Shoulder dystocia: Intrapartum diagnosis, management, and outcome
- John F Rodis, MD
John F Rodis, MD
- Professor of Obstetrics and Gynecology
- University of Connecticut School of Medicine
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 occurs in 0.2 to 3 percent of all births and represents an obstetric emergency [1,2]. Few shoulder dystocias can be anticipated and prevented, as most occur in the absence of risk factors. Therefore, the obstetrician must be prepared to recognize a shoulder dystocia immediately and proceed through an orderly sequence of steps to affect 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, bone fractures, maternal trauma), but the latter are 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 management of pregnancies at risk are discussed separately. (See "Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies".)
The fetal biacromial diameter (the distance between the outermost parts of the fetal shoulders) normally enters the pelvis at an oblique angle with the posterior shoulder ahead of the anterior one, rotating to the anterior-posterior 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). 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; the posterior shoulder may be obstructed by the sacral promontory. Anterior obstruction is more common than posterior obstruction. If descent of the fetal head continues while the anterior or posterior shoulder remains impacted, then stretching of the nerves in the brachial plexus may occur and may result in nerve injury.
Injuries diagnosed at birth may have resulted from prenatal insults, trauma related to labor and the impacted shoulder itself, or from the provider's attempt to deliver the infant. Acidemia may result from compression of the umbilical cord, from compression of the vessels in the fetal neck by a tight nuchal cord, or a combination of factors .
Shoulder dystocia is a subjective clinical diagnosis. It should be suspected when the fetal head retracts into the perineum (ie, turtle sign) after expulsion due to reverse traction from the shoulders being impacted at the pelvic inlet. The diagnosis is made when the routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder.
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- Initial steps
- - Avoid increasing traction
- Approaches for relieving dystocia
- - Suprapubic pressure
- - McRoberts maneuver
- - Delivery of the posterior arm
- - Delivery of the posterior shoulder (Menticoglou maneuver)
- Posterior axilla sling traction (PAST)
- - Rubin maneuver
- - Woods screw maneuver
- - Gaskin all-fours maneuver
- - Clavicular fracture
- - Zavanelli maneuver
- - Abdominal rescue
- - Symphysiotomy
- REDUCING THE RISK OF COMPLICATIONS
- GUIDELINES FROM NATIONAL ORGANIZATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS