in cases of
suspected macrosomia should focus on the risks of and alterna-
tives to, vaginal birth and induction at or near term, particularly
as recent evidence suggests early term induction significantly re-
duces the risk of shoulder dystocia and neonatal fractures.20–22
Clearly, the neonatal consequences of early term birth need to
be considered when deciding timing of delivery and the parents
made aware of the possible short and longer-­term complications.
Elective caesarean should be offered with an estimated fetal
weight of >5000 g in non-­diabetics and >4500 g in diabetics in ac-
cordance with national guidelines and consensus opinions.23
The impact of shoulder dystocia simulation training on ma-
ternal and neonatal outcome is a controversial area with mixed
evidence. Currently, in the UK the Clinical Negligence Scheme
for Trusts mandates shoulder dystocia training.24 It is possible
that training is helpful in reducing adverse outcomes by simply
addressing areas of weakness and creating an effective multi-
disciplinary environment. A large trial reported that following
training, the number of staff able to competently manage severe
shoulder dystocia within five minutes increased from 43 to 84%.25
There is also evidence that a significant reduction in obstetric
BPIs,24,26 shorter head-­to-­body-­delivery times27 and less traction
on the fetal neck28,29 can be achieved. However, contrary to this,
are results by Kim et al.30 who reported an increase in shoulder
7
dystocia numbers post-­training with no decrease in the number
of reported birth injuries, PPH or cases of perineal trauma. These
findings are significant and highlight that training alone may be
insufficient. Instead, training should be combined with risk strat-
ification, counselling and enhanced labour surveillance in an at-
tempt to reduce the occurrence of shoulder dystocia.
Our findings are important as they provide detailed informa-
tion about specific maternal and neonatal complications specific
to the type and number of manoeuvres. We also clearly show an
increased risk of shoulder dystocia with increasing fetal weight,
diabetes and maternal obesity. This information can be used to
identify women at increased risk for shoulder dystocia, in order
to provide enhanced prenatal counselling. This may be more rele-
vant in high-­income countries where the imperative for better risk
stratification of women prior to birth is clear, given the increasing
focus on lifelong disease burden from acquired hypoxic injury and
permanent BPI. As highlighted by the outcome of the Montgomery
case, it is vital that women are counselled appropriately and alter-
nate delivery options clearly discussed and documented.
A U T H O R C O NT R IB U T IO NS
All authors listed contributed to the project. The project was con-
ceived by SK. Data were cross-­referenced for accuracy by FM, with
CF performing statistical analysis. FM and SK drafted the initial
manuscript, with subsequent revisions by all authors. All authors
have approved this manuscript.
REFERENCES
1. Royal College of Obstetricians and Gynaecologists. Green-
top guideline No. 42, Shoulder Dystocia, 2012. [Accessed 28
December 2016.] Available from URL: http://www.nhsla.com/
safety/Documents/Shoulder%20Dystocia%20-%2017.pdf
2. Sokol RJ, Blackwell SC, Bulletins-Gynecology ACoOaGCoP. ACOG
practice bulletin: Shoulder dystocia. Int J Gynaecol Obstet 2003; 80:
87–92.
3. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dysto-
cia. Obstet Gynecol 1985; 66: 762–768.
4. Gherman RB, Chauhan S, Ouzounian JG et al. Shoulder dystocia:
the unpreventable obstetric emergency with empiric manage-
ment guidelines. Am J Obstet Gynecol 2006; 195: 657–672.
5. Hoffman MK, Bailit JL, Branch DW et al. A comparison of obstet-
ric maneuvers for the acute management of shoulder dystocia.
Obstet Gynecol 2011; 117: 1272.
6. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia:
an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol
1993; 168: 1732–1739.
7. Gurewitsch ED, Kim EJ, Yang JH et al. Comparing McRoberts’ and
Rubin’s maneuvers for initial management of shoulder dystocia:
an objective evaluation. Am J Obstet Gynecol 2005; 192: 153–160.
8. National Collaborating Centre for Women’s and Children’s Health
(Great Britain), National Institute for Health and Clinical Excellence
(Great Britain). Intrapartum Care: Care of Healthy Women and Their
Babies During Childbirth. London: RCOG Press, 2007.
