Shoulder dystocia is a rare birth complication, less than 1% of vaginal births, that can not be predicted before it actually presents itself during delivery where the one or both of the baby’s shoulders are stuck behind the birthers pubic bones not allowing the baby to be birthed. There is nothing the birther did or did not do for this birth complication to occur. A provider may not recognize shoulder dystocia until the baby’s head is delivered and then goes back into the mother, called “turtle sign”. Another way to know is if more than 1 minute has passed after the birth of the head and no progress of the body, as usually the body is delivered within 30 seconds of the head emerging. Over 50% of these complicated births have no previous or apparent risk factors.
Although there is no way to tell during labor and delivery, the main risk factor for increasing the chance of having shoulder dystocia is having an assisted vaginal delivery, including vacuum extractor, forceps, epidural, induction, etc. Induced birthers are 2.85 times more likely to have shoulder dystocia than a physiological birth.
Other risk factors:
● Induction of labor, increases risk by 2.11x
● Augmentation of labor with oxytocin, increases risk by 4.74
● Obesity, BMI over 30, increases risk by 2.85x
● Induced and obese birthers, increases risk by 5.64x
● Diabetes, increases risk by 2-4x
● Previous shoulder dystocia birth, increases risk by x10
● Over weight or gaining excess weight during pregnancy
● Gestational diabetes
● Baby weighs more than 8 lbs 13 oz (fetal macrosomia), however almost half the cases are babies weighing less than 8.8lbs
● Pelvic opening is too small or abnormal shape
● Mother is not in a position that allows the most space for baby to emerge
● Baby is not in optimal birthing position
● Long first or second stage of labor
● Secondary arrest
● Pregnant with multiples
● More than 42 weeks gestational age
● Using inappropriate maneuvers to delivery baby
Risks and potential outcomes to the mother
Birth injuries
Birth trauma and emotional impact
Postpartum hemorrhage, 1 in 100 women affected
Severe tearing of the perineum, vaginal wall to rectum
Rectovaginal fistula (abnormal connection between the vagina and rectum)
Uterine rupture
Separation of pubic bones
Damage to bladder, anal sphincter, and/or rectum
Future obstetric issues
Risks and potential outcomes to baby
Nerve damage
Brachial plexus injury, 1 in 10 babies affected
Bone fractures
Brain damage
Loss of oxygen
Horner’s syndrome
Compressed umbilical cord
Brain injury
Death
Brachial Plexus Birth Injuries
● <10% of birth injuries are permanent
● See a physical therapist to maximize results
● Surgeries are available for babies who are not getting results
Nerve surgery
Osteotomy
Tendon transfers
Open reduction of the shoulder joint (capsulorrhaphy)
Free muscle transfers
● Many children improve or recover by 3 to 12 months old
● Erb’s palsy (most common brachial plexus injury) generally fully recovers within 12 months
● Klumpe’s Palsy (less common) recovery rate is 40% by 12 months
● Homor syndrome full recovery is rare without surgery
● 82% of babies are fully recovered by 18 months old
● 1 in 100 babies will experience permanent damage
In adults, we know that common symptoms include: weakness or numbness, loss of sensation, loss of movement (paralysis), and increased pain as the injury is close to the spinal cord and may also cause burning numbness (paresthesias or dysesthesias). Symptoms for babies may be similar.
Best ways to decrease the risk of shoulder dystocia
● Manage diabetes and weight gain appropriately
● Scheduling a cesarean section
● Avoid labor medications and inductions
● Avoid jerking or tugging on the baby’s head during delivery (increases incidence of brachial plexus injuries)
● Avoid fundal pressure (increases incidence of brachial plexus injuries)
● Avoid downward traction until the shoulder is not stuck (increases incidence of brachial plexus injuries)
An Obstetric Emergency
Once it has been identified as a birth complication, action happens really fast as you’ll want the baby delivered before asphyxia from umbilical cord compression occurs within minutes as the fetal pH drops at about 0.14 per minute during delivery of the body, although the actual time limit varies. Avoid any traction or jerking of the head to pull the body out as this is associated with neonatal traumas. Instead, begin using the HELPERR manoeuvers immediately by putting yourself and the baby in better positions to deliver the baby. The order is not important.
H- Help: Your obstetrician will call for help and ask you to refrain from pushing as it may worsen the impaction.
