Shoulder dystocia (SD) occurs when a baby’s head is delivered vaginally, but their shoulders get stuck in the mother’s body (1). It is a delivery complication that requires additional obstetric maneuvers to fully deliver the baby. Most commonly, the baby’s shoulder is stuck behind a bone in the mother’s pelvis. SD occurs in 0.2-3% of vaginal deliveries that happen in vertex position (2).
SD is a serious complication, and has a high perinatal morbidity and mortality rate (3). It is a significant contribution to birth injury in the baby, including brachial plexus injuries and Erb’s palsy. These are conditions in which nerves in the baby’s neck and shoulders become stretched or torn, causing weakness or paralysis of the arm, which can be permanent. These injuries occur when excessive force or traction is applied to the baby’s head during delivery.
Risk factors for shoulder dystocia
A broad variety of conditions and circumstances that increase the risk of the shoulder getting stuck on the pelvis during delivery have been identified. These conditions are (1,3):
- Gestational diabetes
- Family or personal history of diabetes
- Macrosomia (large baby) or past history of macrosomia
- Past history of shoulder dystocia
- Postmaturity (baby past due date)
- Cephalopelvic disproportion (the baby’s head is too large for the size of the mother’s pelvis)
- Baby is male
- Use of assistive delivery devices, such as forceps or vacuum extractors
- Prolonged or arrested labor
- Use of the labor-enhancing drugs Pitocin or Cytotec for induction of labor
- The mother is short in stature
- The mother is obese or gained more than 35 pounds during pregnancy
- The mother has a narrow or abnormal pelvis
- The mother is over the age of 35 (this is considered advanced maternal age)
- Conduction (local) anesthesia is used
Management of shoulder dystocia
It is very important that the size of the mother’s pelvis be measured at the first prenatal visit so that as the due date approaches, the physician can use the measurements to assess the size of the mother’s pelvis in relation to the size of the baby (3). In addition, a thorough history of the mother should be taken by the physician to determine if the mother has any risk factors for shoulder dystocia. The mother and baby must be closely watched and evaluated during the pregnancy. The physician must discuss the risks and benefits of different delivery methods. The option of a scheduled C-section should be discussed, especially if the mother has one or more of the risk factors for shoulder dystocia. The greater the number of risk factors present, the greater the risk of shoulder dystocia and permanent brachial plexus injury.
A mother and baby should be closely monitored during labor and delivery, especially in high-risk situations (3). An essential monitoring tool is the fetal heart rate monitor, which measures a baby’s heart rate in response to contractions. When a baby’s heart rate is nonreassuring (abnormal) or they are showing signs of fetal distress, it almost always means that the baby is being deprived of oxygen. When this occurs, it is usually an indication that the baby should be delivered immediately. Physicians should also monitor for failure of the shoulders to descend, failure of the restitution of the fetal head, difficulty delivering the face and chin, and the head remaining tightly applied to the vulva or retracting (“turtle sign”) (3).
Failure to monitor a baby can lead to hypoxic-ischemic encephalopathy (HIE) because without fetal heart rate monitoring, a baby could be severely oxygen-deprived with nobody noticing.
Shoulder dystocia is an emergency because the baby’s oxygen supply is reduced when the head is out but the body is still inside the birth canal. The key to avoiding injury is to have a delivery plan that is executed calmly, without excessive force or traction.
Physicians are taught to use the HELPERR mnemonic device to manage SD (1):
- H: Call for help. If the doctor recognizes SD, they should immediately call for extra assistance, including another obstetrician, an anaesthetist, and a pediatric resuscitation team. Maternal pushing should be discouraged and the patient should be moved to where her buttocks is at the edge of the bed.
- E: Evaluate episiotomy. Episiotomy (the surgical cutting of the vagina to aid a difficult delivery) alone is unlikely to relieve SD, as it is usually related to bone impact.
- L: Legs. In most cases, the mother should be put into the McRoberts’ position, with her legs flexed back toward her chest. McRoberts’ method is the most effective intervention.
- P: Pressure. Usually, suprapubic pressure is applied just below the belly button and it helps move the shoulders into the correct position.
- E: Enter maneuvers. Various maneuvers can be used at the entry point to assist in moving the fetus out.
- R: Remove the posterior arm. After the lower arm is pulled out, the common approach is to deliver the impacted shoulder.
- R: Roll the patient. The patient will then usually be rolled into all-fours position.
Avoiding improper pressure
Physicians and the medical team should never apply fundal pressure, where force is applied just below the breast (3). Fundal pressure forces the baby’s shoulder more tightly against the pelvis. Physicians should also avoid applying excessive force to the fetal head or neck.
