Obstetric maneuvers for shoulder dystocia and associated fetal

morbidity
Robert B. Gherman, LCDR, MC, USNR, Joseph G. Ouzounian, MD,
and T. Murphy Goodwin, MD
Los Angeles, California
OBJECTIVE: We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery.
STUDY DESIGN: A retrospective review of 285 cases of shoulder dystocia that occurred between January
1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers
used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1)
those resolved with McRoberts maneuver, suprapubic pressure, or proctoepisiotomy or a combination of
these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm,
or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral
fracture, or fetal death caused by asphyxial complications.
RESULTS: The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%)
clavicular fractures, and 12 (4.2%) humeral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal
death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of
bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of
158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs
21/158, p = 0.1).
CONCLUSIONS: Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated
with an increased rate of bone fracture or brachial plexus injury. (Am J Obstet Gynecol 1998;178:1126-30.)

Key words: Shoulder dystocia, obstetric maneuvers, brachial plexus injury

The anticipation of shoulder dystocia mandates a thorough prospective evaluation for fetal macrosomia, maternal diabetes mellitus, postterm pregnancy, prior shoulder
dystocia, and avoidance of prolonged second stage of
labor coupled with midpelvic operative delivery.1-5
Unfortunately, these associated risk factors lack both sensitivity and specificity.6 Shoulder dystocia remains an unpredictable occurrence, occurring in 0.2% to 2.1% of all
deliveries.7, 8
Because shoulder dystocia is an infrequent event, obstetricians have little opportunity to become comfortable

From the Division of Maternal-Fetal Medicine, Department of Obstetrics

and Gynecology, University of Southern California School of Medicine.
Poster Presentation, presented at the Sixty-fourth Annual Meeting of the
Pacific Coast Obstetrical and Gynecological Society, Coeur dAlene,
Idaho, September 17-21, 1997.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the
Department of Defense, or the United States Government.
Reprint requests: Robert B. Gherman, MD, Department of Obstetrics
and Gynecology, Division of Maternal-Fetal Medicine, Portsmouth
Naval Hospital, 620 John Paul Jones Circle, Portsmouth, VA 23708.
0002-9378/98 $5.00 + 0 6/6/89323

1126

during this emergency situation. Systematic institution of

a preplanned set of maneuvers is necessary to effect delivery in a timely manner and minimize fetal morbidity.
Neonatal injury occurs in as many as 42% of cases9 and
remains a major cause of litigation.
Because of the low incidence and unpredictability of
shoulder dystocia, no prospective, randomized studies
assessing the impact of obstetric maneuvers on neonatal
morbidity have been done. Several authors10, 11 have
noted that no specific technique has proved superior to
others with respect to the rate of neonatal injury. Our
goals were (1) to determine the fetal injury rate associated with shoulder dystocia and (2) to determine
whether fetal manipulative techniques increased the risk
of brachial plexus injury or bone fracture.
Material and methods
We reviewed the maternal and neonatal charts of cases
of shoulder dystocia occurring between Jan. 1, 1991, and
Dec. 31, 1995, at Los Angeles County/University of
Southern California Womens Hospital. All deliveries
were performed by residents or certified nurse-midwives.

