SE M I N A R S I N P E R I N A T O L O G Y 38 (2014) 184–188

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Shoulder dystocia: Definitions and incidence

Alexandra Hansen, MDa, and Suneet P. Chauhan, MDn,b
a
Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
b
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UT Health Science Center at Houston,
Houston, Texas

article info abstract

Keywords: Though subjective in nature, both the American College of Obstetricians and Gynecologists
Shoulder dystocia practice bulletin and the Royal College of Obstetricians and Gynaecologists green guideline
Diabetes are in agreement on the descriptor of shoulder dystocia: requirement of additional
Operative vaginal delivery obstetric maneuvers when gentle downward traction has failed to affect the delivery of
Guidelines the shoulders. The rate of shoulder dystocia is about 1.4% of all deliveries and 0.7% for
vaginal births. Compared to non-diabetics (0.6%), among diabetics, the rate of impacted
shoulders is 201% higher (1.9%); newborns delivered by vacuum or forceps have 254%
higher likelihood of shoulder dystocia than those born spontaneously (2.0% vs. 0.6%,
respectively). When the birthweight is categorized as o4000, 4000–4449, and 44500 g, the
likelihood of shoulder dystocia in the US vs. other countries varies significantly. Future
studies should focus on lowering the rate of shoulder dystocia and its associated morbid-
ities, without concomitantly increasing the rate of cesarean delivery.
& 2014 Elsevier Inc. All rights reserved.

Shoulder dystocia has been described as unpreventable, Definitions

unpredictable, and an undeniably uncommon1 obstetric
emergency.2 The potential complications for impacted
shoulder include maternal hemorrhage, fourth-degree lacer-
ation, fracture of the clavicle or humerus, temporary or
permanent brachial plexus injury, hypoxic ischemic ence-
phalopathy, and neonatal death.3,4 If the brachial plexus
palsy persists beyond 1 year, there is potential for micro-
surgical reconstruction with financial and quality-of-life
implications5 and, consequently, litigation.6 Thus, there is a
need for understanding of the fundamentals of shoulder
dystocia—definitions and incidence—so clinicians and
researchers alike can ensure that they are discussing the
same morbidity and plan studies, which can reduce the
associated sequela.
The purpose of this review is to ascertain the various
definitions utilized for shoulder dystocia and determine the
incidence of this obstetric emergency.
According to the American College of Obstetrician and Gynecol-
ogists (ACOG) practice bulletin on the topic, the turtle sign,
which is retraction of the fetal head against the perineum, may
assist in the diagnosis of shoulder dystocia.3 The Royal College of
Obstetricians and Gynaecologists (RCOG) in the guideline on the
topic suggests that to anticipate dystocia, with each vaginal
delivery, the clinicians should routinely observe for one of the
following things: difficulty with delivery of the face and chin,
head either tightly applied to the vulva or retracting, failure of
restitution of the fetal head, and failure of the shoulders to
descend.7 Neither of these documents provides evidence that by
observing any one of these phenomena, clinicians can do any-
thing to mitigate the morbidity linked with shoulder dystocia.
Gherman et al.,2 in their review article on the uncommon
obstetric emergency, noted that it is characterized as the failure
of delivery of the fetal shoulder(s), whether it is the anterior,

n
Correspondence to: 825 Fairfax Ave, Suite 544, Norfolk, VA 23507-1914.
E-mail address: chauhasp@evms.edu (S.P. Chauhan).

http://dx.doi.org/10.1053/j.semperi.2014.04.002
0146-0005/& 2014 Elsevier Inc. All rights reserved.
 S E M I N A R S I N P E R I N A T O L O G Y 38 (2014) 184–188 185

Table 1 – Definitions of shoulder dystocia.

Definitions ACOG PB RCOG GG

1 Tight shoulders No No
2 Any difficulty in extracting the shoulders after delivering the head No No
3 Clinical judgment No No
4 Failure of shoulder delivery after downward traction Yes Yes
5 Deliveries requiring maneuvers in addition to gentle downward traction on the fetal head to affect delivery Yes Yes
6 Time interval of Z60 s from delivery of the head to the delivery of the body No No

ACOG PB, American College of Obstetricians and Gynecologists practice bulletin3; RCOG GG, Royal College of Obstetricians and Gynaecologists
Green guideline.7
Adapted with permission from Gherman et al.2

posterior, or both fetal shoulders. They culled the literature and

provided 6 definitions that researchers have used. We exam-
ined the ACOG and RCOG guidelines3,7 on the topic and noted
that they acknowledge only 2 of the 6 definitions. Among these
6 definitions of shoulder dystocia, only 1 is objective: time
interval of Z60 s from delivery of the head to delivery of the
body.8 Though, objective definitions should be preferred over
subjective descriptors, neither of the national guidelines
accepted it. Thus, based on the fact that ACOG and RCOG
concur, we suggest that clinicians and researchers alike use the
following definition: shoulder dystocia is requirement of “addi-
tional obstetric maneuvers” when “gentle downward traction”
has “failed” to affect the delivery of the shoulders (Table 1).
Incidence
The practice bulletin notes that shoulder dystocia may compli-
cate up to 1.4% of vaginal births.3 The incidence of this obstetric
emergency, according to RCOG, is 0.6% among an unselected
population in the United Kingdom and in North America.7
Gherman et al.2 summarized 18 articles that published on the
incidence and noted that it ranged from 0.2% to 16%, a relative
difference of 7900%. Thus, to better gauge the incidence, we
reviewed the literature for this review. We included publications
in English language that were cited in PubMed and published
between 1985 and 2012 (Table 2). While this search may not be

Table 2 – Incidence of shoulder dystocia with total births.

Ref Country Published Study period Total births SD SD/total births (%)

9
Soni et al. Libya 1985 1983 7829 11 0.1
Jennett et al.10 USA 1992 1977–1990 57,597 472 0.8
Nocon et al.11 USA 1993 1986–1990 14,297 185 1.5
Gonen et al.12 Israel 1996 1994–1995 4480 92 2.3
Bahar13 Kuwait 1996 1989 13,756 160 1.2
Gherman et al.14 USA 1997 1991–1995 58,565 303 0.5
Ecker et al.15 USA 1997 1985–1993 77,616 919 1.2
Gherman et al.16 USA 1998 1991–1995 58,565 303 0.5
Turrentine and Ramirez17 USA 1999 1996–1998 3008 45 1.5
Olugbile and Mascarenhas18 United Kingdom 2000 1991–1995 28,932 134 0.6
Kees et al.19 Israel 2001 1996–1999 24,000 56 0.2
Gudmundsson et al.20 Sweden 2005 1990–1996 16,743 56 0.4
Mollberg et al.21 Sweden 2005 1987–1997 1,213,987 1577 0.1
Gurewitsch et al.22 USA 2006 1993–2004 20,478 385 2.4
Chauhan et al.1 USA 2007 2000–2004 41,200 624 2.1
MacKenzie et al.23 United Kingdom 2007 1991–2005 95,321 514 0.6
Ford et al.24 USA 2007 1998–2002 299,130 4626 1.5
Backe et al.25 Norway 2008 1991–2000 30,574 178 0.6
Draycott et al.26 United Kingdom 2008 1996–1999; 2001–2004 39,220 586 2.0
Foad et al.27 USA 2008 1997, 2000, and 2003 11,555,823 30,814 0.3
Melendez et al.28 United Kingdom 2009 2000–2006 21,376 182 0.9
Grobman et al.29 USA 2011 2205–2006 14,812 254 1.7
Inglis et al.30 USA 2011 2003–2009 18,677 158 1.3
Walsh et al.31 Ireland 2011 2004–2008; 1994–1998 77,624 451 0.7
Paris et al.32 USA 2011 1998–2009 94,842 953 1.4
Ouzounian et al.33 USA 2012 1995–2004 16,071 221 1.6
Tsuret et al.34 Israel 2012 1988–2010 240,189 451 0.2
Overland et al.35 Norway 2012 1967–2006 1,914,544 13,109 0.7
16,059,256 57,819 0.4

Ref, reference; SD, shoulder dystocia.

186 SE M I N A R S I N P E R I N A T O L O G Y 38 (2014) 184–188

exhaustive, it should provide better granularity than done thus
far.
We identified 28 articles that provided the rate of total
births and the incidence of shoulder dystocia.1,9–35 With over
16 million births, the rate of impacted shoulder was 0.4%
(57,819/16,059,256; Table 2). When these 28 publications were
segregated by whether published in the United States1,10,11,14–
17,22,24,27,29,30,32,33
vs. other countries,9,12,13,18–21,23,25,26,28,31,34,35

Table 3 – Incidence of shoulder dystocia with vaginal births.

SD/vaginal
Ref Country Published Study period Vaginal births SD births (%)

Chauhan et al.1 USA 2007 2000–2004 29,621 624 2.1

Nocon et al.11 USA 1993 1986–1990 12,532 185 1.5
Gonen et al.12 Israel 1996 1994–1995 3985 92 2.3
Gherman et al.16 USA 1998 1991–1995 50,114 303 0.5
Olugbile and Mascarenhas18 United Kingdom 2000 1991–1995 24,100 134 0.6
Gudmundsson et al.20 Sweden 2005 1990–1996 15,594 56 0.4
Gurewitsch et al.22 USA 2006 1993–2004 15,891 385 2.4
MacKenzie et al.23 United Kingdom 2007 1991–2005 79,781 514 0.6
Draycott et al.26 United Kingdom 2008 1996–1999; 2001–2004 29,025 586 2.0
Inglis et al.30 USA 2011 2003–2009 11,862 158 1.3
Walsh et al.31 Ireland 2011 2004–2008; 1994–1998 66,098 451 0.7
Paris et al.32 USA 2011 1998–2009 67,949 953 1.4
Ouzounian et al.33 USA 2012 1995–2004 13,998 221 1.6
Tsur et al.34 Israel 2012 1988–2010 240,189 451 0.2
Overland et al.35 Norway 2012 1967–2006 1,914,544 13,109 0.7
2,575,283 18,222 0.7

Ref, reference; SD, shoulder dystocia.

Table 4 – Shoulder dystocia among non-diabetics and diabetics.

Ref Country Published SD Non-DM and SD DM and SD

Chauhan et al.1 USA 2007 624 90% (562) 10% (62)

Nocon et al.11 USA 1993 185 94% (174) 6% (11)
Gherman et al.16 USA 1998 285 65% (185) 35% (100)
Draycott et al.26 United Kingdom 2008 586 99% (579) 1% (7)
Grobman et al.29 USA 2011 254 92% (233) 8% (21)
Ouzounian et al.33 USA 2012 221 80% (176) 20% (45)
Tsur et al.34 Israel 2012 451 85% (383) 15% (68)
Overland et al.35 Norway 2012 13,109 97% (12,767) 3% (342)
15,715 96% (15,059) 4% (656)

Ref, reference; SD, shoulder dystocia; DM, diabetes mellitus (gestational and pre-gestational).

Table 5 – Shoulder dystocia with spontaneous vs. operative vaginal delivery.

Ref Country Published SD SD with SVD SD with OVD

Chauhan et al.1 USA 2007 624 84% (523) 16% (101)

Gherman et al.16 USA 1998 303 90% (272) 10% (31)
Kees et al.19 Israel 2001 56 59% (33) 41% (23)
Gurewitsch et al.22 USA 2006 385 69% (265) 31% (120)
MacKenzie et al.23 United Kingdom 2007 514 65% (332) 35% (182)
Draycott et al.26 United Kingdom 2008 586 75% (442) 25% (144)
Grobman et al.29 USA 2011 254 75% (191) 25% (63)
Inglis et al.30 USA 2011 158 92% (145) 8% (13)
Ouzounian et al.33 USA 2012 221 92% (203) 8% (18)
Tsur et al.34 Israel 2012 451 88% (395) 12% (56)
Overland et al.35 Norway 2012 13,109 79% (10,391) 21% (2718)
16,661 79% (13,192) 21% (3469)

Ref, reference; SD, shoulder dystocia; SVD, spontaneous vaginal delivery; OVD, operative (vacuum or forceps) vaginal delivery.
 S E M I N A R S I N P E R I N A T O L O G Y 38 (2014) 184–188 187

