Shoulder dystocia


Shoulder dystocia occurs when, after delivery of the head of the newborn, the baby’s anterior shoulder gets caught above the mother’s pubic bone.

Frequency is about 1% of vaginal births.

No satisfactory clinical method that predicts shoulder dystocia.

Signs of shoulder dystocia, include retraction of the babies head back into the vagina, known as “turtle sign”.

Complications in the newborn, may include brachial plexus injury or clavicle fracture.

Complications for the mother may include vaginal or perineal tears, postpartum bleeding, or uterine rupture.

Risk factors for shoulder dystocia: Gestational diabetes, previous history of the condition, operative vaginal delivery, obesity in the mother, an overly large baby, epidural anesthesia.

Shoulder dystocia is also more prevalent among women with obesity than normal weight women by a factor of 2 to 2.5 among women with a BMI of 35 or higher.

It is diagnosed when the body fails to deliver within one minute of delivery of the baby’s head.

In a minority of shoulder dystocia deliveries the turtle sign, involving the appearance and retraction of the baby’s head, occurs when the baby’s shoulder is obstructed by the maternal pelvis.

It is a type of obstructed labor, and it is an obstetric emergency.

Efforts to release a shoulder include: a woman on her back pushing the legs outward and upward, pushing on the abdomen above the pubic bone, and making a cut in the vagina, manually rotate the babies shoulders or placing the women on all fours.

Death as a result of shoulder dystonia is very rare.

A complication of shoulder dystocia is damage to the upper brachial plexus nerves, supplying the sensory and motor components of the shoulder, arm and hands.

The ventral roots, containing the motor pathway, are most vulnerable to injury.

Manual stretching of the nerves is the proposed mechanism of injury, with tearing of the nerve roots.

Risk factors:

Age >35

Short in stature

Small or abnormal pelvis

More than 42 weeks gestation

Estimated fetal weight > 4500g

Maternal diabetes with a-4 fold increase in risk.

Need for oxytocics.

Prolonged first or second stage of labor.

Turtle sign

No shoulder rotation or descent

Instrumental delivery.

Recurrence rates are relatively high.

Shoulder dystocia in a previous delivery increases the risk, 10% higher than in the general population.

About 16% of deliveries where shoulder dystocia occurs have conventional risk factors including: diabetes, fetal macrosomia, and maternal obesity.

Treating a shoulder dystocia the following procedures are performed in the order listed and the sequence ends whenever a technique is successful.

Ask for help of an obstetrician, anesthesia, and for subsequent resuscitation of the infant that may be needed.

Leg hyperflexion and abduction at the hips, the McRoberts’ maneuver.

McRobert’s maneuver is effective in 40-80% of patients.

Anterior shoulder disimpaction by suprapubic pressure.

Rotation of the shoulder by Rubin maneuver.

Manual delivery of posterior arm.


Roll over on all fours

Intentional fracturing the clavicle is another prior to Zavanelli’s maneuver or symphysiotomy, both of which are considered extraordinary treatment measures.

Labor positions and maneuvers are sequentially performed in attempt to facilitate delivery, including:


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