When shoulder dystocia occurs, it is crucial for physicians to quickly deliver the baby (3). Often, physicians waste valuable time by attempting a vaginal delivery, and many times, use faulty delivery techniques. Physicians must follow standards of care (defined as what a reasonably prudent medical professional would do under similar circumstances). It is critical to quickly move on to an emergency C-section delivery if the baby cannot be born in a safe and quick vaginal delivery. Failure to quickly deliver a distressed baby with a nonreassuring heart rate can cause severe oxygen deprivation and hypoxic-ischemic encephalopathy (HIE).
Complications of shoulder dystocia for the fetus
Shoulder dystocia increases the risk of the baby suffering numerous injuries, such as the following (3):
- Brachial plexus injuries and Erb’s palsy. The brachial plexus is a network of nerves in the shoulder and neck area. Sometimes when shoulder dystocia occurs, the physician attempts vaginal delivery and pulls too hard on the baby’s head. This excessive force can cause the brachial plexus nerves to be severely stretched and torn, which can cause the arm to be rotated toward the body and hang limply at the baby’s side. This is called Erb’s palsy, which is characterized by partial or total paralysis of the child’s arm. Brachial plexus injuries complicate 2.3-16% of SD births (3,4). Fewer than 10% of brachial plexus injuries result in permanent brachial plexus dysfunction.
- Birth asphyxia, neonatal encephalopathy (NE), and hypoxic-ischemic encephalopathy (HIE). Shoulder dystocia also places the baby at risk of experiencing birth asphyxia, neonatal encephalopathy, and hypoxic-ischemic encephalopathy. There are a number of reasons birth asphyxia, NE, and HIE can occur during a shoulder dystocia situation. Firstly, shoulder dystocia can cause labor to be prolonged or arrested, and a prolonged second stage of labor is associated with birth asphyxia, chorioamnionitis, and sepsis, all of which can cause neonatal encephalopathy and HIE. Secondly, shoulder dystocia can also cause the baby’s umbilical cord to be compressed, which can cause a lack of oxygen to the brain and birth asphyxia (3). Umbilical cord compression requires emergency intervention to prevent the baby from having brain damage and HIE.
- Clavicular and humerus fractures. When shoulder dystocia occurs, both of the baby’s arms can be injured, such as a fracture of the left arm (humerus) and a brachial plexus injury in the right arm. The baby’s collarbone (clavicle) can also be broken when shoulder dystocia occurs. Broken bones in a newborn are very troubling because often, the medical team cannot see or feel the broken bones and the baby is left in pain for too long.
These dangerous events associated with shoulder dystocia can typically be avoided if the medical team quickly recognizes the dystocia and/or abnormal and non-reassuring heart tracings and delivers the baby by prompt C-section delivery.
Risks of shoulder dystocia for the mother
A mother experiencing shoulder dystocia is at risk of the following complications:
- Perineal tears
- Vaginal and cervical lacerations
- Bladder atony
Legal help for shoulder dystocia and hypoxic-ischemic encephalopathy (HIE)
At ABC Law Centers, we have extensive experience handling birth injury cases involving shoulder dystocia, hypoxic-ischemic encephalopathy (HIE), and other birth injuries. Our firm’s lawyers give personal attention to each child and family they help and they are available 24/7 to speak with you.
If you require the help of a birth injury lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury. ABC Law Centers is a national birth injury firm that has been helping families and children impacted by birth injuries since the firm’s inception in 1997. Partners Jesse Reiter and Rebecca Walsh are currently recognized as two of the best medical malpractice lawyers in America by U.S. News and World Report, which also recognized ABC Law Centers as one of the best medical malpractice firms in the nation. Call us anytime for more information. We do not charge any legal fees unless we win.
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- Shoulder dystocia. (n.d.). Retrieved March 1, 2019, from https://www.marchofdimes.org/complications/shoulder-dystocia.aspx
- (n.d.). Retrieved March 1, 2019, from https://www.uptodate.com/contents/shoulder-dystocia-intrapartum-diagnosis-management-and-outcome?search=shoulder dystocia&source=search_result&selectedTitle=1~42&usage_type=default&display_rank=1
- Politi, S., Dʼemidio, L., Cignini, P., Giorlandino, M., & Giorlandino, C. (2010). Shoulder dystocia: an Evidence-Based approach. Journal of prenatal medicine, 4(3), 35-42.
- Royal College of Obstetricians & Gynecologists. (2012). Shoulder Dystocia[Brochure]. Author. Retrieved March 1, 2019, from https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf