Shoulder Dystocia CK

CLINICAL OVERVIEW
Shoulder Dystocia
Elsevier Point of Care (see details)
Updated August 7, 2023. Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action
When shoulder dystocia is diagnosed, consider notifying those in attendance and request
assistance, instruct mother to stop pushing, and prepare to perform therapeutic maneuvers
Key Points
Shoulder dystocia is defined as a vaginal cephalic delivery requiring additional obstetric maneuvers to
Outline deliver fetus after head has been delivered and gentle traction has failed
Occurs when 1 or both fetal shoulders are obstructed at level of maternal pelvic inlet
Typically results from impaction of anterior fetal shoulder against maternal pubic symphysis owing to
absolute or relative size discrepancy between fetal shoulders and maternal pelvic inlet
Risk factors for shoulder dystocia include prior shoulder dystocia, fetal macrosomia, and maternal diabetes
Have poor prognostic value; most cases occur in absence of identifiable risk factors
Requires prompt recognition and management to avoid significant morbidity or mortality
Diagnosed when clinician is unable to deliver fetal anterior shoulder with gentle downward traction on
fetal head
Requires rapid, ingrained, and coordinated stepwise action plan; various management guidelines and
protocols are available 1 2 3
Immediately upon diagnosis, request assistance (eg, anesthesiologist/anesthetist, neonatal team, additional
nurses, another obstetrician, if indicated), instruct mother to stop pushing, and begin contemporaneous
documentation of management
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Employ maneuvers to disengage fetal shoulder from maternal pelvis
McRoberts maneuver is first maneuver (with or without suprapubic pressure)
Secondary techniques include delivery of posterior arm, rotational maneuvers, and Gaskin all-fours
maneuver
Maneuvers of last resort include Zavanelli technique, intentional fetal clavicular fracture, and
abdominal rescue
Complications include:
Neonatal: brachial plexus palsy, fracture of clavicle and/or humerus, and rarely, hypoxic-ischemic
encephalopathy and death
Maternal: postpartum hemorrhage, perineal lacerations, anal sphincter injuries, and uterine rupture
Shoulder dystocia cannot be accurately predicted or prevented
Consider elective cesarean delivery in select cases of suspected macrosomia or history of prior shoulder
dystocia; discuss risks of surgery with patient
Induction of labor because of suspected fetal macrosomia is not recommended at any gestational age
Pitfalls
Practitioners should be prepared to manage this obstetric emergency at every delivery 3
Although risk factors for shoulder dystocia exist (eg, history of shoulder dystocia), most cases are
encountered in the absence of risk factors
Do not apply fundal pressure in management of shoulder dystocia; it may result in fetal injury or uterine
rupture, and it may exacerbate the impaction
Terminology
Clinical Clarification
Shoulder dystocia is an uncommon, unpredictable, and unpreventable obstetric emergency defined by
inability to deliver the fetal shoulder(s) with standard gentle traction during vaginal cephalic delivery
(Related: Abnormal Labor) 1 2 3
Occurs when 1 or both fetal shoulders become obstructed at level of maternal pelvic inlet
Typically results from impaction of anterior fetal shoulder against maternal pubic symphysis
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Can also result from impaction of posterior shoulder on maternal sacral promontory
Occurs in up to 3% of vaginal deliveries of fetuses presenting in vertex presentation 3
Increases the likelihood of adverse outcomes for mother and fetus and requires prompt recognition and
management to avoid morbidity or mortality
Diagnosis
Clinical Presentation
History
Diagnosis occurs at time of delivery after fetal head has emerged from
vagina
Pertinent antepartum history may include: 4
History of prior shoulder dystocia

Shoulder dystocia. - When delivery
History of gestational diabetes of fetal head is not followed by
delivery of shoulders, anterior
shoulder has often become caught
Birth weight of the largest prior newborn behind maternal pubic symphysis.
Current estimated fetal weight (clinical or sonographic)
Risk factors have poor predictive value
Most shoulder dystocia cases occur in absence of risk factors
Majority of parturients with risk factors do not have shoulder dystocia
Physical examination
Signs of shoulder dystocia may include: 2
Difficulty with delivery of face and chin
Retraction of the delivered fetal head (chin) against the maternal perineum (turtle sign)
This is suggestive, but not diagnostic, of shoulder dystocia 3
Failure of restitution of fetal head (lack of spontaneous realignment of fetal head with shoulders after
delivery of head)
Failure of shoulders to descend
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Causes and Risk Factors
Causes
Results from absolute or relative size discrepancy between fetal shoulders and maternal pelvic inlet
Fetal shoulders may descend in anteroposterior orientation instead of into normal wider, oblique
diameter of maternal pelvis
Typically, anterior shoulder is obstructed by pubic symphysis 3
Less often, posterior shoulder impacts on maternal sacral promontory
Persistent anteroposterior location of fetal shoulders at pelvic brim can occur with: 3
Increased resistance between fetus and vaginal walls (eg, fetal macrosomia)
Large fetal chest relative to biparietal diameter (eg, infants of females with diabetes)
Failure of truncal rotation to occur (eg, precipitous labor)
Risk factors and/or associations
Other risk factors/associations

There are well defined risk factors; however, they have extremely poor predictive value for shoulder
dystocia 3
Clinicians should be aware of risk factors to anticipate problems for patients at high risk for shoulder
dystocia, but most cases occur in absence of identifiable risk factors
Clinicians should be prepared to manage shoulder dystocia in all deliveries
Risk factors include:
Prior shoulder dystocia
Shoulder dystocia in previous pregnancy increases risk in future pregnancy 5
Incidence of recurrence is approximately 10% 3
True incidence is unknown; many physicians and patients choose cesarean delivery over trial of
labor in subsequent pregnancies when there has been a history of complicated delivery or
neonatal injury
Second episode of shoulder dystocia is more likely to be associated with injury to newborn than first
episode 4
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Most subsequent deliveries will not be complicated by shoulder dystocia 3
Increased fetal birth weight
Macrosomia (birth weight of 4000 g or more) 6 increases risk for shoulder dystocia 5
Limited as risk factor by poor predictive value 5
Difficult to accurately predict birth weight (by Leopold maneuvers, maternal assessment, or
ultrasonography)
Accuracy of estimated fetal weight for suspected macrosomia using ultrasonographic biometry
is no better than that obtained with clinical palpation 6
Even when certain ultrasonography characteristics and risk factors for shoulder dystocia are
present, their ability to predict shoulder dystocia is poor 7
Many cases of shoulder dystocia (about 40%-60%) occur in infants weighing less than 4000 g 8
Most macrosomic infants (about 70%-90%), even those weighing more than 5000 g, are delivered
without any long-term sequelae 8
Maternal diabetes (gestational or preexisting)
Increases risk of shoulder dystocia, neonatal clavicular fracture, and neonatal brachial plexus palsy,
regardless of birth weight 6
Maternal diabetes increases the overall risk of shoulder dystocia by 70% 8
In 4 studies, rate of shoulder dystocia was 1.9% for females with diabetes versus 0.6% for those
without 9
Associated with fetal macrosomia 6
Maternal glucose level increases are associated with increases in newborn birth weight
Increased risk of shoulder dystocia in females with diabetes may be due to altered fetal body shape
Compared with macrosomic infants of females without diabetes, macrosomic infants of females
with diabetes tend to have: 6
Greater total body fat
Greater shoulder and upper extremity circumferences
Greater upper extremity skinfold measurements
Smaller head to abdominal circumference ratios
Limited as risk factor by poor predictive value
Although increased birth weight and maternal diabetes are associated with increased risk of
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shoulder dystocia, most cases occur in pregnant patients without diabetes who give birth to infants
of normal weight 3
For the occurrence of shoulder dystocia, diabetes (gestational or preexisting) has a low sensitivity of
7.2% and low positive predictive value of 1.4% 5
Among combined studies, 96% of cases of shoulder dystocia occurred among pregnant patients
without diabetes 9
Other proposed risk factors, alone and in combination, include: 3 4
Antepartum:
Maternal obesity
Multiparity
Gestational age of 41 weeks or more 4
Intrapartum:
Induction of labor
Operative vaginal delivery (use of forceps, vacuum extractor, or other devices to facilitate delivery)
In combined studies, the rate of shoulder dystocia was 2% in operative vaginal deliveries and 0.6%
in spontaneous vaginal deliveries 9
Overall, 21% of newborns with shoulder dystocia had operative deliveries 9
Labor abnormalities
No labor pattern has been found to be predictive of shoulder dystocia 3
Combination of individual risk factors for prolonged second stage (eg, increased birth weight) and
interventions that may occur in setting of prolonged second stage (eg, midpelvic operative delivery)
is associated with increased risk of shoulder dystocia 3
Epidural anesthesia
Diagnostic Procedures
Primary diagnostic tools

Diagnosed during delivery when clinician is unable to deliver fetal anterior shoulder with gentle
downward traction on fetal head 10
Routine traction (ie, that used in routine vaginal delivery) in axial direction is used; avoid any other
traction 2
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Requires additional obstetric maneuvers (eg, McRoberts, Rubin, Woods), in addition to gentle
downward traction on fetal head, to accomplish delivery 9
Time is not a component of the diagnosis 9
Turtle sign (ie, retraction of fetal head against perineum) suggests, but is not diagnostic of, shoulder
dystocia 3
Treatment
Goals
Accomplish vaginal delivery
Minimize time from delivery of fetal head to delivery of remainder of

body
Prevent fetal asphyxia, neonatal brachial plexus palsy, and neonatal death
McRoberts maneuver. - The least
Minimize maternal and fetal injury invasive maneuver to disimpact the
shoulders is the McRoberts
maneuver. Sharp ventral flexion of
the maternal hips results in ventral
Disposition rotation of the maternal pelvis and
an increase in the useful size of the
outlet.
Recommendations for specialist referral
Urgent assistance from multiple disciplines is often required (eg,
anesthesiologist/anesthetist, neonatal team, additional nurses, another
obstetrician)
Treatment Options
Manage systematically with rapid, ingrained, and coordinated stepwise Axial traction. - Gentle, symmetric
action plan 11 pressure on the head will move the
posterior shoulder into the hollow
1 2 3 of the sacrum and will encourage
Various management guidelines and protocols are available
delivery of the anterior shoulder.
Care should be taken not to “pry”
No randomized clinical trials have compared maneuvers to alleviate the anterior shoulder out
shoulder dystocia asymmetrically because this might
lead to trauma to the anterior
Management may vary based on individual clinical situation brachial plexus.
However, regardless of management strategies and maneuvers used,

maternal and infant complications are unpredictable and may be
unavoidable 3
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All maneuvers can increase stretch of brachial plexus
Immediate steps to take on diagnosis 2 3
Request help (eg, anesthesiologist/anesthetist, neonatal team, additional Delivery of posterior arm. - By
nurses, another obstetrician) passing 1 hand into vagina along
posterior fetal arm, practitioner may
flex that arm until forearm may be
Remain calm and communicate situation
gripped and swept across fetal chest,
delivering posterior arm and
Instruct mother to stop pushing shoulder.
Can exacerbate impaction of fetal shoulders
Allows some time to prepare for further maneuvers
Begin contemporaneous documentation of management
Note time of diagnosis, maneuvers, and delivery
Checklists or standardized documentation forms are suggested 12 3
Rubin II maneuver. - This maneuver

Position patient so that clinician has adequate access for performing involves applying pressure to the
maneuvers most accessible part of the fetal
shoulder (ie, either the anterior or
Typically, patient supine with buttocks at edge of bed posterior shoulder) to effect
shoulder adduction (A). B, Curved
3 arrows shows rotation of fetal
If traction forces are applied, use axial traction only
shoulders.
Axial traction is applied in alignment with fetal spine and with

downward component (typically along vector 25°-45° below horizontal
plane with patient in lithotomy position) 3
Avoid lateral traction as sole maneuver to effect delivery, in absence of

ancillary obstetric maneuvers
Perform maneuvers to disengage impacted shoulder(s) from maternal pelvis
Perform McRoberts maneuver first 3 11

Gaskin all-fours maneuver. -
Exploits the effects of gravity and
Simple, noninvasive, and effective technique increased space in hollow of sacrum
to facilitate delivery of posterior
Method shoulder and arm.
2 assistants each grasp a maternal leg and sharply flex thigh back
against abdomen (hyperflexion) 13
Causes cephalad rotation of pubic symphysis and flattening of lumbar lordosis, which may free
impacted shoulder
Often combined with suprapubic pressure 2 3
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Assists in disengaging the impacted shoulder
Assistant applies external pressure with palm or fist just above pubic bone (suprapubic) from side of
fetal back
Direct pressure on fetal anterior shoulder both downward (to below pubic bone) and laterally
(toward fetal face or sternum)
Rotates the anterior fetal shoulder into wider oblique pelvic diameter
Do not apply fundal pressure; it may exacerbate the impaction, cause fetal injury, and result in
uterine rupture
Apply gentle, routine axial traction to assess if anterior shoulder is released
If unsuccessful, attempt to deliver posterior arm 3 14
Next suggested maneuver based on American College of Obstetricians and Gynecologists consensus and
expert opinion 3
Posterior arm delivery reduces diameter of fetal shoulders by width of that arm; 2 maneuver has a high
degree of success 3
Method 15
Place hand in vagina and trace posterior fetal arm from shoulder to elbow
Vaginal access with whole hand is best gained posteriorly into sacral hollow, the most spacious area
of pelvis
Apply pressure at antecubital fossa to flex fetal forearm, if needed, to reach fetal wrist
Grasp fetal wrist/forearm, gently sweep it across fetal chest, and deliver arm out of vagina in a straight
line
Consider episiotomy if additional internal vaginal access is needed to facilitate delivery of posterior arm
and possible subsequent maneuvers (eg, internal rotation of shoulders) 2 3
Routine use not indicated
Episiotomy alone does not relieve bony impaction or decrease risk of brachial plexus palsy
Internal rotational maneuvers of neonatal shoulder may be used instead of, or after, unsuccessful posterior
arm delivery attempt 3
Rubin maneuver
Insert 1 hand vaginally behind posterior aspect of most accessible (anterior or posterior) fetal
shoulder and rotate shoulder toward fetal chest 15
Adducts fetal shoulder girdle and reduces its diameter
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Woods screw maneuver
Rotate fetus by exerting pressure on anterior clavicular surface of posterior shoulder, turning fetus
until anterior shoulder emerges from behind maternal pubic symphysis 15
Attempts to rotate fetal torso about 180° to allow shoulder descent
Other secondary maneuvers
Gaskin all-fours maneuver 16
Consider for females without anesthesia 3 who are mobile 2
May be useful option in community setting
Method
Position patient on hands and knees
Apply gentle downward traction on posterior shoulder (against maternal sacrum) or upward
traction on anterior shoulder
Allows gravitational forces to push posterior shoulder anteriorly
Posterior axilla sling traction 3 17
Recently described technique; reserved for cases in which more commonly used methods have been
unsuccessful
Thread 12- or 14-French soft catheter around posterior shoulder to create a sling
Apply moderate traction to sling to allow shoulder to be delivered
Experimental extraction device 18
Under investigation currently and not available for clinical use; single-use device for extraction of
fetal shoulders
Use to mimic the mechanism of action of the most common maneuvers to dislodge impacted
shoulder
If these maneuvers are initially unsuccessful, they may be repeated 3
No association between maneuver chosen and neonatal injury (after adjusting for duration) 3
All maneuvers can increase stretch on brachial plexus; neonatal injury can occur regardless of
procedure chosen
Base decision on training, clinical experience, and prevailing circumstances 2
For severe shoulder dystocia not responsive to standard measures, aggressive approaches may be warranted
3
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Consider heroic, last-resort maneuvers after evaluating potential significant maternal and fetal risks 15
There is no clearly established time point at which irreversible brain injury can be predicted 8
Risk of fetal hypoxic-ischemic injury is very low with head to body delivery interval up to 5 minutes 2
19
May be reasonable to consider extraordinary measures to effect delivery once 4 to 5 minutes have
elapsed and fetus remains undelivered 15
Maneuvers of last resort include:
Zavanelli maneuver (rarely used) 3
Vaginal replacement of fetal head followed by cesarean delivery
Rotate fetal head back to direct occiput anterior position
Flex head and use constant, firm pressure to push head back into vagina; hold until cesarean
delivery is accomplished
Uterine relaxant is often required
Associated with high risk of fetal morbidity and mortality and maternal morbidity 3
Intentional fetal clavicular fracture 3
Pulling anterior clavicle outward to help decrease bisacromial diameter
Difficult to perform and associated with neonatal injury to underlying structures
Abdominal rescue 3 20
Laparotomy and hysterectomy to manually dislodge anterior shoulder from above, then effect
vaginal delivery
Nondrug and supportive care

