Shoulder Dystocia

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6/16/2021 Shoulder dystocia: Intrapartum diagnosis, management, and outcome - UpToDate

Official reprint from UpToDate®

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© 2021 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Shoulder dystocia: Intrapartum diagnosis, management,


and outcome
Author: John F Rodis, MD
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2021. | This topic last updated: Apr 08, 2021.

INTRODUCTION

A vaginal delivery is complicated by shoulder dystocia when, after delivery of the fetal head,
additional obstetric maneuvers beyond gentle traction are needed to enable delivery of the
fetal shoulders. It represents an obstetric emergency. Few shoulder dystocias can be
anticipated and prevented, as most occur in the absence of risk factors. Therefore, the obstetric
provider must be prepared to recognize a shoulder dystocia immediately and proceed through
an orderly sequence of steps to accomplish delivery in a timely manner. The goal of
management is to prevent fetal asphyxia and permanent Erb's palsy or death, while avoiding
physical injury (eg, fetal fracture, maternal tissue trauma), but the latter is acceptable if needed
to prevent permanent injury in the child.

Intrapartum diagnosis and management of shoulder dystocia will be reviewed here. Risk factors
for shoulder dystocia and planning delivery of pregnancies at high risk are discussed
separately. (See "Shoulder dystocia: Risk factors and planning delivery of high-risk
pregnancies".)

PATHOPHYSIOLOGY

● Normal descent of the shoulders – Normally, the fetal bisacromial diameter (the distance
between the outermost parts of the fetal shoulders) enters the pelvis at an oblique angle
with the posterior shoulder ahead of the anterior one, rotating to an anterior-posterior

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position at the pelvic outlet with external rotation of the fetal head. The anterior shoulder
can then slide under the symphysis pubis for delivery ( figure 1).

● Descent in shoulder dystocia – If the fetal shoulders remain in an anterior-posterior


position during descent or descend simultaneously rather than sequentially into the pelvic
inlet, then the anterior shoulder can become impacted behind the symphysis pubis or
descent of the posterior shoulder may be obstructed by the sacral promontory. Anterior
obstruction is more common than posterior obstruction.

It is hypothesized that failure of the bisacromial diameter to undergo normal rotation to an


oblique position occurs because of resistance between the fetal skin and vaginal walls;
resistance of a large fetal chest relative to the biparietal diameter, which may occur with
macrosomia; or because of rapid fetal descent, which may occur with precipitous labor
[1,2].

● Mechanisms of injury – Neonatal injuries diagnosed at birth may be caused by prenatal,


as well as intrapartum, events. If descent of the fetal head continues while descent of the
anterior or posterior shoulder remains obstructed, then the nerves in the brachial plexus
may stretch, which may result in nerve injury. Umbilical cord compression, compression of
fetal neck vessels leading to cerebral venous obstruction, excessive vagal stimulation and
bradycardia, or a combination of factors may result in asphyxia [3,4]. In addition, the
provider's attempt to deliver the fetus may result in traumatic injury.

PREVALENCE

Shoulder dystocia occurs in 0.2 to 3.0 percent of births [5]. The wide variation is due to
differences in the prevalence of macrosomia and diabetes among study populations and to the
subjective nature of the diagnosis, which is based on the provider's assessment of the difficulty
of the delivery. (See 'Diagnosis' below.)

The prevalence of shoulder dystocia has been increasing, probably related to the increasing
prevalence of risk factors for high birth weight, such as maternal obesity and diabetes [6,7].

DIAGNOSIS

Clinical criteria — Shoulder dystocia is a subjective clinical diagnosis. It should be suspected


when the fetal head retracts into the perineum after expulsion (ie, turtle sign) due to reverse
traction from the impacted shoulders at the pelvic inlet. The diagnosis is made when the

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routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of
the anterior shoulder.

Severity of shoulder dystocia is also subjective and decided retrospectively based on need for
multiple maneuvers to effect delivery and whether or not the fetus and/or the mother
sustained injury as a result.

Attempts at objective criteria for diagnosis — A more objective definition would be more
useful, but none are widely accepted. The most common objective criteria for diagnosis of
shoulder dystocia is a head-to-body delivery interval >60 seconds, which was two standard
deviations above the mean value (24 seconds) of 210 deliveries that did not necessitate any
ancillary obstetric maneuvers (eg, McRoberts position, delivery of the posterior arm, suprapubic
pressure) [8]. A head-to-body delivery interval >60 seconds was subsequently found to identify
newborns with higher birth weight, lower one-minute Apgar scores, and higher prevalence of
birth injury, thus supporting its use as an objective criteria for shoulder dystocia [9]. Although
promising, this definition has not been studied extensively and further investigation is needed
to validate its use for diagnosis of shoulder dystocia and determine the optimum threshold for
predicting adverse neonatal outcomes.

MANAGEMENT

General principles

● Shoulder dystocia is an obstetric emergency.