other countries (Ireland, Israel, Norway, Sweden, and United

Fig – Birthweight of newborns with shoulder dystocia.
the rates were 0.3% (40,262/12,330,681) and 0.5% (17,557/
3,728,575), respectively. To assess the contemporary rate of
shoulder dystocia in the United States, we focused on 8
publications1,24,27,29,30,32,33 after 2000, and in these reports,
the incidence was 0.3% (38,035/12,061,033) of total births. But
this rate is substantially influenced by a publication by Foad
et al.,27 with over 11 million births and based on a database of
ICD codes, with inherent shortcomings.36 Thus, excluding
this singular publication, the rate of shoulder dystocia, based
on 7 publications since 2000 in the US, is 1.4% (7,221/505,210)
of all births and is consistent with the ACOG bulletin.3
We also ascertained the rate of shoulder dystocia with vaginal
births because, by definition, it does not occur with cesarean
delivery (Table 3). Among the 15 publications1,11,12,16,18,20,22,23,26,30–35
that provided the incidence of shoulder dystocia, the rate was
0.7% (18,222/2,575,283) of vaginal births. When these publica-
tions were segregated into those done in the US vs. other
countries, the rate was substantially different. Among the 7
publications1,11,16,22,30,32,33 from the US, the rate was 1.4%
(2,829/201,967) and for the 8 articles12,18,20,23,26,31,34,35 from
Kingdom), it was 0.6% (15,393/2,373,316) (Table 3).
Both gestational and pre-gestational diabetes are consid-
ered to be risk factors for shoulder dystocia.3 Thus, we ascer-
tained the likelihood of dystocia among non-diabetics and
diabetics. Four studies26,33–35 reported on the incidence among
these 2 groups and the combined results indicate that the rate
is 0.6% (13,905/2,173,795) for non-diabetics and 1.9% (462/
23,961) among diabetics, a relative difference of 201%. Eight
publications1,11,16,26,29,33–35 provided data on what proportion
of newborns with an impacted shoulder were born of diabetics
vs. non-diabetic parturients. Overall, 96% of shoulder dystocia
occurred among non-diabetic women (Table 4).
Since operative vaginal delivery is also considered a risk
factor for shoulder dystocia,3 we ascertained the likelihood of
impacted shoulders when vacuum or forceps are used, as
well as what proportion of dystocias occur with assisted
vaginal births. Of the 6 publications22,23,26,33–35 that provided
data on dystocia with spontaneous vs. operative vaginal
deliveries, the likelihoods were 0.6% (12,028/2,131,475) and
2.0% (3,238/161,953), respectively, a relative difference of
254%. Overall, 11 publications1,16,19,22,23,26,29,30,33–35 provided
data on the proportion of newborns with shoulder dystocia
who were delivered spontaneously vs. with assistance of
forceps or vacuum. Overall, 21% of newborns with shoulder
dystocia had operative vaginal deliveries (Table 5).
With shoulder dystocia, it is often assumed that the newborns
are macrosomic (birthweight of 4000 g or more). We identified 6
publications1,12,21,23,33,35 that categorized the birthweight as
o4000, 4000–4449, or 44500 g. There were over 16,000 cases of
shoulder dystocia in these 6 articles and while 27% were not
macrosomic, 39% of the newborns weighed between 4000 and
4449 g and the remaining 34% weighed at least 4500 g (Table 5).
Surprisingly, the birthweight distribution of newborns with
dystocia varied significantly (p o 0.0001) for the 2 publica-
tions1,33 from the US vs. 4 reports12,21,23,35 from other coun-
tries (Fig.). The possible explanations for this finding include
variation in the definition of shoulder dystocia, indications
and threshold for doing cesarean delivery or trial of labor
after cesarean, and publication bias (Table 6).
Conclusions
Two national guidelines—ACOG and RCOG—define shoulder
dystocia similarly, albeit subjectively. The rate of shoulder

Table 6 – Birthweight of newborns with shoulder dystocia.

Ref Country Published SD BW o 4.0 kg and SD BW 4–4.5 kg and SD BW 4 4.5 kg and SD

1
Chauhan et al. USA 2007 624 65% (407) 26% (164) 8% (53)
Gonen et al.12 Israel 1996 92 50% (46) 43% (40) 7% (6)
Mollberg et al.21 Sweden 2005 1,577 19% (295) 39% (611) 43% (671)
MacKenzie et al.23 United Kingdom 2007 514 38% (197) 39% (200) 23% (117)
Ouzounian et al.33 USA 2012 221 51% (112) 35% (77) 14% (32)
Overland et al.35 Norway 2012 13,109 26% (3344) 39% (5155) 35% (4610)
16,137 27% (4401) 39% (6247) 34% (5489)

Ref, reference; SD, shoulder dystocia; BW, birthweight.

188 SE M I N A R S I N P E R I N A T O L O G Y
dystocia is about 1.4% of all deliveries and 0.7% of all vaginal
births. The likelihood of shoulder dystocia is 201% higher
among diabetics (1.9%) vs. non-diabetics (0.6%) and 254%
higher with operative (2.0%) vs. spontaneous vaginal delivery
(0.6%). For inexplicable reasons at present, compared to other
countries, shoulder dystocia is significantly more likely to
occur among non-macrosomic newborns in the US. Future
studies should focus on innovative ways to decrease the rate
of shoulder dystocia and its associated morbidities, without
concomitantly increasing the cesarean delivery rate.
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