Documentation
Contemporaneous documentation of management of shoulder dystocia is recommended to record

significant facts and observations regarding the event and its sequelae 3
Aids in:
Accurately informing patients and future health care professionals concerning delivery events
Counseling patients regarding future risks
Items to document include: 15
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Type of delivery; if instrumental, document station and indication
Time interval between delivery of fetal head and body
Which shoulder was anterior and which was posterior
Timing and sequence of maneuvers performed including episiotomy
Timing, duration, and angle of traction applied
Medical and nursing personnel in attendance
Neonatal assessment of infant
Condition of infant:
Apgar scores
Umbilical cord blood gas levels
Evidence of injury
Reduced movement of either arm
Information should be given to patient or family
Standardized forms
Use of a standardized form, in addition to narrative delivery note, can: 12
Ensure accurate and faithful attention to standards
Document that care was provided according to accepted standards
Provide accurate reflection of events that occurred
Improve inclusion of critical elements within medical record
Complications and Prognosis
Complications
Neonatal 3
Risk of neonatal injury increases with number of maneuvers performed 14
Most common 3
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Neonatal brachial plexus palsy
Neonatal brachial plexus palsy is defined as weakness or paralysis

of an upper extremity of a newborn with passive range of motion
greater than active range of motion 21
The rate of neonatal brachial plexus palsy is about 1 in 1000