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Am J Obstet Gynecol

Shoulder dystocia was considered to have occurred if,

after delivery of the fetal head, additional obstetric maneuvers other than gentle downward traction and episiotomy were required.12
The management of shoulder dystocia at our institution recommends McRoberts maneuver as the initial
technique.13 If McRoberts maneuver is unsuccessful,
providers then add suprapubic pressure or perform a
proctoepisiotomy. Either Woods corkscrew maneuver or
posterior arm extraction is subsequently used when the
previous maneuvers fail to alleviate the shoulder dystocia. If these direct fetal manipulative techniques do not
effect delivery, the previously listed maneuvers are attempted while the patient is anesthetized. Either the
Zavanelli maneuver (cephalic replacement) or symphysiotomy, or both, are used when all other procedures have
failed.
Maternal charts were reviewed for demographic and
clinical data from the antepartum and intrapartum periods. The type, sequence, and combination of obstetric
maneuvers used were documented as were the specific
maneuver(s) noted to have relieved the dystocia.
Neonatal charts were reviewed for the diagnosis of
humeral fracture, clavicular fracture, or brachial plexus
injury. Neonatal fractures were documented by radiographic examination; brachial plexus palsies were confirmed by pediatric neurologic examination.
The cases were divided into the following two groups:
(1) those alleviated with McRoberts maneuver, suprapubic pressure, or proctoepisiotomy or a combination of
these and (2) those requiring additional fetal manipulation, such as Woods maneuver, posterior arm extraction,
or the Zavanelli maneuver. Fetal injury was defined as either brachial plexus injury, bone fracture, or fetal death
caused by asphyxial complications.
Unpaired t tests, 2 analysis, Fishers Exact t test, and
calculation of odds ratios with 95% confidence intervals,
where appropriate, were performed with Statview 4.1
(Abacus Concepts, Inc., Berkeley, Calif.) and EpiInfo
6.02 (Centers for Disease Control and Prevention,
Atlanta). A p value of 0.05 was considered statistically significant.
Results
During the 5-year period there were 58,565 total deliveries and 50,114 vaginal deliveries. Of 303 cases of shoulder dystocia identified (incidence 0.61%), 289 charts
(95.4%) were available for review. Four cases were excluded from analysis because the maneuver used to effect delivery was not described. The maternal, fetal, and
intrapartum demographic characteristics are listed in
Table I.
Among 285 episodes of shoulder dystocia analyzed,
fetal injury occurred in 71 (24.9%) infants. Injuries included 48 (16.8%) cases of brachial plexus injury, 27

Gherman, Ouzounian, and Goodwin 1127

Table I. Maternal, fetal, and intrapartum demographics

among 285 shoulder dystocia cases
Maternal age (yr)
Parity
0
1
Estimated gestational age
>42 wk
37-42 wk
<37 wk
Birth weight (gm)
Diabetes
Gestational
Pregestational
Instrumental delivery
Forceps
Vacuum
Epidural anesthesia
Second stage of labor (min)

27.8 0.4 (14-44)

2.1 0.1 (0-10)
45(15.8%)
240 (84.2%)
39.8 0.1 (32.1-46.0)
23 (8.1%)
248 (87%)
14 (4.9%)
4118.8 27.1 (2665-6280)
100 (35.1%)
84
16
31 (10.9%)
6
25
49 (17.2%)
71.2 4.1 (1-411)

Values are mean SD or number and percent.

(9.5%) clavicular fractures, and 12 (4.2%) humeral fractures. There were 46 cases of unilateral Erbs palsy, one
case of bilateral Erbs palsy, and one case of Klumpkes
palsy. Nearly two thirds of the nerve injuries (31 of 48,
64.6%) occurred in the right brachial plexus. None of
the neonates displayed evidence of other peripheral
nerve injury. One infant, delivered with use of a symphysiotomy after a failed Zavanelli maneuver, had evidence of hypoxic ischemic encephalopathy and a
markedly abnormal-appearing electroencephalogram
and died at age 3 months.
Sixteen cases of brachial plexus palsy had a concomitant bone fracture, with the clavicle (15/16, 94%) being
most commonly injured. A statistically significant increase in bone fracture was seen with increasing birth
weight (Table II), with 7 of 112 (6.3%) fetuses weighing
<4000 gm and 32 of 173 (18.5%) fetuses weighing >4000
gm (p = 0.003, odds ratio 0.29, 95% confidence interval
0.11 to 0.73) having bone fracture. When birth weight
rose above 4000 gm, statistically significant increases in
both clavicular and humeral fracture occurred (p = 0.02
and 0.05, respectively). However, no statistically significant increase in brachial plexus injury was noted with increasing birth weight. Nerve injury occurred in 14 of 112
(12.5%) fetuses weighing <4000 gm and in 34 of 173
(19.7%) weighing >4000 gm (p = 0.15).
Slightly more than 50% (158/285) of the shoulder dystocia cases were resolved with McRoberts maneuver, either alone or in combination with either suprapubic
pressure or proctoepisiotomy or both. In the remaining
cases (127/285, 44.6%), Woods maneuver, posterior
arm extraction, or Zavanelli maneuver was added to accomplish delivery. All maneuvers were associated with
fetal injury (Table III).
The overall incidence of fetal bone fracture was not increased with the addition of fetal manipulation: 21 of 127

1128 Gherman, Ouzounian, and Goodwin

June 1998
Am J Obstet Gynecol

Table II. Relationship of birth injury to birth weight in shoulder dystocia cases (n = 285)
Birth weight

No. of cases
Brachial plexus
Bone fracture
Clavicle
Humerus

<3000 gm

3000-3499 gm

3500-3999 gm

4000-4499 gm

4500 gm

3 (1.0%)
0
0

23 (8.1%)
3 (13.0%)
0

86 (30.2%)
11 (12.8%)
7 (8.1%)
6
1

118 (41.4%)
26 (22.0%)
17 (14.4%)
12
5

55 (19.3%)
8 (14.5%)
15 (27.3%)
9
6

Table III. Relationship of fetal injury to maneuver(s) used during alleviation of shoulder dystocia
Maneuver

No.

