Shoulder dystocia and injuries: prevention and managementKenneth Kwek and George S.H. Yeo

Purpose of review

Shoulder dystocia is an obstetric emergency that is often

unpredictable and unanticipated. Despite the identification

of various clinical risk factors, our ability to predict and

prevent shoulder dystocia is very limited. Effective and

timely clinical management is essential to offer the best

chance of a satisfactory outcome.

Recent findings

Upon diagnosis of the condition, a team working in

tandem to resolve the problem is very effective. Use of the

McRoberts maneuver, application of suprapubic pressure,

with an adequate episiotomy allow resolution of over 50%

of cases, with a low risk of fetal injury. Secondary

maneuvers include rotation of the shoulders and delivery

of the posterior shoulder. These are technically more

challenging and may be associated with a higher risk of

fetal injury. More drastic action may be considered in dire

cases where even secondary maneuvers fail. These

include the Zavanelli maneuver, symphysiotomy or

iatrogenic clavicular fracture. These techniques, while

seldom required, may be lifesaving in extremely severe

cases.

Summary

Upon resolution of the clinical event, it is essential to

document the entire event, and to discuss the clinical

problem and management with the parents. These actions

will reduce the risk of medical litigation, and improve

patient satisfaction with clinical care.

Keywords

maneuvers, organization, shoulder dystocia, teamwork

Curr Opin Obstet Gynecol 18:123–128. # 2006 Lippincott Williams & Wilkins.

Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital,Singapore

Correspondence to George S.H. Yeo, Chief of Obstetrics, Department of MaternalFetal Medicine, KK Women’s and Children’s Hospital, 100 Bukit Timah Road,Singapore 22989Tel: +65 6394 1009; fax: +65 6394 1017; e-mail: mfm93b@pacific.net.sg

Current Opinion in Obstetrics and Gynecology 2006, 18:123–128

# 2006 Lippincott Williams & Wilkins1040-872X

Introduction

Shoulder dystocia has been aptly described as being

infrequent, unanticipated and unpredictable [1], fea-

tures that contribute to the nightmare awaiting the per-

son attending the delivery. Timely intervention allows

rapid delivery of the baby in the majority of cases; how-

ever, the condition is associated with a significant risk of

fetal hypoxia and injury to both mother and baby.

Despite the identification of clinical risk factors, various

preventive strategies such as elective caesarean section

or induction of labour at 38 weeks for high-risk women

have thus far proven ineffective at significantly reducing

the occurrence of this obstetric emergency, while

increasing the rate of caesarean section. In lieu of effec-

tive preventive strategies, various interventional strate-

gies such as maternal positioning, obstetric maneuvers

and surgical or destructive procedures have been well

researched and reviewed. These have been shown to

be effective in the vast majority of cases. The presence

of a competent team in the delivery suite, well versed in

these procedures, is essential and may be facilitated

through the institution of regular simulations and drills

[2•]. Such drills have been recommended in the recent

confidential enquiry into maternal deaths [3]. While no

substitute for clinical experience, such drills at least

allow staff some ‘hands-on’ practice, which they would

otherwise only rarely perform in an actual clinical setting

[4].

Upon diagnosis of shoulder dystocia, a cascade of events

should be triggered beginning with rapid activation of a

team to assist in maneuvers and concluding with the

safe delivery of the infant, who is handed to the waiting

neonatal team. An important aspect, which is often over-

looked, is the organization of the various team members

such that each has a significant role in the resolution of

the emergency.

Clinical significance of shoulder dystocia

Shoulder dystocia essentially occurs when there is diffi-

culty in delivering the fetal shoulders, which fail to

rotate, resulting in impaction above the pelvic inlet. In

most cases, the anterior shoulder is impacted behind the

pubic symphysis; however, in very severe cases the pos-

terior shoulder may also get stuck above the sacral pro-

montory. In this latter situation, given the relative anat-

omy of the maternal pelvis and the fetus, the fetal

mouth would almost certainly not be visible at the intro-

123

itus unless a vigorous instrumental delivery had been

performed for delivery of the fetal head. It is likely

that in such instances the Zavanelli maneuver might

be considered. The procedure would be akin to redu-

cing the fetal head with digital pressure from the vagina

prior to delivery, at the time of caesarean section in the

second stage of labour.

Various definitions of shoulder dystocia exist depending

upon how difficulty in delivery is defined [5]: when

there is subjective difficulty; upon application of sec-

ondary maneuvers; or by a prolonged head-to-shoulder

delivery interval [6]. These differences may account for

the varying incidence reported in the literature of

between 0.2 and 3% [6]. Shoulder dystocia is associated

with significant maternal morbidity such as perineal

trauma and postpartum hemorrhage [7]. The perinatal

mortality from shoulder dystocia is up to 1.8% [5] and

the risk of fetal injury is about 25% [5,8,9].

Insult to the baby from hypoxia results from compres-

sion of the neck and central venous congestion as well as

compression of the umbilical cord, reduced placental

intervillous flow from prolonged increased intra-uterine

pressure and secondary fetal bradycardia. A combination

of these factors, together with possible pre-existing fetal

acidosis, may result in clinical deterioration out of pro-

portion to the duration of hypoxia. Although there are

some data that suggest that there is no statistically sig-

nificant linear relationship between the head-to-body

delivery interval and fetal acid-base status [10], a rela-

tively brief delay in delivery of the shoulders may be

associated with a fatal outcome [8].

Brachial plexus injury is a rare occurrence [11•] but

occurs in about 25% of cases with shoulder dystocia [5,

11,12•,13•]. This injury has been commonly attributed

to excessive traction on the fetal head; however, there

are increasing data on brachial plexus injury occurring in

the absence of such traction and even in cases without

shoulder dystocia [14–16,17•].

Prediction and prevention of shoulderdystocia

The assessment of women for the risk of shoulder dys-

tocia is a continuous process, beginning even before

pregnancy, when factors such as maternal diabetes mel-

litus, obesity or a history of shoulder dystocia or macro-

somia in a previous pregnancy warn us of a significantly

increased risk of shoulder dystocia. Antenatal risk factors

consistently reported are fetal macrosomia, diabetes

mellitus in pregnancy, excessive maternal weight gain

and post-date pregnancy. It is likely that absolute birth-

weight threshold is not as important as birthweight per-

centile for specific populations. In an Asian population,

a birthweight above 3600 g (almost the 90th percentile

for the population) was associated with a relative risk

16.1 times higher for the occurrence of shoulder dystocia

compared to pregnancies resulting in the delivery of an

infant weighing less than 3600 g [18].

Intrapartum events such as a prolonged labour and the

need for instrumental delivery should alert us to the risk

of shoulder dystocia [6]. In two recent retrospective ana-

lyses, the risk of shoulder dystocia among infants deliv-

ered by vacuum extraction was significantly higher than

those delivered by forceps [19••,20••]. This is hypothe-

sized to be owing to more favourable force vectors

achieved with forceps delivery [20••].

Despite the awareness of these well established and

thoroughly reviewed risk factors, our ability to predict

the occurrence of shoulder dystocia in any one particular

pregnancy is deficient. In a recent analysis, a combina-

tion of risk factors yielded a cumulative odds ratio of

23.2 for shoulder dystocia [21••]. As in other analyses,

however, the positive predictive value of a combination

of risk factors was only around 3.4% [21••,22]. With

these data in mind, it is not surprising that the applica-

tion of clinical risk factors as a guide to prevent shoulder

dystocia by elective caesarean section or by early induc-

tion of labour has not been successful in reducing the

overall rate of shoulder dystocia, while increasing obste-

tric intervention. The American College recommends

antenatal evaluation for risk factors and consideration

of elective caesarean section if estimated fetal weight

is above 5000 g in nondiabetic patients and above

4500 g in diabetic patients [23]. The post-test probabil-

ity of identifying a macrosomic fetus antenatally is, how-

ever, very variable [24•], and these recommendations do

not take into consideration the size and individualized

characteristics of the mother. Hence these recommenda-

tions are not necessarily applicable in different popula-

tions.

Team management of shoulder dystocia

The concept of team care for the management of

shoulder dystocia is important, as a birth attendant may

have difficulty performing the various maneuvers alone

[25•]. A formalized activation system, good leadership

and organization of the various team members, with

each one well trained in the management of obstetric

emergencies, will facilitate a smooth delivery of the

baby.

Preparation and team activation

All medical and midwifery staff in the delivery suite

should be prepared to respond to a case of shoulder dys-

tocia through a pre-arranged protocol. If shoulder dysto-

124 Maternal-fetal medicine

cia can be anticipated on the basis of risk factors, certain

precautions may be taken such as putting an experi-

enced team on alert for activation and preparing the

delivery room by removing unnecessary equipment to

allow more room to move. The patient’s bladder should

also be emptied prior to delivery. There is some evi-

dence that the prophylactic use of the McRoberts man-

euver and suprapubic pressure does not hasten delivery

of the shoulders in such patients [26,27]. The effect of

such prophylactic strategies on reducing shoulder dysto-

cia per se, however, is difficult to assess [26,28]. The

optimal position for birth remains controversial, but in

these high-risk cases the dorsal lithotomy position is

generally preferred [29], with the bed ‘broken’ such

that the patient’s buttocks are at the edge of the bed.

Upon encountering difficulty in the delivery of the

shoulders, the immediate response is to summon assis-

tance, in line with the ‘H’ in the ‘HELPERR’ mnemo-

nic in the advanced life support in obstetrics course

(ALSO) [30,31]. Getting a supporting team to respond

is facilitated by a formalized activation system, either

through a ‘call tree’, alarm buzzer or a public address

announcement. These mechanisms serve to alert the

relevant staff in parallel, allowing rapid reaction. The

use of the public address system has proven very effec-

tive in reducing decision–delivery interval in crash

caesarean section [32].

Maneuvers to achieve delivery of theshoulders

Shoulder dystocia signifies a failure of downward forces

to deliver the anterior shoulder. In this instance, further

downward traction will probably be ineffective until

some other maneuver has been performed to alter the

relationship between the fetal shoulders and the bony

pelvis. Fundal pressure should be avoided as this further

impacts the shoulder on the pelvic brim, with possible

risk of increasing fetal trauma.

Primary maneuvers

The first maneuvers to be attempted should be those

that offer the lowest risk of fetal injury, with the highest

chance of success. Most reviews agree that these initial

maneuvers include the McRoberts maneuver [9], appli-

cation of suprapubic pressure and an episiotomy. Low-

ering the bed and the side-rails of the bed facilitate

these maneuvers

The long history in the development of the McRoberts

maneuver illustrates the utility of this time-tested pro-

cedure [33]. The maneuver ideally requires two assis-

tants, one to hold each leg of the woman, such that the

knees and hips are flexed, and the thighs are held

against the abdomen. This has the effect of causing a

cephalad rotation of the pubic symphysis, reducing the

inclination of the pelvic inlet, effectively offering a

larger antero-posterior diameter to the fetal shoulders

[34]. In addition, there are data that show that the

McRoberts maneuver increases net expulsive forces by

converting voluntary maternal pushing efforts into

enhanced intrauterine pressure independently of con-

tractions [29].

Application of suprapubic pressure results in a down-

ward force on the anterior fetal shoulder, facilitating its

dis-impaction from above the pubic symphysis. This

force may be applied by the primary accoucheur, but it

is ideally applied by an assistant over the abdomen of

the patient. This position allows the application of the

force to be applied slightly obliquely towards the face of

the baby, which encourages adduction of the fetal

shoulders, reducing the bisacromial diameter.

The use of an episiotomy is not essential to resolve the

dystocia, as the obstruction is at the bony pelvis. A

timely episiotomy, however, allows the accoucheur

more room to perform the various internal maneuvers,

and probably aids in resolving severe shoulder dystocia

[35•,36–38]. A prophylactic episiotomy probably does

not reduce the risk of shoulder dystocia [28].

These primary measures are very effective, allowing

delivery of the baby without the need to proceed to sec-

ondary measures in about 50% of cases [7,39]. The

procedures are generally safe; however, maternal sym-

physeal separation and femoral neuropathy have been

reported [40].

Secondary maneuvers

Failure to deliver the baby with the primary maneuvers

signifies a more severe degree of dystocia, and second-

ary maneuvers should be attempted. These maneuvers

are generally slightly more challenging and are asso-

ciated with a higher risk of fetal injury.

The fetal shoulders ideally enter the pelvic inlet in a

transverse or oblique diameter, which is larger than the

antero-posterior diameter. When the anterior shoulder is

impacted above the pubic symphysis, rotation of the

fetal shoulders to an oblique pelvic diameter offers a

better chance of delivery. This rotation may be accom-

plished by applying digital pressure from behind either

the anterior shoulder or posterior shoulder towards the

fetal face [41], which has the additional effect of

encouraging shoulder adduction and reduction of the

bisacromial diameter. Alternatively, digital pressure

may be applied from in front of the posterior shoulder,

Shoulder dystocia and injuries Kwek and Yeo 125

in a progressive corkscrew fashion to release the oppo-

site impacted anterior shoulder. A combination of pres-

sure on both shoulders in opposite directions as well as

concomitant suprapubic pressure may further facilitate

shoulder rotation. Pressure on the anterior aspect of

the anterior shoulder is not described, possibly as this

may be associated with a higher risk of iatrogenic clavi-

cular fracture. Through these procedures, the head is

supported and is not rotated

Delivery of the posterior arm or shoulder is another

effective maneuver for resolving shoulder dystocia. In

the classical description, the hand is placed behind the

posterior shoulder and the arm is traced to the elbow,

swept across the fetal chest and delivered. For this

description to be adhered to, either the posterior

shoulder would have to be very low in the vagina and

easily delivered or the accoucheur’s hand would have to

be inserted very deep to be able to reach the antecubital

fossa of the extended fetal arm. In our experience, this

classical maneuver is seldom possible as only the axilla

can be felt when the shoulder is high. In such instances,

traction on the posterior axilla has allowed delivery of

the posterior shoulder, followed by the arm. More com-

monly, the posterior arm is flexed at the elbow, present-

ing a ‘nuchal hand’ on the ipsilateral side of the head. In

this situation, sweeping the arm or hand across the face

of the baby to the contralateral side of the head allows

significant adduction of the shoulders and delivery of

the posterior arm. Following this, it is relatively easy to

rotate the baby and deliver the anterior shoulder. Deliv-

ery of the posterior arm is associated with an increased

rate of humeral fracture [9]; however, this injury gener-

ally heals very well with no long-term morbidity.

Alternative positions may also be employed that may

facilitate delivery of the baby. In the all-fours maneuver,

the woman is on her hands and knees. The act of turn-

ing the woman or the effect of gravity may result in

favourable rotation of the shoulders without digital pres-

sure. In this position, delivery of the posterior arm may

be facilitated, but suprapubic pressure is not possible

[42•]. This procedure, when used alone, resulted in suc-

cessful delivery within an average of 2–3 minutes in over

80% of cases in one series [43].

There have been numerous anecdotal reports of the uti-

lity of turning the woman to the left lateral position.

The process of turning the woman may be useful, and

the position allows for more lateral traction, particularly

if the woman was initially in a semi-recumbent position

on a delivery bed. There are concerns, however, that the

lateral traction on the fetal head and neck increases the

risk for fetal injury. In addition, appropriate application

of suprapubic pressure is difficult in this position [42•].

Tertiary maneuvers

These are desperate measures, which are considered

only in dire emergencies, when primary and secondary

measures fail to achieve delivery of the baby. These

procedures are associated with the highest risk of fetal

injury and maternal trauma, but may be considered as a

last resort.

Cephalic replacement (Zavanelli maneuver) is essen-

tially a reversal of the delivery process whereby the

fetal neck is flexed, restitution is reversed and the

head rotated back to the occipito-anterior position, and

digital pressure applied to replace the fetal head within

the uterine cavity. The use of tocolysis with terbutaline

or glyceryl trinitrate to facilitate the process has been

described. It is possible that the most severe cases,

with bilateral shoulder dystocia, where both shoulders

are stuck above the pelvic inlet are most amenable to

cephalic replacement. If the posterior shoulder can be

felt in the hollow of the sacrum, the posterior arm

should be delivered as described above.

A symphysiotomy is the only procedure that results in

an absolute increase in pelvic diameters. The technique

is well described but rarely performed. It entails cathe-

terization, a stabbing incision halfway down into the

thickness of the pubic symphysis that allows sponta-

neous separation of the joint from the distending forces.

Complications such as bladder neck injury and infection

have been reported. Postoperative care is important,

when abduction of the hips should be restricted to pre-

vent destabilization of the pelvis through compromising

the sacro-iliac joint.

Deliberate fracture of the clavicle has been described,

by applying upward digital pressure on the fetal clavicle,

against the maternal pubic ramus. Although the fracture

of the clavicle would decrease the bisacromial diameter,

there is a significant risk of brachial plexus injury. The

procedure is seldom performed, and cleidotomy, which

involves separation of the clavicle with a blade or pair of

scissors, is probably best reserved for shoulder dystocia

following an intra-uterine death.

The use of hysterotomy or an upper segment uterine

incision has been described. In this maneuver, the uter-

ine incision allows either more direct pressure to achieve

shoulder rotation or to directly dislodge the anterior

shoulder for vaginal delivery, or the facilitation of cepha-

lic replacement to allow abdominal delivery. This is by

no means always effective, and tragic consequences

have been described [44]. The use of tocolytic agents

to facilitate shoulder rotation or cephalic replacement

has also been described [44].

126 Maternal-fetal medicine

Organization and training of the team

When shoulder dystocia is diagnosed, the immediate

call for help, particularly if an effective activation system

is employed, often results in a crowd of assistants and

spectators. The organization of the team and knowing

where to deploy individuals as they arrive is important

for effective team management. Familiarity with the

organization prepares staff to fill any role in the team,

and helps them to realize what is expected of them in

that role.

The leader of the management team is the first senior

person to arrive at the bedside. This is the primary care

giver and should be the one giving instructions to the

patient and to other staff. The patient is instructed

briefly on the emergency situation and encouraged to

bear down with the primary maneuvers being per-

formed. If no assistance has arrived, the patient herself

and the birth partner should assist in maintaining the

McRoberts position. The accoucheur may apply supra-

pubic pressure directly.

As assistants arrive, they may be deployed in the follow-

ing order of priority: one on each side of the bed to

maintain the McRoberts position (these assistants

should also lower the bed and the side rails); one to

apply suprapubic pressure (should be located on the

side of the bed facing the fetal back to allow ‘adducting’

oblique pressure); one to assist the primary care giver

between the patients legs (to support the head and

neck of the baby and to assist in the secondary maneu-

vers); and one designated record keeper and time

keeper. The neonatologist and anaesthetist may also

be deployed in any of these roles if required unless or

until their specialty role becomes apparent.

As shoulder dystocia is largely unpredictable, all staff in

the delivery suite must be prepared to respond to this

emergency at all times (Clinical Negligence Scheme for

Trusts Maternity Standards [45•]). Training, with the

utilization of models, simulations and drills, can help to

increase the preparedness of staff, allowing them to ade-

quately fill any of the roles in the team [2,45•].

Communication and documentation

Following resolution of an episode of shoulder dystocia,

it is important to speak to the parents of the baby,

explaining the sequence of events, the measures taken

and their rationale. The parents are usually very trauma-

tized by the events and must be approached with great

sensitivity and care.

It is equally important to document the sequence of

events from each team member’s perspective. This

serves as an instructional tool for future reference and

learning, especially when considered in tandem with

the outcome of the baby. Shoulder dystocia is among

the four most common causes of medical litigation in

obstetrics [46] and has been estimated to account for

up to 11% of obstetric claims. Good documentation is

often lacking following an occurrence of shoulder dysto-

cia [47]. If this can be improved and coupled with effec-

tive patient communication we may attain improved

professional safety to practicing obstetricians and gyne-

cologists in case of medical litigation [46].

Conclusion

The 5th Annual Report of the Confidential Enquiry into

Stillbirths and Deaths in Infancy (CESDI) demon-

strated that ‘avoidable factors’ were identified and

‘different management could have reasonably been

expected to have altered the outcome’ in 66% of the

56 infant deaths following shoulder dystocia.

With a high vigilance in all vaginal deliveries, familiarity

with the various maneuvers and an organized system of

team activation and response, we can improve the clin-

ical management of this unpredictable emergency and

improve the outcome of both mother and baby.

References and recommended reading.

Papers of particular interest, published within the annual period of review, havebeen highlighted as:• of special interest•• of outstanding interest

Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 226).

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35

�Gurewitsch ED, Donithan M, Stallings SP, et al. Episiotomy versus fetalmanipulation in managing severe shoulder dystocia: a comparison of out-comes. Am J Obstet Gynecol 2004; 191:911–916.

This paper suggests that an episiotomy may not be required in management ofshoulder dystocia as long as the maneuvers can be completed.

36 Breeze AC, Lees CC. Managing shoulder dystocia. Lancet 2004; 364:2160–2161.

37 Gurewitsch ED, Allen RH. Management of shoulder dystocia. Lancet 2005;365 (9466):1228 (author reply 1228–1229).

38 Cleary-Goldman J, Robinson JN. The role of episiotomy in current obstetricpractice. Semin Perinatol 2003; 27:3–12.

39 McFarland MB, Langer O, Piper JM, et al. Perinatal outcome and the typeand number of maneuvers in shoulder dystocia. Int J Gynecol Obstet 1996;55:219–224.

40 Heath T, Gherman RB. Symphyseal separation, sacroiliac joint dislocationand transient lateral femoral cutaneous neuropathy associated withMcRoberts maneuver. A case report. J Reprod Med 1999; 44:902–904.

41 Ramsey PS, Ramin KD, Field CS. Shoulder dystocia. Rotational maneuversrevisited. J Reprod Med 2000; 45:85–88.

42

�McEwan AJ, IR. The Problem of Shoulder Dystocia. Curr Obstet Gynecol2004; 14:62–67.

A review on the risk factors and management of shoulder dystocia.

43 Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducingshoulder dystocia during labor. J Reprod Med 1998; 43:439–443.

44 Sandmire HF. Catastrophic shoulder dystocia. Int J Gynecol Obstet 2004;85:190–194.

45

�Crofts JF, Attilakos G, Read M, et al. Shoulder dystocia training using a newbirth training mannequin. BJOG 2005; 112:997–999.

This paper illustrates the utility of the use of training mannequins for training staffon the management of shoulder dystocia.

46 Mavroforou A, Koumantakis E, Michalodimitrakis E. Physicians’ liability inobstetric and gynecology practice. Med Law 2005; 24:1–9.

47 Deering S, Poggi S, Hodor J, et al. Evaluation of residents’ delivery notesafter a simulated shoulder dystocia. Obstet Gynecol 2004; 104:667–670.

128 Maternal-fetal medicine