deliveries, and it is persistent in about 1 in 10,000 births 22 23
Erb palsy. - This infant experienced
Incidence in literature varies from 4% to 40%, possibly owing to shoulder dystocia, resulting in left
variations in definition of shoulder dystocia 24 brachial plexus palsy, affecting C5,
C6, and C7 and resulting in Erb
Shoulder dystocia that occurs in pregnancies complicated by palsy. This injury paralyzed the
diabetes (pregestational or gestational) is more likely to result abductors, external rotators, and
extensors of his left shoulder and
in neonatal brachial plexus palsy 25
injured the flexors and supinators of
his forearm. His arm is adducted
Risk factors exist for neonatal brachial plexus palsy in the setting and internally rotated at the
of shoulder dystocia (diabetes, birth weight of 4000 g or more, shoulder, with pronation and
"call for help" and time longer than 120 seconds from head to extension at the elbow, absent
biceps and brachioradialis tendon
body delivery), but they are not able to predict in a meaningful
jerks, and absent Moro response on
way who will have injury 25 the side of the lesion. Due to
involvement of C7, he manifests
Injury to nerve roots due to stretching or avulsion as they exit wrist drop, with the hand flexed in a
cervical spine "waiter's tip" position and with an
absent triceps jerk.
Ascertaining the etiologies of neonatal brachial plexus palsy is
elusive in part because of the infrequent nature of its
occurrence; lack of objectively differentiating between "gentle" and "excessive" traction; and the
extent to which the head was moved downward, upward, or laterally
Presence of brachial plexus palsy is not evidence that shoulder dystocia occurred 3
About 40% to 50% of neonatal brachial plexus palsy cases are not associated with shoulder
dystocia 24
Injury patterns include: 24
Erb palsy (Duchenne-Erb palsy)
Injury at C5 and C6 (most common; good prognosis) 24
Arm adducted and internally rotated at shoulder
Intermediate (C5-C7)
Additional wrist drop from C7 injury (waiter's tip posture) 24
Klumpke palsy
Isolated injury to C8 and T1 nerve roots (rare)
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Loss of wrist and finger flexion as well as intrinsic hand muscle strength
Entire brachial plexus
Injury from C5 to T1
Arm is flailed and held in neutral position
Fractures of clavicle (most common) and/or humerus
Occur in approximately 10% of cases of shoulder dystocia 24
Less common 3
Diaphragmatic paralysis (C3 and C4 injury)
Horner syndrome (stellate ganglion disrupted)
Facial nerve injuries
Rare
Hypoxic-ischemic encephalopathy
Shoulder dystocia can prohibit adequate respiration, and compression of umbilical cord can
compromise fetal circulation
Mean time of delivery between head and rest of body in a large, retrospective study was 10.75
minutes (range, 3-20 minutes); all cases reported 5 or more maneuvers 14
Risk increases with head to body delivery time of more than 5 minutes 24
Death
Estimated average fetal mortality rate: 0.4% to 0.5% of deliveries complicated by shoulder dystocia
24
Maternal 3
Maternal morbidity occurs in up to 14.7% of deliveries with shoulder dystocia 26
Most common complications 3 24 26
Increased risk of postpartum hemorrhage (Related: Postpartum Hemorrhage)
Higher degree of perineal lacerations (eg, fourth-degree lacerations)
Other complications
Obstetric anal sphincter injuries
Symphyseal separation and lateral femoral cutaneous neuropathy due to aggressive hyperflexion of
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maternal legs
Uterine rupture
Prognosis
Maneuvers to disengage impacted fetal shoulder from maternal pelvis are generally successful and most
cases are relieved without injury to fetus 3
Use of McRoberts maneuver, with or without suprapubic pressure, has been found to relieve about two-
thirds of cases (in 2 large studies) 4
Use of 3 maneuvers (McRoberts, delivery of posterior arm, rotational maneuver) relieves 95% of cases of
shoulder dystocia within 4 minutes 27
Shoulder dystocia simulation and team training protocols may improve communication, use of obstetric
maneuvers, and documentation of events 3 4
While some studies have found a decreased incidence of neonatal brachial plexus palsy with team
training interventions, a systematic review on the effect of simulation exercises on shoulder dystocia
revealed conflicting results 28
Those studies that did show that a decrease in rates of neonatal brachial plexus palsy were
confounded by an increase in both detection of shoulder dystocia and rates of cesarean delivery
Data on the persistence of neonatal brachial plexus palsy at 12 months are contradictory and limited
Universal training of all staff who participate in and perform deliveries would be a large time and
resource burden without proven benefit
Screening and Prevention
Prevention
Shoulder dystocia cannot be accurately predicted or prevented 3
Maternal hyperglycemia should be controlled to decrease risk of fetal macrosomia 6
In cases of suspected fetal macrosomia (estimated fetal weight of at least 4000 g), the following measures
have been evaluated for prevention of shoulder dystocia:
Induction of labor
Induction of labor solely because of suspected fetal macrosomia before 39 weeks of gestation is not
recommended 6
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Does not improve maternal or fetal outcomes 6
Based on the ARRIVE trial, induction at 39 weeks of gestation may be considered 29
Elective cesarean delivery
Most fetuses with macrosomia can be delivered vaginally without resultant shoulder dystocia
Strategies to identify pregnant patients at risk for shoulder dystocia so that prophylactic cesarean
delivery can be considered have poor sensitivity and specificity 14
American College of Obstetricians and Gynecologists suggests considering elective cesarean delivery
in cases of suspected macrosomia and estimated fetal weight as follows: 3
At least 5000 g for pregnant patients without diabetes
At least 4500 g for pregnant patients with diabetes
Risks associated with cesarean delivery should also be considered and discussed
For pregnant patients with a known earlier history of shoulder dystocia, consider the following issues:
Ensure history of shoulder dystocia is known to the individual and the health care professionals during
subsequent pregnancy
Careful delivery planning and shared decision-making are recommended, preferably before the
intrapartum period 3
Discuss prior delivery events with patient
Evaluate patient risk factors
While no reliable factors allow accurate prediction of recurrence, consider: 3
Estimated fetal weight
Gestational age
Maternal glucose intolerance
Severity of prior neonatal injury
Consider cesarean delivery as an option 3
Elective cesarean delivery is not universally recommended for patients with earlier history of shoulder
dystocia 3
Most subsequent deliveries will not be complicated by shoulder dystocia
Discuss potential risks and benefits of cesarean delivery with patient
Base ultimate delivery route decision on available clinical information, future pregnancy plans, and
3 4
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patient preference after proper counseling 3 4
References
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manoeuvres: a retrospective review. BJOG. 118(8):985-90, 2011
28. Wagner SM et al: Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian
meta-analysis. Am J Obstet Gynecol. 225(5):484.e1-484.e33, 2021
29. Grobman WA et al: Labor Induction versus expectant management in low-risk nulliparous women. N Engl J Med.
379(6):513-523, 2018
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Shoulder Dystocia CK