● Shoulder dystocia cannot be accurately predicted by antenatal or intrapartum risk factors,


and thus it and its associated complications cannot be consistently avoided (see "Shoulder
dystocia: Risk factors and planning delivery of high-risk pregnancies"). Therefore, the
clinician should be prepared for possible shoulder dystocia in all vaginal deliveries, be
cognizant of the various maneuvers that have been shown to be effective for delivering the
impacted shoulders, and have a step-wise plan of action, which allows expeditious
execution of diagnosis and treatment.

● The goal of management is to safely effect delivery of the infant before asphyxia and
cortical injury occur from umbilical cord compression and impeded inspiration, and without
causing peripheral neurologic injury or other fetal or maternal trauma.

● Most interventions are intended to disimpact the anterior shoulder from behind the
symphysis pubis by rotating the fetal trunk or delivering the posterior arm and shoulder.

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● In general, the operator has up to five minutes to deliver a previously well-oxygenated term
infant before the risk of asphyxial injury increases [10-12]. The mean umbilical artery pH at
term is 7.27; in two studies, umbilical artery pH was estimated to fall 0.01 and 0.04 pH units
per minute, respectively, in the interval between delivery of the fetal head and the rest of
the body [11,13]. However, in practice, there is a poor correlation between the head-to-
body delivery interval and pH, pCO2, base deficit, neonatal encephalopathy, or death [3,5].
(See "Umbilical cord blood acid-base analysis at delivery".)

Preparation of patient and personnel — When shoulder dystocia is suspected, the pregnant


person and labor room personnel should be given clear instructions and the following
measures are initiated.

● The time of diagnosis is documented. Some providers find it useful for a nurse to verbally
note the passage of time since diagnosis in 60-second increments.

● The patient is told not to push while preparations are made and maneuvers are
undertaken to reposition the fetus.

● Nursing, anesthesia, obstetric, and pediatric staff are called to the labor room, if not
already available, to provide assistance as needed.

● The patient is positioned with their buttocks flush with the edge of the bed to provide
optimal access for executing maneuvers to effect delivery.

● A tight nuchal cord, if present, is released over the fetal head and left intact as umbilical
blood flow helps in neonatal resuscitation and transition. Clamping and cutting the cord
does not help to release the impacted shoulder. If cutting the cord is necessary to extract
the fetus, it should be done after the shoulder dystocia has been resolved.

Clamping and cutting the cord with the head at the perineum is potentially harmful if a
Gunn-Zavanelli-O’Leary maneuver is performed since there is no oxygen delivery to the
fetus between the time the cord is clamped and cut and the time of birth via cesarean [14-
16]. (See 'Gunn-Zavanelli-O'Leary maneuver' below.)

● Excessive downward traction, greater than usual head and neck traction, and fundal
pressure should be avoided because this combination of maneuvers can stretch and injure
the brachial plexus [3,17-20]. These actions may also further impact the shoulders and
cause uterine rupture or other injury. (See 'Avoid forceful downward traction' below and
'Avoid excessive traction on the head and neck' below.)

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● Performing a mediolateral episiotomy may be useful to facilitate delivery of the posterior


shoulder and other internal procedures, but does not by itself help to release the anterior
shoulder and increases perineal trauma [21]. If the perineum was not adequately surgically
incised or lacerated with expulsion of the fetal head, cutting or extending the existing
mediolateral or median episiotomy/laceration immediately following failed downward
traction with and without McRoberts maneuver and before attempting any of the vaginal
maneuvers for resolution of the dystocia is a practical approach. (See "Approach to
episiotomy", section on 'Complications'.)

● A distended bladder, if present, should be drained, which will facilitate suprapubic pressure
and may reduce any space-occupying effects of a full bladder in the vagina.

Avoid forceful downward traction — Although some downward traction on the fetal neck is
necessary to release the anterior shoulder, forceful and excessive downward traction alone
should be avoided because it can increase the risk of fetal injury. We agree with American
College of Obstetricians and Gynecologists’ guidance to apply axial traction in alignment with
the fetal cervico-thoracic spine with a downward component along a vector no more than 45
degrees below the horizontal plane when the laboring patient is in a lithotomy position [5].

The potential harm of forceful downward traction is well-accepted and based on clinical
experience and biologic plausibility, but published data are limited. A retrospective study
reported four cases of shoulder dystocia managed with forceful downward traction on the fetal
neck alone: three were associated with brachial plexus injury and one had a clavicular fracture
[20].

Avoid excessive traction on the head and neck — Clinicians should think about whether
they are applying greater than normal force to deliver the shoulders, and if they perceive this is
the case, then this perception should prompt utilization of maneuvers to resolve the dystocia.
After releasing the shoulder, normal traction will allow delivery of the infant.

