Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Shoulder Dystocia

  • Author: Robert H Allen, MS, PhD; Chief Editor: Christine Isaacs, MD  more...
 
Updated: Dec 18, 2014
 

Overview

Shoulder dystocia was first described in 1730 and is an uncommon obstetric complication of cephalic vaginal deliveries during which the fetal shoulders do not deliver after the head has emerged from the mother’s introitus. It occurs when one or both shoulders becomes impacted against the bones of the maternal pelvis, as shown in the image below.[1]

Two-dimensional sagittal view of shoulder dystocia Two-dimensional sagittal view of shoulder dystocia during which the anterior shoulder is impacted behind the symphysis.

Since this phenomenon occurs because of a relative size or positional discrepancy between the fetal and pelvic bony dimensions, it nearly always occurs in parturients undergoing cephalic vaginal delivery after 34 weeks’ gestation.

Shoulder dystocia occurs for mechanical reasons.[2, 3] During the fetal head’s cardinal movements of descent, flexion, and internal rotation within the bony pelvis, the shoulders descend to reach the pelvic inlet. During the head’s subsequent extension, delivery, and external rotation, prior to final expulsion, the shoulders need to rotate within the bony pelvis in a winding fashion to arrive in the most accommodating dimension of the pelvis, its oblique diameter. If either the fetal shoulder dimensions are too large or the maternal pelvis is too narrow to permit shoulder rotation to the oblique pelvic diameter, persistent anteroposterior orientation of the fetal shoulders may result in the anterior shoulder being obstructed behind the symphysis pubis, impeding delivery and leading to shoulder dystocia. If the sacral promontory also obstructs the posterior shoulder, bilateral (and more difficult) shoulder dystocia occurs.

Antepartum risk factors for shoulder dystocia are listed below in order from greatest to least risk:

  • History of shoulder dystocia in a prior vaginal delivery [4]
  • Fetal macrosomia (having a disproportionately large body compared to head) [5]
  • Diabetes/impaired glucose tolerance (false-positive glucose challenge test) [6]
  • Excessive weight gain (>35 lb) during pregnancy
  • Obesity (body mass index >30 kg/m 2) [7, 8]
  • Asymmetric accelerated fetal growth in nondiabetic patients [9]
  • Postterm pregnancy [6]
  • Parity [8, 10]

Intrapartum risk factors are as follows:

  • Precipitous second stage (< 20 min) [6, 11]
  • Operative vaginal delivery (vacuum, forceps, or both) [5]
  • Prolonged second stage [5]
    • Without regional anesthesia (>2 h for nulliparous patients, or >1 h for multiparous patients)
    • With regional anesthesia (>3 h for nulliparous patient, >2 h for others)
  • Induction of labor for "impending macrosomia" [12]

Despite these well-defined risk factors, shoulder dystocia is impossible to predict because many patients with multiple risk factors do not experience it, and many shoulder dystocias occur in patients with no risk factors. Severe shoulder dystocia can occur during delivery of a small-for-gestational-age infant.[13] The poor predictability relates to shoulder dystocia being caused by a dynamic or evolving mechanical event, rather than by simply the presence of specific antenatal or intrapartum clinical risk factors.

Although shoulder dystocia is impossible to predict or prevent in an individual patient, it has recently been shown prospectively that the incidence of shoulder dystocia can be reduced in a population by diagnosing and treating mild gestational diabetes mellitus (defined as a 2 or more abnormal values after a 3-hour 100-g oral glucose-tolerance test, but with a glucose fasting level < 95 mg/dL). Treating these patients with self-monitoring of blood glucose, diet, and insulin therapy as needed, has resulted in a significant decrease in large-for-gestational-age (LGA) infants, cesarean deliveries, and shoulder dystocia (by 60%).[14]

Considered an obstetric emergency, shoulder dystocia can result in significant fetal and maternal harm if not resolved in a competent and expedient manner. Cord pH drops with increasing head-to-body delivery interval, but the drop does not become clinically significant for about 5 minutes.[15, 16] A 6-minute head-to-body delivery interval has been demonstrated not to be a risk factor for hypoxic ischemic encephalopathy (HIE).[17] Beyond that time, there is increased risk of neonatal depression, acidosis, asphyxia, central nervous system damage, and death.[18, 19, 20]

Next

Indications

Incidence

Although the incidence ranges cited by the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) are 0.6-1.4% and 0.58-0.70%, respectively, the incidence of shoulder dystocia varies in the literature by a factor of 30, from 1 in 769 vaginal to 1 in 25 deliveries.[21, 22] One reason for this wide variation is, in part, the variation in the denominator (eg, all births vs only vaginal births vs only term vaginal births) used to calculate incidence. However, the primary reasons for the variation are (1) difficulty in diagnosis (see diagnosis below) and (2) time to diagnosis.

Based on a host of retrospective studies, most cited incidences range from 0.5-3% of deliveries.[23] Although few in number, prospective studies examining shoulder dystocia incidence among vaginal deliveries in the United States generally report higher values, from 3.3-7%.[22, 24, 25, 26, 27] These higher values among the total of 2100 vaginal cephalic deliveries within the few prospective studies likely reflect the more accurate incidence among the at-risk population (vaginal, cephalic deliveries of at least 34 wk gestation).

Diagnosis

The 2 principal reasons for the wide variation in diagnosis are as follows:

  • There are no objective standardized diagnostic criteria for shoulder dystocia. [28]
  • Milder forms of the condition are difficult to diagnose, or are uneventful and sometimes not coded. [29, 30]

Although the textbook definition is clear, the obstetric provider cannot visualize the obstruction clinically. Two commonly accepted diagnoses are as follows:

  • More than customary traction needed to deliver the fetal trunk. [31]
  • The need to perform ancillary maneuvers to complete delivery after customary traction has failed. [32, 33, 34]

Since "customary traction" varies from clinician to clinician, the diagnosis is inherently subjective (as demonstrated in the following video).

Example of difficulty in diagnosing shoulder dystocia. Although traction here is noticeably more than normally used, no maneuvers were used and the head-to-body interval is under 10 seconds. In this case, the delivery note did indicate shoulder dystocia.

In countries where the standard of care is to wait for a contraction before attempting delivery of the trunk in all vaginal deliveries, the incidence of shoulder dystocia is well below 1%.[35, 36, 37] While waiting for a contraction after the head has delivered increases the head-to-body interval, there is no significant risk of neonatal depression, neonatal acidosis, or birth asphyxia.[37, 38, 39, 40]

In high-volume practices, shoulder dystocia is not consistently coded when it is uneventful.[41] One objective clinical indication that occurs in a minority of shoulder dystocia deliveries is known as the turtle sign, where the fetal head, after it delivers, retracts against the perineum, as shown in the following image.

Turtle sign and double chin are diagnostic in a mi Turtle sign and double chin are diagnostic in a minority of shoulder dystocia deliveries.
Previous
Next

Contraindications

Fundal pressure should not be used in the management of shoulder dystocia, as it is counterproductive. Pressure directed from behind the fetus only further impacts the anterior shoulder, making the shoulder dystocia more difficult to resolve and increasing the risk of permanent brachial plexus injury.[42, 43]

Strong lateral traction (more than 20 lb or 2 to more than 4 times the traction typically used in routine delivery) should also be avoided, as increased lateral traction increases the risk of both transient and permanent brachial plexus injury.[24, 43] The greater the traction, the greater the severity of brachial plexus injury.[44]

Finally, head rotation beyond 90°, as shown in the image below, is to be avoided because it increases the risk of neck and brachial plexus injury.

Although this presentation appears to be left occi Although this presentation appears to be left occipitoanterior, the left shoulder is actually anterior. The head is rotated about 180 degrees. Used with permission from Elsevier.
Previous
Next

Anesthesia

Because of the time constraints during shoulder dystocia, anesthesia has a limited role. If cephalic replacement is necessary, uterine relaxants such as intravenous nitroglycerine or halogenated inhalational agents should be administered to decrease the risk of uterine rupture.

Previous
Next

Equipment

No specialized equipment is required. Obstetric skill and team coordination are essential.

Previous
Next

Positioning

Management of shoulder dystocia primarily involves repositioning the laboring patient or the fetus. These are discussed in detail in the next section.

Previous
Next

Technique

Proper management of shoulder dystocia is important to avoid untoward outcomes. About a dozen techniques can be broadly divided into 2 categories: fetal maneuvers (during which the manipulation is directly upon the fetus) and maternal maneuvers (during which the primary manipulation is on the mother, often done by ancillary personnel).Table. Shoulder Dystocia Maneuvers

Table. (Open Table in a new window)

Fetal Maneuvers Maternal Maneuvers
Rubin maneuver[45] McRoberts maneuver[46, 47, 48]
Jacquemier maneuver (posterior arm delivery)[49, 50] Suprapubic pressure[51]
Woods screw maneuver[2] Gaskin maneuver (all-fours)[52]
Zavanelli maneuver (cephalic replacement)[53] Sims maneuver (lateral decubitus)
Cleidotomy Ramp maneuver
Shute forceps maneuver Symphysiotomy

Episiotomy is not listed because it offers no mechanical or clinical benefit when fetal maneuvers are not used. Studies have demonstrated that episiotomy does not decrease risk of brachial plexus injury and increases the risk of perineal trauma.[54, 55] The only reason to perform an episiotomy in the setting of shoulder dystocia is to eliminate soft tissue resistance that is interfering with the ability to insert the whole hand into the hollow of the sacrum posteriorly to perform fetal maneuvers.