They'll use the safety checklist and call for additional help from other healthcare providers including an anesthesiologist, a neonatologist and extra labor and delivery nurse.
E-Evaluate for episiotomy: Your obstetrician will decide if you need an episiotomy to assist with the delivery of your baby by trying to make room for rotation maneuvers.
L- Legs: Your obstetrician may use the McRoberts maneuver. Use this simple and effective technique first!
Your obstetrician will ask you to press your thighs up (contract) against your belly (abdomen).
This method helps to flatten and rotate your pelvis and is associated with resolving shoulder dystocia in 39-42% in one study and up to 90% in another.
However, it does not reduce the risk for bone or nerve damage to the baby and they still have a 10.2% chance of having brachial plexus injuries.
P- Pressure: Your obstetrician will use suprapubic pressure (press on your lower belly above your pubic bone).
This puts pressure on your baby’s shoulder in an attempt to rotate and deliver it.
E- Enter maneuvers: Your obstetrician may perform enter maneuvers or internal rotation by reaching up into your vagina, called the Rubin 1 maneuver, to try and manually turn your baby.
R- Remove posterior arm: Your obstetrician may use Jacquemier’s maneuver by removing one of your baby’s arms from the birth canal.
This may make it easier for their shoulders to pass through.
R- Roll the birther: Your obstetrician may use the Gaskin maneuver by having the birther turn over on their hands and knees to get into a new, more favorable birthing position.
In severe cases where the HELPERR mnemonic tools do not help deliver the baby, very invasive techniques will be considered:
Clavicle fracture to break the baby’s collarbone to allow the shoulders to fit.
Zavanelli maneuver: your obstetrician will manually push the baby's head back into the birther's uterus and perform a cesarean section.
Symphysiotomy: your obstetrician will cut the cartilage between the pubic bones to help enlarge the pelvic opening to deliver the baby.
Post Birth Optimal Recovery for Baby
It is extremely important to delay clamping the umbilical cord as much of the blood may have been pushed into the placenta. Even if there is a nuchal cord, cutting it before the cord has stopped pulsating and turned white and flat results in a dramatic increase in asphyxia, cerebral palsy, and death. The umbilical cord is an extra life support for the baby and increases their overall quality of life. If the cord needs to be cut, rapidly milk the cord towards the baby 4 times before cutting (still not optimal but better than cutting alone). Birther and baby will also greatly benefit from immediate skin to skin, even while both are being checked over!
Additional Resources
Bibliography
Ghweman, MD, R. (2002, February). Pearls on the McRoberts maneuver, 14(2), 49–53. Retrieved September 5, 2023, from https://www.mdedge.com/obgyn/article/61087/pearls-mcroberts-maneuver
Green-top Guideline No.42. (2012, March). Shoulder Dystocia Guideline, 2nd Edition. RCOG. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/shoulder-dystocia-green-top-guidel ine-no-42/
Hill, MD, A. D., Lense, MD, J., & Roepcke, MD, MPS, F. (2020, July 15). Shoulder Dystocia: Managing an obstetric emergency. American Family Physician. https://www.aafp.org/pubs/afp/issues/2020/0715/p84.html Author disclosure: No relevant financial affiliations
Khan, L. (2019, June 26). Shoulder Dystocia. TeachMeObGyn. https://teachmeobgyn.com/labour/emergencies/shoulder-dystocia/
The Royal Women’s Hospital. “Guideline: Shoulder Dystocia”. The Royal Women’s Hospital, 07/27/2020. https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/shoulder-dystocia-g uideline_280720.pdf
Sirota, MD, MHA, I., Francis, MD, A., Chevalier, MD, MPH, M., & Ashmead, MD, G. (2014). Shoulder dystocia and labor induction stratified by maternal weight. Obstetrics & Gynecology, 123(Supplement 1). https://doi.org/10.1097/01.aog.0000447182.21511.09
Sparkman, MHA, RN, BSN, L. (2020, August 26). Nursing Maneuvers for Shoulder Dystocia. RELIAS. September 5, 2023, https://www.relias.com/blog/nursing-maneuvers-shoulder-dystocia#:~:text=The%20McRoberts%20Maneuver% 20is%20often,42%25%20of%20shoulder%20dystocia%20cases
YouTube. (2019). Shoulder Dystocia.
YouTube. Retrieved September 5, 2023, from https://www.youtube.com/watch?v=BvkKMwDaryg
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