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Shoulder Dystocia CK

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CLINICAL OVERVIEW

Requires prompt recognition and management to avoid significant morbidity or mortality

McRoberts maneuver is first maneuver (with or without suprapubic pressure)

Shoulder dystocia cannot be accurately predicted or prevented

Occurs in up to 3% of vaginal deliveries of fetuses presenting in vertex presentation 3

Pertinent antepartum history may include: 4

History of prior shoulder dystocia

Current estimated fetal weight (clinical or sonographic)

Risk factors have poor predictive value

Most shoulder dystocia cases occur in absence of risk factors

Majority of parturients with risk factors do not have shoulder dystocia

Difficulty with delivery of face and chin

This is suggestive, but not diagnostic, of shoulder dystocia 3

Failure of shoulders to descend

Typically, anterior shoulder is obstructed by pubic symphysis 3

Less often, posterior shoulder impacts on maternal sacral promontory

Failure of truncal rotation to occur (eg, precipitous labor)

Risk factors and/or associations

Other risk factors/associations

Clinicians should be prepared to manage shoulder dystocia in all deliveries

Risk factors include:

Prior shoulder dystocia

Shoulder dystocia in previous pregnancy increases risk in future pregnancy 5

Incidence of recurrence is approximately 10% 3

Increased fetal birth weight

Limited as risk factor by poor predictive value 5

Maternal diabetes (gestational or preexisting)

Maternal diabetes increases the overall risk of shoulder dystocia by 70% 8

Associated with fetal macrosomia 6

Greater total body fat

Greater shoulder and upper extremity circumferences

Greater upper extremity skinfold measurements

Smaller head to abdominal circumference ratios

Limited as risk factor by poor predictive value

Other proposed risk factors, alone and in combination, include: 3 4

Gestational age of 41 weeks or more 4

Overall, 21% of newborns with shoulder dystocia had operative deliveries 9

No labor pattern has been found to be predictive of shoulder dystocia 3

Primary diagnostic tools

Time is not a component of the diagnosis 9

Minimize time from delivery of fetal head to delivery of remainder of

However, regardless of management strategies and maneuvers used,

Immediate steps to take on diagnosis 2 3

Can exacerbate impaction of fetal shoulders

Allows some time to prepare for further maneuvers

Begin contemporaneous documentation of management

Note time of diagnosis, maneuvers, and delivery

Checklists or standardized documentation forms are suggested 12 3

Rubin II maneuver. - This maneuver

Axial traction is applied in alignment with fetal spine and with

Avoid lateral traction as sole maneuver to effect delivery, in absence of

Perform maneuvers to disengage impacted shoulder(s) from maternal pelvis

Perform McRoberts maneuver first 3 11

Often combined with suprapubic pressure 2 3

Apply gentle, routine axial traction to assess if anterior shoulder is released

If unsuccessful, attempt to deliver posterior arm 3 14

Routine use not indicated

Adducts fetal shoulder girdle and reduces its diameter

Attempts to rotate fetal torso about 180° to allow shoulder descent

Other secondary maneuvers

Gaskin all-fours maneuver 16

Consider for females without anesthesia 3 who are mobile 2

May be useful option in community setting