Shoulder Dystocia
For Medical Students, Doctors, Midwives, and Healthcare Professionals
Learning Objectives
By the end of this lesson, participants will be able to:
Define shoulder dystocia and understand its pathophysiology
Identify risk factors and recognize clinical signs
Apply systematic management protocols (HELPERR mnemonic)
Understand prevention strategies and documentation requirements
Recognize complications and implement appropriate follow-up care
Definition and Pathophysiology
Shoulder Dystocia is an obstetric emergency occurring when the fetal head delivers but the anterior shoulder becomes impacted behind the maternal symphysis pubis, preventing delivery of the body.
Incidence: 0.2-3% of all vaginal deliveries, with higher rates in diabetic pregnancies and macrosomic infants.
Pathophysiology:
Disproportion between fetal shoulder diameter and maternal pelvic outlet
Most commonly involves anterior shoulder impaction behind symphysis pubis
Posterior shoulder may also impact on sacral promontory
Increases risk of brachial plexus injury, fractures, and asphyxia
Risk Factors
Maternal Factors:
Diabetes mellitus (pre-gestational or gestational)
Obesity (BMI >30 kg/m²)
Previous history of shoulder dystocia
Prolonged second stage of labor
Assisted vaginal delivery (forceps/vacuum)
Maternal height <150cm
Fetal Factors:
Macrosomia (estimated fetal weight >4000g or >4500g)
Post-term pregnancy (>42 weeks)
Male fetus
Labor Factors:
Prolonged first stage of labor
Secondary arrest of labor
Precipitous delivery
Clinical Recognition
Cardinal Sign: "Turtle sign" - fetal head retracts against the perineum after delivery, resembling a turtle withdrawing into its shell.
Other Signs:
Inability to deliver shoulders with normal gentle downward traction
Difficulty visualizing the neck
Impaction sensation during attempted delivery
Time Factor: Diagnosis is confirmed when shoulders fail to deliver within 60 seconds of head delivery or after gentle traction attempts.
Management Protocol: HELPERR Mnemonic
H - Help: Call for immediate assistance
Experienced obstetrician
Anesthesiologist
Pediatrician/neonatologist
Additional nursing staff
E - Evaluate for Episiotomy
Consider generous mediolateral episiotomy if needed for space
Not always necessary but may facilitate maneuvers
L - Legs (McRoberts Maneuver)
Hyperflex maternal hips to chest (135° flexion)
Most effective single maneuver (success rate 42-90%)
Flattens sacrum and increases pelvic outlet
P - Pressure (Suprapubic Pressure)
Apply firm, continuous pressure above symphysis pubis
Direction: posteriorly and caudally
Never apply fundal pressure (contraindicated)
E - Enter the Vagina (Internal Maneuvers)
Rubin's Maneuver: Push posterior aspect of anterior shoulder toward fetal chest
Woods' Screw Maneuver: Rotate posterior shoulder 180° in corkscrew fashion
R - Remove Posterior Arm
Insert hand posteriorly, grasp fetal forearm
Flex elbow and sweep arm across chest and out
Success rate: 72-84%
R - Roll Over (Gaskin Maneuver)
Position mother on hands and knees
Allows posterior shoulder to become anterior
Useful when other maneuvers fail
Additional Maneuvers (if HELPERR fails)
Zavanelli Maneuver:
Replace fetal head into vagina and perform cesarean section
Rarely used, high morbidity
Consider only when all else fails
Symphysiotomy:
Division of symphysis pubis
Rarely performed in developed countries
Reserved for extreme cases
Complications
Maternal:
Postpartum hemorrhage (11-25%)
Third and fourth-degree perineal tears
Uterine rupture (rare)
Psychological trauma
Fetal/Neonatal:
Brachial plexus injury (4-40%)
Erb's palsy (C5-C6)
Klumpke's palsy (C8-T1)
Clavicular fracture (10-15%)
Humeral fracture (4%)
Hypoxic brain injury
Perinatal death (rare, <1%)
Prevention Strategies
Antepartum:
Optimize maternal glucose control in diabetic patients
Consider elective cesarean section for estimated fetal weight >4500g (diabetic) or >5000g (non-diabetic)
Discuss delivery options with high-risk patients
Intrapartum:
Avoid excessive fundal pressure during delivery
Consider assisted delivery risks in macrosomic pregnancies
Prepare for potential shoulder dystocia in high-risk cases
Documentation Requirements
Essential Elements:
Time of head delivery
Time to diagnosis recognition
Maneuvers performed and sequence
Personnel involved
Fetal condition at birth
Maternal condition
Complications identified
Legal Considerations:
Thorough, contemporaneous documentation
Clear timeline of events
Objective description of maneuvers
Communication with family documented
Post-Delivery Management
Immediate Care:
Neonatal resuscitation if required
Assessment for birth injuries
Maternal assessment for complications
Adequate pain relief and support
Follow-up:
Pediatric evaluation for brachial plexus injury
Physiotherapy referral if indicated
Maternal debriefing and psychological support
Documentation review and learning opportunities
References
American College of Obstetricians and Gynecologists. (2022). Shoulder Dystocia. Practice Bulletin No. 178. Obstet Gynecol, 140(5), 1083-1095.
Royal College of Obstetricians and Gynaecologists. (2012). Shoulder Dystocia. Green-top Guideline No. 42. RCOG Press.
Gherman, R.B., Chauhan, S.P., Ouzounian, J.G., et al. (2006). Shoulder dystocia: the unpreventable obstetric emergency with empirical management guidelines. Am J Obstet Gynecol, 195(3), 657-672.
Hoffman, M.K., Bailit, J.L., Branch, D.W., et al. (2014). A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol, 123(2 Pt 1), 272-278.
World Health Organization. (2015). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization.
Collège National des Gynécologues et Obstétriciens Français. (2018). Dystocie des épaules. Recommandations pour la pratique clinique. CNGOF.
Society of Obstetricians and Gynaecologists of Canada. (2016). Shoulder Dystocia. SOGC Clinical Practice Guideline No. 296. J Obstet Gynaecol Can, 38(8), 723-734.
Leung, T.Y., Stuart, O., Suen, S.S., et al. (2011). Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres: a retrospective review. BJOG, 118(8), 985-990.
Chauhan, S.P., Gherman, R., Hendrix, N.W., et al. (2010). Shoulder dystocia: comparison of the ACOG practice bulletin with another national guideline. Am J Perinatol, 27(2), 129-136.
Doumouchtsis, S.K., Arulkumaran, S. (2006). Head-to-body delivery interval in shoulder dystocia: does it affect neonatal outcome? BJOG, 113(10), 1133-1137.