Five maneuvers (Rubin, Jacquemier, Woods, and McRoberts maneuvers, and suprapubic pressure), either singly or in combination, accomplish delivery nearly 100% of the time. The Gaskin maneuver is primarily used by midwives; although effective, obstetricians have not adopted it in part due to the overwhelming use of epidural anesthesia. The others are used less commonly or resorted to only after primary ones have failed.[56] Recent research has demonstrated there are fewer brachial plexus injuries when fetal maneuvers are used initially.[57, 58, 59, 60, 61, 62]

Rubin maneuver

The Rubin maneuver involves inserting one hand in the vagina posteriorly or anteriorly along the dorsal aspect of the fetal shoulder and rotating the shoulder inward (adduction) about 30° until the shoulders lie in the oblique diameter of the pelvis.

By applying pressure to the dorsal aspect of the shoulder, the rotation adducts the fetal shoulders, reducing their bisacromial diameter. This increases the clearance between the shoulders and the pelvis by about 20 mm.[63] Another advantage is that it ensures the clinician knows the correct orientation of the shoulders, which is not always obvious. Ensuring the correct orientation of the shoulders avoids the rotation of the head beyond 90°, which can cause fetal injury. If the Rubin rotation can be accomplished, the anterior shoulder should emerge from below the symphysis with little or no additional traction. Using rotation as an initial maneuver decreases the risk of brachial plexus injury.[64]

See the image below.

Rubin maneuver. Insertion of left index and middle Rubin maneuver. Insertion of left index and middle fingers anteriorly to access posterior aspect of anterior (left) shoulder. Pressure by the fingers can sometimes rotate the fetal trunk into the (wider) oblique plane.

Posterior arm delivery (Jacquemier maneuver)

In this maneuver, the clinician’s hand (including the thumb) is inserted in the vagina in an effort to deliver the posterior arm (not just the shoulder) first. When the left shoulder is anterior, the operator’s right hand is used; if the right shoulder is anterior, the operator’s left hand is used. Sliding the hand along the dorsal aspect of the humerus and pressing it against the fetal chest, the clinician then palpates the elbow. If the elbow is already flexed, the operator grasps the fetal forearm and wrist and sweeps the forearm over the chest and across the infant’s face, extending the arm at the elbow and shoulder to deliver it first.

Movements should be directed only medially, toward and then across the fetal chest, supporting and continually pressing the humerus against the chest to avoid possible humerus fracture from attempting to flex it laterally against the vaginal sidewall.

If the elbow is extended, the forearm is difficult to reach and deliver. The operator should attempt to flex it by applying pressure with his or her finger to the dorsal aspect of the forearm and, if needed, simultaneously press on the ventral aspect of the elbow crease to cause it to bend. After flexion of the elbow, the operator grasps and sweeps the forearm and wrist as described above. If the elbow will not flex, the operator should continue directly into the Woods screw maneuver. Once the posterior arm is delivered, the fetal trunk almost always follows because of the additional 20 mm of clearance.[61] If not, the delivered arm can be used to help rotate the trunk (as in the Woods screw maneuver) so that the remaining anterior shoulder is brought to occupy the oblique plane of the pelvis, anterior to the pubic symphysis.

See the image below.

Sagittal view of insertion of right hand (thumb in Sagittal view of insertion of right hand (thumb included) to grasp, and ultimately deliver, the right (posterior) arm.

Woods screw maneuver

The Woods screw maneuver is an extension of the posterior Rubin maneuver. The fetal trunk is rotated at least 180° using pressure on the dorsal aspect of the posterior shoulder to help adduct the shoulders. The rotation is skew rather than planar and directed toward the operator (caudal relative to the patient). The winding motion, similar to the way a screw advances by turning it, furthers the descent and expulsion of the trunk of the fetus. This 180° rotation is usually successful at delivering the trunk. If not, the rotation and forward motion is repeated. Care should be used here to rotate inward toward the opposite shoulder (achieving shoulder adduction) as the opposite rotation necessarily abducts the fetal shoulders, increasing the bisacromial diameter. This is a modification of the original Woods maneuver, which used abduction and simultaneous application of fundal pressure, both of which are counterproductive.

Because the intent is to rotate 180°, the clinician should use the left hand when the fetus’ right shoulder is anterior and the right hand for a left anterior shoulder. Although initially awkward and counterintuitive, this allows the clinician’s arm to sweep in a natural direction that supinates the arm without having to substitute the opposite hand mid procedure.

See the image below.

Woods screw maneuver.

McRoberts maneuver

The McRoberts maneuver is the usual first-line maneuver for shoulder dystocia in the United States. Two assistants hyperflex the mother’s thighs against her abdomen.[32] This raises the symphysis pubis about 9 mm, which may provide sufficient clearance to release the anterior shoulder from behind the symphysis.[61] By flattening the lumbosacral spine, McRoberts positioning may also advance the posterior fetal shoulder into the hollow of the sacrum.

The McRoberts maneuver alone resolves up to 46% of shoulder dystocia deliveries with little additional traction required.[65] However, the introduction of the maneuver did not decrease the rate of injury.[66] Providers must maintain awareness of the natural tendency to increase traction. Care should be taken to limit to at most moderate traction and to avoid repeated or extended attempts. Failure to resolve shoulder dystocia at this point should prompt progression to additional maneuvers. McRoberts positioning can be continued during the performance of additional maneuvers as it improves operator access to the posterior shoulder.

See the image below.

Sagittal view of McRoberts maneuver (assistants no Sagittal view of McRoberts maneuver (assistants not shown), with legs hyperflexed on the abdomen. Change in pelvic geometry shown, where the symphysis is raised about 9 mm by rotating about the lumbar-sacral joint.

Suprapubic pressure

Suprapubic pressure is usually performed by a nurse who applies stout directional (45° downward) pressure to the maternal abdomen just above the pubic symphysis. This pressure should be applied to the posterior aspect of the anterior shoulder, pushing toward the opposite side from where the attendant is positioned. The effects of this are 2-fold: (1) to compress soft tissue that may be making the impaction worse and (2) to help rotate the anterior shoulder away from the symphysis pubis and into the diagonal conjugate of the maternal pelvis.

Suprapubic pressure is often used concomitantly with the McRoberts maneuver. Since both maneuvers ultimately rely on clinician traction to the head to accomplish delivery of the fetal trunk, the same caution in applying traction following suprapubic pressure should be observed. When suprapubic pressure is used to assist manual rotation of the fetal shoulders (as in Woods screw or Rubin maneuver), then the direction of the suprapubic pressure should be reversed to encourage rotation of the anterior shoulder in the same rotational direction (clockwise or counterclockwise as determined by initial fetal shoulder position) as the operator is guiding the posterior shoulder.

See the image below.

Caudal view of suprapubic pressure, where palm (or Caudal view of suprapubic pressure, where palm (or fist) of an assistant's hand is applied just above the pubic symphysis. Direction of pressure should be lateral and downward, applied to the posterior aspect of the anterior shoulder in an attempt to rotate the trunk.
Previous
Next

Pearls

Insert fingers prior to attempting delivery to ensure proper assessment of the shoulder orientation.

Wait for a contraction after suspecting a shoulder dystocia or observing a turtle sign. In most instances, the shoulders deliver spontaneously. The additional 2-3 minutes on the perineum does not increase the risk of neonatal depression, acidosis, or birth asphyxia.

Use fetal maneuvers early in the management of shoulder dystocia deliveries to become adroit and remain competent and facile at them.

During the McRoberts maneuver, suprapubic pressure, or both, keep traction to the head limited in magnitude and directed axially as much as possible.

Avoid repeating attempts at traction, as they are likely to increase in magnitude and increase the risk for brachial plexus injury.

Be aware that the McRoberts maneuver and suprapubic pressure are less effective in patients who are obese because the additional soft tissue prevents full abduction of the thighs against the abdomen and transmission of pressure applied by ancillary personnel to the anterior shoulder.

Unless room is needed posteriorly to perform fetal maneuvers, an episiotomy is not needed and is potentially damaging to the patient’s perineum.

As part of training and continuing medical education, shoulder dystocia simulations should be conducted to assess and improve communication, documentation, and, most importantly, clinical management. Practitioners trained with shoulder dystocia simulation drills experience better clinical outcomes and fewer shoulder dystocia-associated injuries after training than before.[59, 67] Standardized forms are helpful for clear and consistent documentation; however, using forms does not improve outcomes without concomitant training.[68]

Previous
Next

Complications

There are many complications from shoulder dystocia. Postpartum hemorrhage can result from uterine atony caused by either overdistention from fetal macrosomia or dysfunctional contractility caused by mechanical obstruction. Third- or fourth-degree perineal laceration or episiotomy extension can also occur. Since episiotomy is not necessary for most shoulder dystocia deliveries, this complication may often be avoidable. However, fetal size alone may cause these extensive lacerations. Potential long-term consequences include wound breakdown, fistula formation, dyspareunia, and fecal incontinence.

Neonatal clavicle fracture is not uncommon among deliveries without shoulder dystocia. It is a recognized complication of shoulder dystocia and is most often not preventable because of the compression of the acromial aspect of the shoulder from the symphysis pubis. Some clavicle fractures can result from direct downward application of suprapubic pressure, but this often resolves the shoulder dystocia and is therefore useful. Fortunately, clavicle fracture usually resolves without intervention or sequelae within the neonatal period.

Fractured humerus can occur with a posterior arm delivery if the operator forces the arm against resistance encountered while sweeping it. This too may be unavoidable in successful resolution of shoulder dystocia. Humeral fractures are treated with immobilization and generally fully heal within the neonatal period.

Brachial plexus injury to the newborn is the most common complication of shoulder dystocia. Most of these injuries resolve before discharge from the hospital. However, some last longer and can be permanent, with varying levels of limited motion depending on the nature and extent of the injury. This injury is caused by deviation or rotation of the fetal head from the shoulder. The best way to reduce the likelihood of this complication is by using, at most, moderate traction on the head during maternal maneuvers. Traction should be directed in line with the axis of the fetal spine. Axial traction poses much less risk to the brachial plexus than lateral (downward or upward) traction.[3]

As residents are more likely to experience shoulder dystocia-related brachial plexus injury,[57] simulation training can provide experience in management, which results in improved clinical outcome with fewer adverse outcomes.[69] Introduction of a shoulder dystocia protocol has been shown to decrease brachial plexus injury incidence by a factor of 6 and to increase clear and consistent documentation by a factor of 7.[67]

Infants of women who experience a shoulder dystocia complication following a second stage length of 1-3 hours are 5 times more likely to have a brachial plexus injury than those whose shoulder dystocia complication followed a second stage less that 1 hour.[70] Among infants with permanent shoulder dystocia–associated brachial plexus injuries, an antecedent precipitous second stage is 3 times more common than a prolonged second stage.[27] Given these associations, consideration of preexistent risk factors for shoulder dystocia prior to use of operative vaginal delivery for treatment of a prolonged second stage is prudent. In those circumstances in which a second-stage length is not modifiable by the provider (eg, precipitous second stage), deliberate and conscious awaiting of the next contraction prior to the application of traction has been associated with a lower incidence of shoulder dystocia.[38]

Although rare, devastating complications of catastrophic shoulder dystocia include neonatal hypoxic ischemic encephalopathy and death. The mechanism for oxygen deprivation is usually attributed to variable compression of the umbilical cord during the obstructed delivery. To help prevent this complication, the cord should never be clamped until at least the anterior shoulder has been successfully delivered.

Sudden fetal circulatory collapse can result from a precipitous drop in neonatal blood pressure following delivery after shoulder dystocia. This can occur with the sudden release of the partial (venous greater than arterial) compression of the umbilical cord immediately upon delivery. If unrecognized, improper resuscitation may lead to asphyxia or death. Pediatricians should consider volume resuscitation when a fetus is suddenly more depressed or born with no heart rate immediately following shoulder dystocia.[71]

Clinician injury has also been reported. One provider ruptured tendons between the third and fourth fingers from a pincer grasp of the head with those 2 fingers.[72] Another sustained a mallet finger deformity in while delivering the posterior arm.[73]

Previous
 
Contributor Information and Disclosures
Author

Robert H Allen, MS, PhD Associate Research Professor, Departments of Biomedical Engineering, and Gynecology and Obstetrics, School of Medicine, Johns Hopkins University

Disclosure: Received ownership interest from Birth Injury Prevention, LLC for founder.

Coauthor(s)

Edith D Gurewitsch, MD Associate Professor of Gynecology and Obstetrics, Johns Hopkins University School of Medicine; Associate Professor of Biomedical Engineering, Johns Hopkins University; Director of In-Patient Obstetrical Services, Associate Director of Labor and Delivery, Johns Hopkins Hospital

Edith D Gurewitsch, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Medical Association, MedChi The Maryland State Medical Society, Royal Society of Medicine, Society for Maternal-Fetal Medicine

Disclosure: Received ownership interest from Birth Injury Prevention, LLC for consulting; Received grant/research funds from National Center for Injury Prevention & Control for principal investigator.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

John G Pierce, Jr, MD Associate Professor, Departments of Obstetrics/Gynecology and Internal Medicine, Medical College of Virginia at Virginia Commonwealth University

John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of Virginia, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Acknowledgements

We thank the Centers for Disease Control/National Center for Injury Prevention and Control for sponsoring the research we performed from 2004-2007 under their Grants for Traumatic Injury Biomechanics Research program. We also thank the National Collegiate Inventors and Innovators Alliance, which also supported our research.

References
  1. Swartz DP. Shoulder girdle dystocia in vertex delivery: clinical study and review. Obstet Gynecol. 1960 Feb. 15:194-206. [Medline].

  2. Woods CE, Westburg NY. A principle of physics as applicable to shoulder dystocia. Am J Obstet Gynecol. 1943. 45796-804.

  3. Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol. 2007 Sep. 50(3):607-23. [Medline].

  4. Smith RB, Lane C, Pearson JF. Shoulder dystocia: what happens at the next delivery?. Br J Obstet Gynaecol. 1994 Aug. 101(8):713-5. [Medline].

  5. Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstet Gynecol. 1978 Nov. 52(5):526-9. [Medline].

  6. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol. 1985 Dec. 66(6):762-8. [Medline].

  7. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol. 2004 Feb. 103(2):219-24. [Medline].

  8. Mazouni C, Menard JP, Porcu G, Cohen-Solal E, Heckenroth H, Gamerre M, et al. Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia. Eur J Obstet Gynecol Reprod Biol. 2006 Nov. 129(1):15-8. [Medline].

  9. 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 Aug. 54(8):478-82. [Medline].

  10. Overland EA, Vatten LJ, Eskild A. Risk of shoulder dystocia: associations with parity and offspring birthweight. A population study of 1 914 544 deliveries. Acta Obstet Gynecol Scand. 2012 Apr. 91(4):483-8. [Medline].

  11. Poggi SH, Stallings SP, Ghidini A, Spong CY, Deering SH, Allen RH. Intrapartum risk factors for permanent brachial plexus injury. Am J Obstet Gynecol. 2003 Sep. 189(3):725-9. [Medline].

  12. Gonen O, Rosen DJ, Dolfin Z, Tepper R, Markov S, Fejgin MD. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol. 1997 Jun. 89(6):913-7. [Medline].

  13. Ruis KA, Allen RH, Gurewitsch ED. Severe shoulder dystocia with a small-for-gestationaI-age infant: a case report. J Reprod Med. 2011 Mar-Apr. 56(3-4):178-80. [Medline].

  14. Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med. 2009 Oct 1. 361(14):1339-48. [Medline]. [Full Text].

  15. Leung TY, Stuart O, Sahota DS, Suen SS, Lau TK, Lao TT. Head-to-body delivery interval and risk of fetal acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a retrospective review. BJOG. 2011 Mar. 118(4):474-9. [Medline].

  16. Stallings SP, Edwards RK, Johnson JW. Correlation of head-to-body delivery intervals in shoulder dystocia and umbilical artery acidosis. Am J Obstet Gynecol. 2001 Aug. 185(2):268-74. [Medline].

  17. Allen RH, Rosenbaum TC, Ghidini A, Poggi SH, Spong CY. Correlating head-to-body delivery intervals with neonatal depression in vaginal births that result in permanent brachial plexus injury. Am J Obstet Gynecol. 2002 Oct. 187(4):839-42. [Medline].

  18. Hope P, Breslin S, Lamont L, Lucas A, Martin D, Moore I, et al. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol. 1998 Dec. 105(12):1256-61. [Medline].

  19. Ouzounian JG, Korst LM, Phelan JP. Permanent Erb's palsy: a lack of a relationship with obstetrical risk factors. Am J Perinatol. 1998 Apr. 15(4):221-3. [Medline].

  20. O'Shaughnessy MJ. Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia. Obstet Gynecol. 1998 Oct. 92(4 Pt 2):693-5. [Medline].

  21. Christoffersson M, Rydhstroem H. Shoulder dystocia and brachial plexus injury: a population-based study. Gynecol Obstet Invest. 2002. 53(1):42-7. [Medline].

  22. Spong CY, Beall M, Rodrigues D, Ross MG. An objective definition of shoulder dystocia: prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol. 1995 Sep. 86(3):433-6. [Medline].

  23. Gherman RB. Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol. 2002 Jun. 45(2):345-62. [Medline].

  24. Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: an engineering study of clinician-applied forces. Obstet Gynecol. 1991 Mar. 77(3):352-5. [Medline].

  25. Bofill JA, Rust OA, Devidas M, Roberts WE, Morrison JC, Martin JN Jr. Shoulder dystocia and operative vaginal delivery. J Matern Fetal Med. 1997 Jul-Aug. 6(4):220-4. [Medline].

  26. Beall MH, Spong C, McKay J, Ross MG. Objective definition of shoulder dystocia: a prospective evaluation. Am J Obstet Gynecol. 1998 Oct. 179(4):934-7. [Medline].

  27. Poggi SH, Allen RH, Patel CR, Ghidini A, Pezzullo JC, Spong CY. Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery. Am J Obstet Gynecol. 2004 Sep. 191(3):874-8. [Medline].

  28. Ramieri J, Iffy L. Shoulder Dystocia. Apuzzio JJ, Vintzileos AM, Iffy L. Operative obstetrics. 3rd ed. London: Taylor & Francis; 2006. 253-64.

  29. Cohen AW, Otto SR. Obstetric clavicular fractures. A three-year analysis. J Reprod Med. 1980 Sep. 25(3):119-22. [Medline].

  30. Gonik B, Hollyer VL, Allen R. Shoulder dystocia recognition: differences in neonatal risks for injury. Am J Perinatol. 1991 Jan. 8(1):31-4. [Medline].

  31. Gonik B, Stringer CA, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol. 1983 Apr 1. 145(7):882-4. [Medline].

  32. American College of Obstetricians and Gynecologists. ACOG practice bulletin clinical management guidelines for obstetrician-gynecologists. Number 40, November 2002. Obstet Gynecol. 2002 Nov. 100(5 Pt 1):1045-50. [Medline].