McRoberts*
112
McRoberts plus suprapubic pressure*
31
McRoberts plus suprapubic pressure plus proctoepisiotomy*
7
8
McRoberts plus proctoepisiotomy*
McRoberts plus Woods*
30
McRoberts plus Woods* plus proctoepisiotomy
8
McRoberts plus Woods plus posterior arm extraction*
27
McRoberts plus Woods plus posterior arm extraction*
16
plus proctoepisiotomy
McRoberts plus Woods plus posterior arm extraction
2
plus other*,
McRoberts plus posterior arm extraction*
31
McRoberts plus posterior arm extraction*
13
plus proctoepisiotomy
*Maneuver noted to have effect on delivery.
Includes one case of Zavanelli maneuver and one
Includes one neonatal death at age 3 months.

No.
injured
20 (17.9%)
7 (22.6%)
1 (14.3%)
0 (0%)
3 (10%)
3 (37.5%)
10 (37.0%)
8 (50%)
2 (100%)
14 (45.2%)
7 (53.9%)

Brachial
plexus
13 (11.6%)
7 (22.6%)
1 (14.3%)
0 (0%)
2 (6.7%)
2 (25%)
4 (14.8%)
5 (31.3%)

Clavicular
fracture

Humeral
fracture

12 (10.7%)
4 (12.9%)
1 (14.3%)
0 (0%)
2 (6.7%)
2 (25%)
1 (3.7%)
2 (12.5%)

1 (0.89%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
4 (14.8%)
2 (12.5%)

0 (0%)

0 (0%)

1 (50%)

9 (29%)
5 (38.5%)

1 (3.2%)
2 (15.4%)

2 (6.5%)
2 (15.4%)

case of symphysiotomy after failed Zavanelli.

(16.5%) versus 18 of 158 (11.4%), p = 0.21. Although

similar rates of clavicular fracture existed between the
two groups, an increased incidence of humeral fracture
occurred in those delivered with fetal manipulative techniques. Almost all humeral fractures were associated with
attempts at posterior arm extraction, with one fracture
associated with use of McRoberts maneuver alone. No
statistically significant differences were noted between
the two groups with respect to brachial plexus palsy
(27/127 vs 21/158, p = 0.1).
Those infants experiencing brachial plexus palsy, delivered with fetal manipulation techniques, did not differ
with respect to multiple antepartum or intrapartum characteristics (Table IV). Although more clavicular injuries
occurred in those fetuses with brachial plexus injury undergoing McRoberts maneuver, suprapubic pressure, or
proctoepisiotomy, 9 of 21 (42.9%) versus 5 of 27
(18.5%), this difference was not statistically significant.
Only four (8.9%) persistent brachial plexus palsies were
present among the 45 infants with documented 1-year
follow-up.
Comment
This study represents the largest evaluation to date of
the impact of obstetric maneuvers for the alleviation of

shoulder dystocia and associated fetal morbidity. We

found that approximately one quarter of all infants experiencing shoulder dystocia experienced nerve or bone
injury. Although the incidence of bone fracture with
birth weight >4000 gm was increased, no increased rate
of brachial plexus palsy was found. The rate of resolution
of brachial plexus injury was >90%, with an extremely
low rate of persistent nerve injury after a delivery complicated by shoulder dystocia (4/285, 1.4%).
Our described overall incidence of fetal injury (25%)
and permanent brachial plexus injury (4/50,114) after
shoulder dystocia are consistent with previous findings.
Hopwood14 found only five fetal fractures and four infants with neuromuscular retardation among 92 cases
of shoulder dystocia in a community hospital (9.8%).
Twenty-four (15%) neonates were identified as having either brachial plexus injury, fractured clavicles, or both
among 162 shoulder dystocias described by Gonik et al.11
In the 187 cases evaluated by Baskett and Allen, 15 28
brachial plexus palsies and 12 fractures (21.4%) were
found. Nocon et al.8 noted 14 fractured clavicles and 28
brachial plexus injuries, for an injury rate of 22.7%.
In accord with previous studies8, 15 we found that
brachial plexus injury occurred regardless of the procedure used to disimpact the shoulder. This is in accord

