SHOULDER DYSTOCIA

Following complete emergence of the fetal head during vaginal delivery, the remainder
of the body may not rapidly follow. The anterior fetal shoulder can become wedged behind the
symphysis pubis and fail to deliver using normally exerted downward traction and maternal
pushing. Because the umbilical cord is compressed within the birth canal, such dystocia is an
emergency.
Several maneuvers, in addition to downward traction on the fetal head, may be performed
to free the shoulder. This requires a team approach, in which effective communication and
leadership are critical.
Consensus regarding a specific definition of shoulder dystocia is lacking. Some
investigators focus on whether maneuvers to free the shoulder are needed, whereas others use the
head to body delivery time interval as defining (Beall, 1998). Spong and coworkers (1995)
reported that the mean head-to-body delivery time in normal births was 24 seconds compared
with 79 seconds in those with shoulder dystocia. These investigators proposed that a head-to-
body delivery time > 60 seconds be used to define shoulder dystocia. Currently, however, the
diagnosis continues to rely on the clinical perception that the normal downward traction needed
for fetal shoulder delivery is ineffective.
Because of these differing definitions, the incidence of shoulder dystocia varies. Current
reports cite an incidence between 0.6 percent and 1.4 percent (American College of Obstetricians
and Gynecologists, 2012b). There is evidence that the incidence has increased in recent decades,
likely due to increasing fetal birthweight (MacKenzie, 2007). Alternatively, this increase may be
due to more attention given to appropriate documentation of dystocia (Nocon, 1993).

Maternal and Neonatal Consequences

In general, shoulder dystocia poses greater risk to the fetus than the mother. Postpartum
hemorrhage, usually from uterine atony but also from vaginal lacerations, is the main maternal
risk (Jangö, 2012; Rahman, 2009). In contrast, significant neonatal neuromusculoskeletal injury
and even mortality are concerns. MacKenzie and associates (2007) reviewed 514 cases of
shoulder dystocia and found that 11 percent were associated with serious neonatal trauma.
Brachial plexus injury was diagnosed in 8 percent, and 2 percent suffered a clavicle,
humeral, or rib fracture. Seven percent showed evidence of acidosis at delivery, and 1.5 percent
required cardiac resuscitation or developed hypoxic ischemic encephalopathy. Mehta and
colleagues (2007) found a similar number of injuries in a study of 205 shoulder dystocia cases, in
which 17 percent had injury.
Again, most involved the brachial plexus. These specific injuries are described more fully
in Chapter 33 (p. 648). Of predictors, increasing fetal weight, maternal body mass index, and
secondstage duration and a prior shoulder dystocia appear to raise the neonatal injury risk with
shoulder dystocia (Bingham, 2010; Mehta, 2006).

Prediction and Prevention

There has been considerable evolution in obstetrical thinking regarding the preventability
of shoulder dystocia. Although there are clearly several risk factors associated with this
complication, identification of individual instances before the fact has proved to be impossible.
The American College of Obstetricians and Gynecologists (2012b) reviewed studies and
concluded that:
1. Most cases of shoulder dystocia cannot be accurately predicted or prevented.
 2. Elective induction of labor or elective cesarean delivery for all women suspected of
having a macrosomic fetus is not appropriate.
3. Planned cesarean delivery may be considered for the nondiabetic woman with a fetus
whose estimated fetal weight is > 5000 g or for the diabetic woman whose fetus is
estimated to weigh > 4500 g.

Birthweight
Commonly cited maternal characteristics associated with increased fetal birthweight are
obesity, postterm pregnancy, multiparity, diabetes, and gestational diabetes. There is universal
agreement that increasing birthweight is associated with an increasing incidence of shoulder
dystocia. In one study of nearly 2 million vaginal deliveries, Overland and coworkers (2012)
noted that in 75 percent of shoulder dystocia cases, newborns weighed > 4000 g. That said, the
concept that cesarean delivery is indicated for large fetuses, even those estimated to weigh 4500
g, should be tempered. Rouse and Owen (1999) concluded that a prophylactic cesarean delivery
policy for macrosomic fetuses would require more than 1000 cesarean deliveries with attendant
morbidity as well as millions of dollars to avert a single permanent brachial plexus injury.

Intrapartum Factors
Some labor characteristics have been associated with an increased shoulder dystocia risk
and include prolonged secondstage labor, operative vaginal delivery, and prior shoulder dystocia
(Mehta, 2004; Moragianni, 2012; Overland, 2009). Of these, the risk of recurrent shoulder
dystocia ranges from 1 to 13 percent (Bingham, 2010; Moore, 2008; Ouzounian, 2013).
For many women with prior shoulder dystocia, a trial of labor may be reasonable. The
American College of Obstetricians and Gynecologists (2012b) recommends that estimated fetal
weight, gestational age, maternal glucose intolerance, and severity of prior neonatal injury be
evaluated and risks and benefits of cesarean delivery discussed with any woman with a history of
shoulder dystocia. After discussion, either mode of delivery is appropriate.

Management
Because shoulder dystocia cannot be accurately predicted, clinicians should be well
versed in its management principles. Because of ongoing cord compression with this dystocia,
one goal is to reduce the head-to-body delivery time. This is balanced against the second goal,
which is avoidance of fetal and maternal injury from aggressive manipulations. Accordingly, an
initial gentle attempt at traction, assisted by maternal expulsive efforts, is recommended.
Adequate analgesia is certainly ideal. Some clinicians advocate performing a large
episiotomy to provide room for manipulations. Of note, Paris (2011) and Gurewitsch (2004) and
their colleagues reported no change in the brachial plexus injury rate for groups in which
episiotomy was not performed during shoulder dystocia management.
After gentle traction, various techniques can be used to free the anterior shoulder from its
impacted position behind the symphysis pubis. Of these, moderate suprapubic pressure can be
applied by an assistant, while downward traction is applied to the fetal head. Pressure is applied
with the heel of the hand to the anterior shoulder wedged above and behind the symphysis.
The anterior shoulder is thus either depressed or rotated, or both, so the shoulders occupy
the oblique plane of the pelvis and the anterior shoulder can be freed. The McRoberts maneuver
was described by Gonik and associates (1983) and named for William A. McRoberts, Jr., who
popularized its use at the University of Texas at Houston. The maneuver consists of removing
the legs from the stirrups and sharply flexing them up onto the abdomen (Fig. 27-7). Gherman
and associates (2000) analyzed the McRoberts maneuver using x-ray pelvimetry. They found
that the procedure caused straightening of the sacrum relative to the lumbar vertebrae, rotation of
the symphysis pubis toward the maternal head, and a decrease in the angle of pelvic inclination.
Although this does not increase pelvic dimensions, pelvic rotation cephalad tends to free
the impacted anterior shoulder. Gonik and coworkers (1989) tested the McRoberts position
objectively with laboratory models and found that the maneuver reduced the forces needed to
free the fetal shoulder.