  33. Resnik R. Management of shoulder girdle dystocia. Clin Obstet Gynecol. 1980 Jun. 23(2):559-64. [Medline].

  34. Royal College of Obstetricians and Gynaecologists. Shoulder Dystocia. Green-top Guideline, No 42, 2nd Ed. Mar 2012. Available at http://www.rcog.org.uk/womens-health/clinical-guidance/shoulder-dystocia-green-top-42.

  35. Overland EA, Vatten LJ, Eskild A. Risk of shoulder dystocia: associations with parity and offspring birthweight. A population study of 1 914 544 deliveries. Acta Obstet Gynecol Scand. 2012 Apr. 91(4):483-8. [Medline].

  36. Locatelli A, Incerti M, Ghidini A, Longoni A, Casarico G, Ferrini S. Head-to-body delivery interval using 'two-step' approach in vaginal deliveries: effect on umbilical artery pH. J Matern Fetal Neonatal Med. 2011 Jun. 24(6):799-803. [Medline].

  37. Zanardo V, Gabrieli C, de Luca F, Trevisanuto D, De Santis M, Scambia G. Head-to-body delivery by "two-step" approach: effect on cord blood hematocrit. J Matern Fetal Neonatal Med. 2013 Aug. 26(12):1234-8. [Medline].

  38. Locatelli A, Incerti M, Ghidini A, Greco M, Villa E, Paterlini G. Factors associated with umbilical artery acidemia in term infants with low Apgar scores at 5 min. Eur J Obstet Gynecol Reprod Biol. 2008 Aug. 139(2):146-50. [Medline].

  39. Allen RH, Rosenbaum TC, Ghidini A, Poggi SH, Spong CY. Correlating head-to-body delivery intervals with neonatal depression in vaginal births that result in permanent brachial plexus injury. Am J Obstet Gynecol. 2002 Oct. 187(4):839-42. [Medline].

  40. Stallings SP, Edwards RK, Johnson JW. Correlation of head-to-body delivery intervals in shoulder dystocia and umbilical artery acidosis. Am J Obstet Gynecol. 2001 Aug. 185(2):268-74. [Medline].

  41. Christoffersson M, Rydhstroem H. Shoulder dystocia and brachial plexus injury: a population-based study. Gynecol Obstet Invest. 2002. 53(1):42-7. [Medline].

  42. Gross SJ, Shime J, Farine D. Shoulder dystocia: predictors and outcome. A five-year review. Am J Obstet Gynecol. 1987 Feb. 156(2):334-6. [Medline].

  43. Mollberg M, Wennergren M, Bager B, Ladfors L, Hagberg H. Obstetric brachial plexus palsy: a prospective study on risk factors related to manual assistance during the second stage of labor. Acta Obstet Gynecol Scand. 2007. 86(2):198-204. [Medline].

  44. Mollberg M, Lagerkvist AL, Johansson U, Bager B, Johansson A, Hagberg H. Comparison in obstetric management on infants with transient and persistent obstetric brachial plexus palsy. J Child Neurol. 2008 Dec. 23(12):1424-32. [Medline].

  45. Rubin A. Management of shoulder dystocia. JAMA. 1964. 189(11):141-3.

  46. Bonnaire C, Bue E. Influence of the position on the shape and dimensions of the pelvis. Gynecol Obstet (Paris). 1899. L11296-310.

  47. Edgar JC. The Practice of Obstetrics. Philadelphia: P Blakiston's Son & Co; 1916.

  48. Gonik B, Stringer CA, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol. 1983 Apr 1. 145(7):882-4. [Medline].

  49. Beer E. A guest editorial: shoulder dystocia and posture for birth: a history lesson. Obstet Gynecol Surv. 2003 Nov. 58(11):697-9. [Medline].

  50. Barnum CG. Dystocia due to the shoulders. Am J Obstet Gynecol. 1945. 50439-42.

  51. Mazzanti GA. Delivery of the anterior shoulder; a neglected art. Obstet Gynecol. 1959 May. 13(5):603-7. [Medline].

  52. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med. 1998 May. 43(5):439-43. [Medline].

  53. Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol. 1985 Jun 15. 152(4):479-84. [Medline].

  54. Paris AE, Greenberg JA, Ecker JL, McElrath TF. Is an episiotomy necessary with a shoulder dystocia?. Am J Obstet Gynecol. 2011 Sep. 205(3):217.e1-3. [Medline].

  55. Gurewitsch ED, Donithan M, Stallings SP, Moore PL, Agarwal S, Allen LM. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol. 2004 Sep. 191(3):911-6. [Medline].

  56. Dildy GA. Hankins GDV, et al. Operative obstetrics. 5th ed. East Norwalk, CT: Appleton & Lange; 1995. 233-56.

  57. Hoffman MK, Bailit JL, Branch DW, Burkman RT, Van Veldhusien P, Lu L. A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol. 2011 Jun. 117(6):1272-8. [Medline].

  58. Leung TY, Stuart O, Sahota DS, Suen SS, Lau TK, Lao TT. Head-to-body delivery interval and risk of fetal acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a retrospective review. BJOG. 2011 Mar. 118(4):474-9. [Medline].

  59. Inglis SR, Feier N, Chetiyaar JB, Naylor MH, Sumersille M, Cervellione KL. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol. 2011 Apr. 204(4):322.e1-6. [Medline].

  60. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol. 1995 Jul. 86(1):14-7. [Medline].

  61. Poggi SH, Spong CY, Allen RH. Prioritizing posterior arm delivery during severe shoulder dystocia. Obstet Gynecol. 2003 May. 101(5 Pt 2):1068-72. [Medline].

  62. Gurewitsch ED, Allen RH. Fetal manipulation for management of shoulder dystocia. Fetal Matern Med Rev. 2006. 17(3):185-204.

  63. Gurewitsch ED, Kim EJ, Yang JH, Outland KE, McDonald MK, Allen RH. Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol. 2005 Jan. 192(1):153-60. [Medline].

  64. Inglis SR, Feier N, Chetiyaar JB, Naylor MH, Sumersille M, Cervellione KL. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol. 2011 Apr. 204(4):322.e1-6. [Medline].

  65. Gherman RB, Goodwin TM, Ouzounian JG, Miller DA, Paul RH. Brachial plexus palsy associated with cesarean section: an in utero injury?. Am J Obstet Gynecol. 1997 Nov. 177(5):1162-4. [Medline].

  66. MacKenzie IZ, Shah M, Lean K, Dutton S, Newdick H, Tucker DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol. 2007 Nov. 110(5):1059-68. [Medline].

  67. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011 Dec. 205(6):513-7. [Medline].

  68. Moragianni VA, Hacker MR, Craparo FJ. The impact of length of second stage of labor on shoulder dystocia outcomes: a retrospective cohort study. J Perinat Med. 2012 Jun. 40(4):463-5. [Medline].

  69. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008 Jul. 112(1):14-20. [Medline].

  70. Moragianni VA, Hacker MR, Craparo FJ. The impact of length of second stage of labor on shoulder dystocia outcomes: a retrospective cohort study. J Perinat Med. 2012 Jun. 40(4):463-5. [Medline].

  71. Mercer J, Erickson-Owens D, Skovgaard R. Cardiac asystole at birth: Is hypovolemic shock the cause?. Med Hypotheses. 2009 Apr. 72(4):458-63. [Medline].

  72. Schramm M. Impacted shoulders--a personal experience. Aust N Z J Obstet Gynaecol. 1983 Feb. 23(1):28-31. [Medline].

  73. Usman S, Parupalli S, Pinto A, Neal N, O'Mahony F. Obstetrician Injury Whilst Managing a Shoulder Dystocia: A Case Report. Open Journal of Obstetrics and Gynecology. 2012. 2(1):62-3.

 
Previous
Next
 
Two-dimensional sagittal view of shoulder dystocia during which the anterior shoulder is impacted behind the symphysis.
Turtle sign and double chin are diagnostic in a minority of shoulder dystocia deliveries.
Rubin maneuver. Insertion of left index and middle fingers anteriorly to access posterior aspect of anterior (left) shoulder. Pressure by the fingers can sometimes rotate the fetal trunk into the (wider) oblique plane.
Sagittal view of insertion of right hand (thumb included) to grasp, and ultimately deliver, the right (posterior) arm.
Sagittal view of McRoberts maneuver (assistants not shown), with legs hyperflexed on the abdomen. Change in pelvic geometry shown, where the symphysis is raised about 9 mm by rotating about the lumbar-sacral joint.
Caudal view of suprapubic pressure, where palm (or fist) of an assistant's hand is applied just above the pubic symphysis. Direction of pressure should be lateral and downward, applied to the posterior aspect of the anterior shoulder in an attempt to rotate the trunk.
Example of difficulty in diagnosing shoulder dystocia. Although traction here is noticeably more than normally used, no maneuvers were used and the head-to-body interval is under 10 seconds. In this case, the delivery note did indicate shoulder dystocia.
Woods screw maneuver.
Although this presentation appears to be left occipitoanterior, the left shoulder is actually anterior. The head is rotated about 180 degrees. Used with permission from Elsevier.
Table.
Fetal Maneuvers Maternal Maneuvers
Rubin maneuver[45] McRoberts maneuver[46, 47, 48]
Jacquemier maneuver (posterior arm delivery)[49, 50] Suprapubic pressure[51]
Woods screw maneuver[2] Gaskin maneuver (all-fours)[52]
Zavanelli maneuver (cephalic replacement)[53] Sims maneuver (lateral decubitus)
Cleidotomy Ramp maneuver
Shute forceps maneuver Symphysiotomy
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.