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Am J Obstet Gynecol

Table IV. Clinical characteristics in cases of brachial plexus palsy

No.
Estimated gestational age (wk)
Birth weight (gm)
Maternal weight (lb)
Epidural anesthetic
Diabetes
Instrumental delivery
Oxytocin use
Active phase (min)
Second stage (min)
Bone injury
Clavicle
Humerus
Persistence at 1 yr follow-up

No fetal manipulation

Fetal manipulation

21
38.5 5.7
4089.8 94.1
179.8 7.5
7
8
4
18
356.31 56.7
80.1 15.9

27
39.1 4.3
4198.3 70.8
181.4 6.5
6
9
4
12
344.5 49.9
88.6 17.5

9
1
1 (3.7%)

with the recent findings of McFarland et al.,16 who noted

a 12.9% rate of neonatal trauma among 62 cases of shoulder dystocia in which only McRoberts maneuver was
used. We also noted that, after McRoberts maneuver was
initially unsuccessful in alleviating the shoulder dystocia,
addition of the Woods corkscrew, posterior arm extraction, or Zavanelli maneuvers to effect delivery did not increase the rate of bone fracture or the incidence of
brachial plexus injury.
It is possible that brachial plexus palsy and bone fracture may arise as a result of the labor process itself or as
an intrauterine event. Brachial plexus injury has been
noted to occur without antecedent shoulder dystocia,17, 18
in infants in cephalic presentation during cesarean section,19 and from the posterior shoulder lodging on the
sacral promontory.18, 20 When the fetal shoulders present
at the pelvic brim in a persistent anteroposterior direction, applied vector forces are not transmitted along the
long axis of the fetal neck. In this circumstance even normal downward traction may stretch the brachial plexus.21
Although it is a rare event, the failure of the Zavanelli
maneuver followed by relief with symphysiotomy deserves special comment. Among the 59 reported cases of
attempted cephalic replacements described by
OLeary,22 6 (10.2%) were unsuccessful. Half of these
failed cases required symphysiotomy to effect vaginal delivery. Failure of the Zavanelli maneuver may be associated with bilateral shoulder dystocia or impaction of the
posterior shoulder on the sacral promontory.
Symphysiotomy, however, should still be used as a last attempt to preserve fetal life because of the significant maternal morbidity associated with this procedure.23
Some authors have described excessive lateral traction
as a cause of brachial plexus injury. This maneuver, either alone or in conjunction with other methods, has
been correlated with nerve injury by some authors.24
One of the limitations of our retrospective study is the inability to quantitate the amount of lateral traction exerted on the fetal head and its correlation with brachial

5
1
3 (14.3%)

Statistical significance

p = 0.64
p = 0.35
p = 0.87
p = 0.84
p = 0.34
p = 0.70
p = 0.56
p = 0.71
p = 0.73
p = 0.13
p = 0.4

plexus injury. Only nine (3.2%) of the charts reviewed

actually attempted to quantify the degree of traction initially applied. We recommend that all obstetricians describe the amount of traction applied during the shoulder dystocia.25
At our tertiary care institution the presence of many
residents and midwives at variable stages of training presents a confounding variable. The diagnosis of shoulder
dystocia and the need for additional maneuvers are directly affected by the experience of the accoucheur. In
some instances strong lateral traction may have been applied to the fetal neck before recourse to obstetric maneuvers. There is, however, no currently accepted
method to quantify excessive traction. We also
acknowledge that complete and accurate information may
not have been consistently recorded, with delivering personnel using rotational maneuvers but minimizing their actions on the medical record. Finally, there may have been
permanent injuries among those infants lost to follow-up.
In summary, these data suggest that brachial plexus injuries may occur during any stage of shoulder dystocia.
Such injuries may also be due to other antepartum or intrapartum events independent of the maneuvers used
during delivery. Although electromyography was not performed in any of our brachial plexus palsies, early postpartum electromyographic evidence of denervation has
been reported,26, 27 supporting the idea that some
brachial plexus injuries are independent of delivery maneuvers. The occurrence of brachial plexus injury therefore should not necessarily be equated with iatrogenic
birth injury.
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