9. Australia’s mothers and babies 2014—in brief. Perinatal statis-
tics series no. 32. Cat no. PER 87. Australian Institute of Health and
Welfare Canberra: AIHW, 2016.
8 Outcomes following shoulder dystocia
10. McFarland M, Hod M, Piper JM et al. Are labor abnormalities more
common in shoulder dystocia? Am J Obstet Gynecol 1995; 173:
1211–1214.
11. Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal
macrosomia and prolonged second stage of labor with midpelvic
delivery. Obstet Gynecol 1978; 52: 526–529.
12. Chauhan SP, Rose CH, Gherman RB et al. Brachial plexus injury:
a 23-­year experience from a tertiary center. Am J Obstet Gynecol
2005; 192: 1795–1800.
13. Dodd JM, Catcheside B, Scheil W. Can shoulder dystocia be reli-
ably predicted? Aust N Z J Obstet Gynaecol 2012; 52: 248–252.
14. Mehta SH, Sokol RJ. Shoulder dystocia: risk factors, predictability,
and preventability. Semin Perinatol 2014; 38: 189–193.
15. Stotland NE, Caughey AB, Breed EM, Escobar GJ. Risk factors
and obstetric complications associated with macrosomia. Int J
Gynaecol Obstet 2004; 87: 220–226.
16. Politi S, DʼEmidio L, Cignini P et al. Shoulder dystocia: an evidence-­
based approach. J Prenatal Med 2010; 4: 35.
17. NHS Litigation Authority. Maternity Claims – Information Sheet
17, Shoulder Dystocia, 2010. [Accessed 29 December 2016.]
Available from URL: http://www.nhsla.com/safety/Documents/
Shoulder%20Dystocia%20-%2017.pdf
18. Sizer L, Arnold P. The changing paradigm of the doctor-­patient
relationship: Montgomery v Lanarkshire Health Board and
developments in the ‘duty to warn’. N Z Med J 2015; 129:
71–76.
19. Sandmire H, O’Halloin T. Shoulder dystocia: its incidence and as-
sociated risk factors. Int J Gynecol Obstet 1988; 26: 65–73.
20. Boulvain M, Senat MV, Perrotin F et al. Induction of labour versus
expectant management for large-­for-­date fetuses: a randomised
controlled trial. Lancet 2015; 385: 2600–2605.
21. Boulvain M, Irion O, Dowswell T, Thornton JG. Induction of la-
bour at or near term for suspected fetal macrosomia. Cochrane
Database Syst Rev 2016: CD000938.
22. Magro-Malosso ER, Saccone G, Chen M et al. Induction of labour
for suspected macrosomia at term in non-­diabetic women: a sys-
tematic review and meta-­analysis of randomized controlled trials.
BJOG 2017; 124: 414–421.
23. Bulletins—Obstetrics ACoOaGCoP. Practice Bulletin No. 173:
Fetal macrosomia. Obstet Gynecol 2016; 128: e195–e209.
24. Draycott TJ, Crofts JF, Ash JP et  al. Improving neonatal outcome
through practical shoulder dystocia training. Obstet Gynecol 2008;
112: 14–20.
25. Crofts JF, Bartlett C, Ellis D et  al. Training for shoulder dystocia:
a trial of simulation using low-­fidelity and high-­fidelity manne-
quins. Obstet Gynecol 2006; 108: 1477–1485.
26. Inglis SR, Feier N, Chetiyaar JB et al. Effects of shoulder dystocia
training on the incidence of brachial plexus injury. Am J Obstet
Gynecol 2011; 204: 322.e321–326.
27. Deering S, Poggi S, Macedonia C et al. Improving resident compe-
tency in the management of shoulder dystocia with simulation
training. Obstet Gynecol 2004; 103: 1224–1228.
28. Deering SH, Weeks L, Benedetti T. Evaluation of force applied
during deliveries complicated by shoulder dystocia using simula-
tion. Am J Obstet Gynecol 2011; 204: 234.e231-235.
29. Crofts JF, Bartlett C, Ellis D et al. Management of shoulder dysto-
cia: skill retention 6 and 12 months after training. Obstet Gynecol
2007; 110: 1069–1074.
30. Kim T, Vogel R, Mackenthun S, Das K. Rigorous simulation train-
ing protocol does not improve maternal and neonatal outcomes
from shoulder dystocia. Obstetrics & Gynaecology 2016; 127: 3S.