Since further descent of the fetal shoulder is prevented by the maternal pelvic bones, increasing
traction is counterproductive and maneuvers to release the impacted shoulder are needed to
resolve the dystocia [22]. A study using force-sensing devices on 29 randomly selected vaginal
births found that clinician-applied peak forces are approximately 47 Newtons (N) for routine
deliveries, 69 N for difficult deliveries, and 100 N for shoulder dystocia deliveries [23]. In one
case, fracture of the clavicle occurred at peak force of approximately 100 N, and appeared to be
related to applying a high peak force quickly rather than gradually and for applying it for a
prolonged period of time (over 30 seconds). However, measuring traction forces during
shoulder dystocia management is not practical.

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Our approach to management

● Step 1: Perform McRoberts maneuver – We perform the McRoberts maneuver first without
and then with suprapubic pressure as the initial approach for releasing the impacted
shoulder, given that it is less invasive than other maneuvers. (See 'McRoberts maneuver'
below and 'McRoberts maneuver with suprapubic pressure' below.)

● Step 2: Deliver the posterior arm – If the McRoberts maneuver with suprapubic pressure is
unsuccessful, we suggest delivery of the posterior arm. Some authorities suggest
beginning with delivery of the posterior arm because of its high success rate, even though
it is a more invasive approach [24]. (See 'Delivery of the posterior arm' below.)

● Step 3: Apply axial traction to deliver the posterior shoulder – If it is not possible to reach
the elbow or forearm because the posterior arm is above the pelvic brim, we attempt to
deliver the posterior shoulder via the axilla, which almost always enables resolution of the
dystocia. (See 'Axillary traction for delivery of the posterior shoulder' below.).

● Step 4: Fracture the clavicle – In the rare cases where shoulder dystocia persists at this
stage, we would fracture the clavicle. (See 'Clavicular fracture' below.)

The initial approach may vary depending upon the clinical situation, clinician preference,
accessibility of assistants, and availability of anesthesia. For example, if the patient has severe
obesity, the author may omit suprapubic pressure. Or if another obstetric provider has tried to
manage a shoulder dystocia, but is unsuccessful, and the author is called to help with the
emergency, he usually immediately attempts to deliver the posterior arm as this maneuver is
often successful and avoids more traction on the fetal head and brachial plexus.

There are no randomized trials comparing results from use of the various maneuvers. The
general consensus is that no maneuver is clearly superior for resolving the dystocia and
preventing fetal brachial plexus injury [5,25,26], as all maneuvers can increase the degree of
stretch on the brachial plexus [27].

It is reasonable to attempt each maneuver a couple of times before quickly moving on to the
next maneuver. As more approaches are attempted, the likelihood of success increases, but the
risk of fetal injury also increases, which may reflect increasingly severe dystocia rather than use
of increasingly morbid approaches [28,29].

Descriptions of maneuvers for release of impacted shoulders

Initial group of maneuvers

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McRoberts maneuver — We suggest the McRoberts maneuver as the initial approach for
releasing the impacted shoulder because it is less invasive than other maneuvers and often
successful, in agreement with the American College of Obstetricians and Gynecologists [5].

● Technique – The McRoberts maneuver requires two assistants, each of whom grasps a
maternal leg and sharply flexes the thigh back against the abdomen ( figure 2) [30]. This
procedure relieves shoulder dystocia via marked cephalad rotation of the symphysis pubis
and subsequent flattening the sacrum, thus removing the sacral promontory as an
obstruction site ( figure 3) [30,31]. In addition, by bringing the pelvic inlet into the plane
perpendicular to the maximum expulsive force, pushing efficiency improves significantly
[32]. McRoberts maneuver does not change the actual dimensions of the maternal pelvis.

● Success rate – McRoberts position alone has successfully alleviated shoulder dystocia in as
many as 42 percent of patients [33]. There is no clear advantage to performing the
maneuver before diagnosis of shoulder dystocia; however, evidence is limited as available
trials are small and underpowered to detect moderate benefits from prophylactic
intervention [34]. On the other hand, there is no disadvantage in employing the maneuver
prophylactically in patients at high risk of shoulder dystocia.

● Complications – Complications are rare. Excessive force or prolonged placement of the


patient's legs in a hyperflexed position has led to maternal complications, such as
symphyseal separation, sacroiliac joint dislocation, and transient lateral femoral cutaneous
neuropathy, in case reports [35].

McRoberts maneuver with suprapubic pressure — This maneuver is most useful in mild


cases of shoulder dystocia and those caused by an impacted anterior shoulder.

It requires use of an assistant to apply pressure suprapubically (not fundally) with the palm or
fist, directing the pressure on the anterior shoulder both downward (to below the pubic bone)
and laterally (toward the fetal face or sternum) in conjunction with the McRoberts maneuver (
figure 2). Suprapubic pressure is supposed to adduct the shoulders or bring them into an
oblique plane, since the oblique diameter is the widest diameter of the maternal pelvis.

Delivery of the posterior arm — Delivery of the posterior arm almost always relieves
impaction of the anterior shoulder and resolves the dystocia [26,36]. It is an appropriate second
maneuver if the less technically demanding and often successful McRoberts maneuver and
suprapubic pressure fail [26]. Ideally, the patient should have adequate anesthesia.

● Technique – A hand is inserted into the vagina to locate the posterior shoulder and arm. If
the fetal abdomen faces the maternal right, the operator's left hand is used; if the fetal
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abdomen faces the maternal left, the right hand is used.

The posterior arm is identified and followed to the elbow. If the elbow is flexed, the
operator can grasp the forearm and hand and pull out the arm. If it is extended, pressure is
applied in the antecubital fossa. This flexes the elbow across the fetal chest and allows the
forearm or hand to be grasped.

The arm is then pulled out of the vagina, which also delivers the posterior shoulder and
reduces the shoulder diameter by 2 to 3 cm as the 13 cm bisacromial diameter becomes a
10 to 11 cm axilloacromial diameter ( figure 4) [24].

If the anterior shoulder cannot be delivered at this point, the fetus can be rotated and the
procedure repeated for the anterior (now posterior) arm.

A similar procedure is followed if the arm is trapped behind the fetus. In this case,
manipulation of the forearm so that it can be swept ventrally and out the vagina may
involve deliberate or inadvertent fracture of the humerus.

● Complications – The greatest risk with delivery of the posterior arm is fracture of the
humerus, which has been reported in 0 to 20 percent of cases; the risk is highest when
used after other maneuvers have failed [20,37-39]. To minimize this risk, it is important to
apply pressure at the antecubital fossa to flex the fetal forearm and then sweep it out over
the infant's chest, rather than grasping and pulling directly on the fetal arm or mid-humeral
shaft.

Axillary traction for delivery of the posterior shoulder — If it is not possible to reach
the elbow or forearm because the posterior arm is above the pelvic brim, it may be possible to
deliver the posterior shoulder before delivering the arm [40-42].

● Technique

• After an assistant gently flexes the fetal head toward the anterior shoulder, the
obstetrician places their right middle finger into the fetus's posterior axilla from the left
side of the pelvis and the left middle finger into the posterior axilla from the right side
of the pelvis (Menticoglou maneuver) ( figure 5).

The two middle fingers in the axilla are then used to pull the posterior shoulder
downward along the curve of the sacrum.

Once the shoulder has been brought down sufficiently, the posterior arm can be
grasped and delivered.

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Pulling the posterior shoulder into the posterior pelvic space may release the anterior
shoulder or allow a rotational maneuver to release the anterior shoulder.

• An alternative approach is for the clinician to insert their hand into the posterior pelvis,
slide the first finger under the axilla and the thumb over the top of the shoulder so that
the fingers encircle the shoulder and the tips of the thumb and first finger touch [43].

The second finger is placed alongside the fetal humerus to hold the arm against the
body.

Traction is then applied through the axilla along the sacral curve until the posterior
shoulder appears over the perineum and the anterior shoulder pivots around the
symphysis.

The posterior shoulder is delivered, followed by the anterior shoulder.

This approach was highly successful (>95 percent) as a first maneuver in a series of 119
cases [43].

● Complications – These maneuvers may be associated with an increased risk of fracture but
do not appear to increase the risk for brachial plexus injury.

Secondary maneuvers

Rubin maneuver — The Rubin maneuver causes adduction of the fetal shoulder so that
the shoulders are displaced from the anteroposterior diameter of the inlet, thereby allowing the
posterior arm to enter the pelvis [44]. Use of a laboratory birthing simulator showed that the
Rubin maneuver required less traction force and resulted in less brachial plexus extension than
the McRoberts maneuver [45]. However, it is more invasive than the McRoberts procedure and
less easily performed in patients without anesthesia.

● Technique

• Under adequate anesthesia, the clinician places one hand in the vagina and on the
back surface of the posterior fetal shoulder, and then rotates it anteriorly (towards the
fetal face). If the fetal spine is on the maternal left, the operator's right hand is used;
the left hand is used if the fetal spine is on the maternal right ( figure 6).

• Alternatively, the Rubin maneuver can be attempted by placing a hand on the back
surface of the anterior fetal shoulder, if it is more accessible.

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Another approach is to combine the Rubin maneuver on the back of the posterior shoulder with
external suprapubic pressure on the front of the anterior shoulder in the opposite direction or
with the McRoberts maneuver. Alternatively, the Rubin and Woods (see below) procedures can
be combined so that one shoulder is being pushed from the back and the other shoulder is
being pushed from the front in the same clockwise or counterclockwise direction. This increases
the rotational force on the shoulders.

Woods screw maneuver — Woods likened shoulder dystocia to the "crossed thread" of a


bolt into a nut. Although a bolt cannot be forced into a nut, it goes through easily when turned
repeatedly [46].

● Technique – The Woods screw maneuver rotates the fetus by exerting pressure on the
anterior, clavicular surface of the posterior shoulder to turn the fetus until the anterior
shoulder emerges from behind the maternal symphysis ( figure 7).

If the fetal spine is on the maternal left, the operator uses the left hand to push on the
clavicle of the posterior arm and rotate the fetus 180 degrees in a counterclockwise
direction. The fetal head and neck should not be twisted. If counterclockwise rotation is
unsuccessful, clockwise rotation may release the shoulder.

As discussed above, the Woods and Rubin maneuvers can be combined so that one
shoulder is being pushed from the front and the other shoulder is being pushed from the
back in the same clockwise or counterclockwise direction. This increases the rotational
force on the shoulders.

Shoulder shrug variation — The shoulder shrug maneuver is a variation of the Woods


screw maneuver [47]. It was described in a report in which its use resolved three cases of
dystocia.

● Technique – The posterior shoulder is grasped at the axilla using the provider's thumb and
index finger in a pincer grip, the axilla is pulled out toward the fetal head to shrug the
shoulder, using the opposite hand to hold the head.

The head and shoulder are then rotated together as a unit 180 degrees toward the fetus's
face to release the anterior shoulder and resolve the dystocia.

Although experience with the maneuver is limited, it is unlikely to be harmful and might
help in cases in which the posterior shoulder is in the pelvis.

Clavicular fracture — The clavicle can be intentionally fractured to shorten the bisacromial


diameter.
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● Technique – The operator uses their fingers to pull the anterior clavicle outward until it
breaks.

● Complications – Intentional clavicular fracture can be difficult to perform and can lead to
injury of underlying vascular and pulmonary structures. Nevertheless, it is less morbid than
the procedures of last resort described below. (See 'Procedures of last resort' below.)

Other maneuvers — The role of the following maneuvers in management of shoulder


dystocia is unclear. They are less well studied than the maneuvers described above, but both
are supported by some evidence.

Gaskin all-fours maneuver — This maneuver, first introduced by Ina May Gaskin, CPM,
places the mother on her hands and knees [48], but not in the knee-chest position. An
alternative is a racing start or "sprinter" position. These positions increase the space in the
hollow of the sacrum and take advantage of gravity, which together facilitate delivery by gentle
downward traction on the posterior shoulder (the shoulder against the maternal sacrum) or
upward traction on the anterior shoulder (the shoulder against the maternal symphysis).

Although not used by most obstetricians, this is one of the initial group of maneuvers used by
some midwives and other clinicians, particularly for the mother in a birthing bed with no or only
local or pudendal anesthesia. Some providers prefer to use it before attempting to deliver the
posterior arm or shoulder since the latter require more technical expertise. Although the
available literature on this maneuver is limited, it supports both the efficacy and low morbidity
of this simple approach [49-52].

Posterior axilla sling traction (PAST) — If the posterior arm and shoulder cannot be
delivered by the methods described above, case reports have described successful outcomes
using a sling to exert traction on the posterior shoulder. This technique may be successful when
other methods fail because it eliminates the space occupied in the pelvis by the operator's
fingers, but may have higher morbidity than other approaches. Until more safety data are
available, we suggest reserving it for cases in which other commonly used techniques have
failed.

● Technique – A size 12 or 14 French soft suction catheter or urinary catheter is folded into a
loop over the operator's index finger and fed through the posterior axilla until the loop can
be retrieved with the operator's other index finger.

The loop is then unfolded to create a sling around the posterior shoulder.

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The two ends of the sling are clamped and moderate traction is applied to the sling to
deliver the shoulder.

The sling can also be used to rotate the shoulders through 180 degrees assisted by counter
pressure on the back of the anterior shoulder.

● Success rate – In a series of 19 cases managed with this technique, four neonates had
transient Erb's palsy and one had permanent Erb's palsy of the anterior arm, and three
neonates had posterior arm humerus fractures [53]. Five of the 19 newborns had died in
utero.

Procedures of last resort — If shoulder dystocia occurs in a labor room and cannot be
resolved by the maneuvers described above, the patient should be moved to an operating room
for cesarean delivery after the Gunn-Zavanelli-O’Leary maneuver, the abdominal rescue
procedure, or symphysiotomy.

Gunn-Zavanelli-O'Leary maneuver — This procedure requires replacement of the fetal


head in the pelvis, followed by cesarean delivery [54].

● Technique – Administer terbutaline (0.25 mg subcutaneously) or another uterine relaxant


(nitroglycerin 50 mcg intravenously in aliquots of 50 mcg every minute as needed to relax
the uterus, to a maximum dose of 250 mcg; an initial bolus of 100 to 200 mcg can be used
but increases the risk of hypotension).

Place a fetal scalp electrode to monitor the fetal heart rate. Bradycardia is common from
head compression during the maneuver.

Rotate the head back to an occiput anterior position (reversal of restitution).

Flex the head from its extended position and push it as far cephalad as possible using firm
pressure with the palm of one hand. The other hand may be used to depress the perineum.
This may relieve umbilical cord compression.

If cephalic replacement is successful, the patient is prepared for surgery and cesarean
delivery is performed.

● Success rate – Over 100 such procedures have been reported, mostly in single case reports,
with a high rate of success [55].

Abdominal rescue — Abdominal rescue has been described in case reports where


classical maneuvers and the Gunn-Zavanelli-O’Leary maneuver were unsuccessful. A low

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transverse hysterotomy is performed to allow transabdominal manual rotation of the anterior


shoulder to the oblique diameter [56,57]. The fetus is then delivered vaginally.

Symphysiotomy — Symphysiotomy (surgical division of the cartilage of the symphysis


pubis) allows the pubic bones to separate, thereby increasing the size of the pelvic opening and
relieving the obstruction to delivery. It is rarely used except in remote areas of resource-limited
countries where operating rooms are unavailable [58]. Although effective [59], we recommend
avoiding symphysiotomy unless all other maneuvers have failed and cesarean delivery is not
possible. If no other option is available, symphysiotomy may be lifesaving. The procedure,
which is also used to release an entrapped fetal head in breech birth, is described separately.
(See "Delivery of the singleton fetus in breech presentation", section on 'Head entrapment'.)

DOCUMENTATION

Clear and complete documentation in the medical record is critically important after deliveries
complicated by shoulder dystocia, as illustrated by the examples in the figure ( figure 8A-B).
We suggest including the following information:

● The best estimate of fetal weight (clinical or ultrasound) should be noted on the labor
admission physical examination. Although the error in estimated fetal weight at term may
be large, documentation confirms that the weight was assessed in consideration of
delivery.

● An operative vaginal delivery should have a description of the indication, fetal station,
position of the head, instrument used, and time required to effect delivery.

● The time the diagnosis of shoulder dystocia was made, how the diagnosis was made, and
the position of the head should be described.

● Each of the steps taken to resolve the dystocia, the order in which they were taken, and the
results, should be described. The elapsed time should be recorded as accurately as
possible.

All significant personnel involved, including nurses, anesthesiologists, pediatricians, and


other obstetric staff should write their own notes.

● Umbilical cord gases (arterial and venous) should be obtained at birth in all shoulder
dystocia cases, even if the infant does not appear to be depressed.

● The time the pediatrician and anesthesiologist were called to the delivery should be noted.

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In addition, the provider should discuss the events that occurred at delivery with the mother,
including an explanation of the problem, the steps taken to correct it, and possible sequelae.

COMPLICATIONS

Infant — Approximately 95 percent of shoulder dystocias were not associated with injury to the
newborn, in a large series (n = 2018 cases) [26]. Injury among the remaining newborns was due
to trauma, asphyxia, or both. The following types and frequencies of newborn injury have been
described in studies including at least 100 cases of shoulder disorder [3,26]. The newborn may
have more than one injury.

● Transient brachial plexus palsy (3.0 to 16.8 percent)


● Clavicular fracture (1.7 to 9.5 percent)
● Humerus fracture (0.1 to 4.2 percent)
● Permanent brachial plexus palsy (0.5 to 1.6 percent)
● Hypoxic-ischemic encephalopathy (0.3 percent [26])
● Death (0 to 0.35 percent)

Clavicular and humeral fractures generally have a benign course, with complete recovery and
no neurological or orthopedic sequelae [60]. The majority of brachial plexus palsies resolve with
conservative therapy, but some children have persistent functional impairment and other
associated morbidities (eg, Horner syndrome). The pathogenesis, clinical features, evaluation,
management, and prognosis of neonatal brachial plexus palsy are discussed in detail
separately. (See "Neonatal brachial plexus palsy".)

It is important to note that neonatal morbidity can occur even when shoulder dystocia is
managed appropriately. Although shoulder dystocia is a major risk factor for brachial plexus
injury [61], many cases of fractured clavicle or brachial plexus injury are not due to shoulder
dystocia or excessive force by the provider. In fact, several series reported antecedent shoulder
dystocia in no more than one-half of the cases of brachial plexus injury in infants [61-64]. A
prenatal insult was documented in a significant number of affected infants [63,64] and these
injuries have been reported following cesarean deliveries [65]. Thus, the forces of labor, fetal
position, and maternal pushing may be sufficient to cause excessive traction on the brachial
plexus [66,67] and fetal bones [68].

Maternal — The most common serious maternal complications of shoulder dystocia are


hemorrhage and fourth-degree lacerations, which occurred in 11 and 3.8 percent of
pregnancies, respectively, in one retrospective study [33]. (See "Overview of postpartum

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hemorrhage" and "Evaluation and management of female lower genital tract trauma" and
"Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation,
and management".)

Additional complications that occur rarely and are most likely related to provider maneuvers to
relieve dystocia include maternal symphyseal separation, lateral femoral cutaneous
neuropathy, cervicovaginal lacerations, urethral injury, bladder laceration, and uterine rupture
[33,69-72].

REDUCING THE RISK OF COMPLICATIONS

Drills — The US Joint Commission (formerly JCAHO) recommends that obstetric departments


consider periodically conducting clinical drills to help staff prepare for shoulder dystocia,
conduct debriefings to evaluate team performance, and identify areas for improvement [73].
Such drills appear to improve recognition and management of shoulder dystocia, and there is
some evidence of improvement in neonatal outcome. (See "Reducing adverse obstetric
outcomes through safety sciences", section on 'Shoulder dystocia'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Shoulder dystocia".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

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● Basics topics (see "Patient education: Shoulder dystocia (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Definition and prevalence: Shoulder dystocia is defined as failure of the shoulders to


spontaneously traverse the pelvis after delivery of the fetal head. It occurs in 0.2 to 3
percent of births. (See 'Introduction' above and 'Prevalence' above.)

● Prediction and preparation: The occurrence of shoulder dystocia cannot be accurately


predicted on the basis of antenatal risk factors or labor abnormalities. Therefore, the
clinician should be prepared for possible shoulder dystocia in all vaginal deliveries and be
cognizant of the various procedures that have been shown to be effective for delivering the
impacted shoulders. (See 'General principles' above.)

● Management

• Shoulder dystocia is an obstetric emergency. The goal of management is to prevent


fetal asphyxia, permanent brachial plexus palsy, or death, while avoiding fetal or
maternal physical injury. However, treatable traumatic injuries (eg, fetal clavicular or
long bone fracture, maternal genital tract laceration) are acceptable if warranted to
prevent permanent injury in the child. (See 'General principles' above.)

• There are no randomized trials comparing results from use of the various maneuvers
to manage shoulder dystocia. The general consensus is that no maneuver is clearly
superior for resolving the dystocia and preventing neurologic injury, and that all
maneuvers can increase the degree of stretch on the brachial plexus, resulting in
brachial plexus injury. (See 'Our approach to management' above.)

• Our general approach to shoulder dystocia is described in the table ( table 1).

- Initial steps in management include having the patient stop pushing, ensuring
proper patient position, assembling necessary personnel, and draining a distended
bladder. (See 'Preparation of patient and personnel' above.)

- We suggest the McRoberts maneuver without and then with suprapubic pressure
as the initial approach for releasing the impacted shoulder, given that it is less
invasive than other maneuvers (Grade 2C). (See 'McRoberts maneuver' above.)

- If the McRoberts maneuver with suprapubic pressure is unsuccessful, we suggest


delivery of the posterior arm (Grade 2C). (See 'Delivery of the posterior arm'

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above.)

- If it is not possible to reach the elbow or forearm, we attempt to deliver the


posterior shoulder by pulling on the axilla to bring it down into the posterior pelvic
space. This may release the anterior shoulder, or allow access to the elbow or
forearm so that the posterior arm can be delivered, or allow a rotational maneuver
to release the anterior shoulder. (See 'Axillary traction for delivery of the posterior
shoulder' above.)

- If the above maneuvers are unsuccessful, we perform a rotational maneuver


(Woods, Rubin). (See 'Rubin maneuver' above and 'Woods screw maneuver' above.)

• The Gaskin all-fours maneuver may be a good initial choice for the mother in a birthing
bed with no or only local or pudendal anesthesia. Some providers prefer to use it
before attempting to deliver the posterior arm or shoulder as the latter require more
technical proficiency. (See 'Gaskin all-fours maneuver' above.)

● Documentation: Clear and complete documentation in the medical record is critically


important after deliveries complicated by shoulder dystocia ( figure 8A-B). (See
'Documentation' above.)

● Prevention: No clear advantage to performing the McRoberts maneuver before diagnosis


of shoulder dystocia has been documented; however, evidence is limited as available trials
are small and underpowered to detect moderate benefits from prophylactic intervention.
There is no harm in employing the maneuver prophylactically in patients at high risk of
shoulder dystocia. (See 'McRoberts maneuver' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

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182:689.
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GRAPHICS

Principal movements in the mechanism of labor and delivery,


left occiput anterior position

Reproduced with permission from: Pritchard JA, MacDonald PC. Williams Obstetrics, 16 th ed,
Appleton-Century-Crofts, New York 1980. p. 397. Copyright © 1980 McGraw Hill.

Graphic 52812 Version 2.0

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McRoberts maneuver and suprapubic pressure

An assistant applies pressure suprapubically with the palm or fist, directing the pressure on the
anterior shoulder both downward (to below the pubic bone) and laterally (toward the baby's face or
sternum), and in conjunction with the McRoberts maneuver. Suprapubic pressure is supposed to
adduct the shoulders or bring them into an oblique plane since the oblique diameter is the widest
diameter of the maternal pelvis. It is most useful in mild cases and those caused by an impacted
anterior shoulder.

Graphic 74910 Version 6.0

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Effect of McRoberts positioning relative to lithotomy position

(A) The patient's legs have been hyperflexed by assistants. The 16 degree rotation for a
10.5-cm obstetric conjugate (ideally) moves the symphisis pubis 9 mm anteriorly and
28 mm in a cephalad direction.

(B) Lithotomy position.

Reproduced with permission from: Poggi SH, Spong CY, Allen AH. Prioritizing posterior arm
delivery during severe shoulder dystocia. Obstet Gynecol 2003; 101:1068. Copyright © 2003
American College of Obstetricians and Gynecologists.

Graphic 58081 Version 3.0

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The effect of the Barnum maneuver in reducing the obstructing


part of the fetal shoulder

The operator has already inserted a hand into the vagina and delivered the posterior
arm by sweeping it across the fetal chest, and thus delivered the posterior shoulder as
well (not shown). A 13-cm bisacromial diameter becomes an 11-cm axillo-acromial
diameter upon delivery of the arm.

Reproduced with permission from: Poggi SH, Spong CY, Allen AH. Prioritizing posterior arm
delivery during severe shoulder dystocia. Obstet Gynecol 2003; 101:1068. Copyright © 2003
American College of Obstetricians and Gynecologists.

Graphic 66929 Version 2.0

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Menticoglou maneuver

After an assistant gently flexes the fetal head toward the anterior shoulder, the obstetrician
places his/her right middle finger into the fetus' posterior axilla from the left side of the
pelvis and the left middle finger into the posterior axilla from the right side of the pelvis.
The two middle fingers in the axilla are then used to pull the posterior shoulder downward
along the curve of the sacrum. Once the shoulder has been brought down sufficiently, the
posterior arm can be grasped and delivered.

Modified from: Menticoglou SM. A modified technique to deliver the posterior arm in severe shoulder
dystocia. Obstet Gynecol 2006; 108:755.

Graphic 107810 Version 2.0

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Rubin maneuver

The clinician places one hand in the vagina behind the posterior fetal shoulder and then
rotates it anteriorly (toward the fetal face). If the fetal spine is on the maternal left, the
operator's right hand is used. Alternatively, the Rubin maneuver can be attempted by placing
a hand behind the anterior shoulder, if it is more accessible.

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Wood's corkscrew maneuver

(A) The posterior shoulder is rotated counterclockwise until (B) it becomes anterior. The anterior
shoulder rotates out from under the symphysis pubis and descends during this process.

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Documentation of delivery complicated by shoulder dystocia

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Documentation of delivery complicated by shoulder dystocia, continued

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Approach to shoulder dystocia

Notify nursing, anesthesia, obstetric, and pediatric staff to come to patient's room, if not already available, to provide assistance
as needed.

Stop maternal pushing while preparations are made and maneuvers are undertaken to reposition the fetus.

Check for and release a tight nuchal cord, if present.

Position the patient with her buttocks flush with the edge of the bed to provide optimal access for executing maneuvers to
affect delivery.

Consider performing a mediolateral or median third- or fourth-degree episiotomy to facilitate delivery of the posterior
shoulder and other internal procedures. Episiotomy by itself does not help to release the anterior shoulder and increases perineal
trauma.

Drain a distended bladder, if present.

Avoid excessive neck rotation, head and neck traction, and fundal pressure because this combination of maneuvers can
stretch and injure the brachial plexus.

Perform maneuvers sequentially until shoulder dystocia is released. The sequence may be modified based on provider
expertise with the various maneuvers.

Perform McRoberts maneuver


Perform McRoberts maneuver with suprapubic pressure
Deliver the posterior arm or Gaskin all-fours maneuver*
If the posterior arm cannot be delivered, deliver the posterior shoulder  
Rotate the fetus (Rubin or Woods maneuver)
Fracture the fetal clavicle
Procedures of last resort:
Gunn-Zavanelli-O'Leary maneuver
Abdominal rescue
Symphysiotomy (potentially high maternal morbidity)

Document your evaluation, assessment, and management.

* Although most obstetricians do not perform the Gaskin all-fours maneuver, this is one of the initial group of maneuvers used my some
midwives and other clinicians, particularly for the mother in a birthing bed with no, only local, or pudendal anesthesia. Some providers
prefer to use it before attempting to deliver the posterior arm or shoulder since the latter require more technical expertise. The
available literature on this maneuver is limited, and its role in the management of shoulder dystocia has not been firmly established;
however, case reports support both the efficacy and low morbidity of this simple approach. Refer to the UpToDate topic on management
of shoulder dystocia for more information.

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Contributor Disclosures
John F Rodis, MD Nothing to disclose Charles J Lockwood, MD, MHCM Nothing to disclose Vanessa A
Barss, MD, FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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