Shoulder dystocia

What is it?

A baby is normally born head first, then one shoulder, then the other. In shoulder dystocia the head is born and then stops. The front shoulder is caught behind the pubic bone.

Two things make this urgent.

The baby cannot breathe yet, because the chest is still inside. And the cord is usually compressed between the baby and the birth canal, so the oxygen supply is interrupted.

The team has minutes rather than seconds, but not many.

The recognized maneuvers

Guidance describes a set of maneuvers. Teams generally work through them in a rehearsed order. ¹

• McRoberts. The mother's legs are sharply flexed back toward her chest. This rotates the pelvis and often frees the shoulder on its own.
• Suprapubic pressure. Pressure applied just above the pubic bone, to push the baby's shoulder out from behind it.
• Internal maneuvers. The clinician reaches inside to rotate the baby's shoulders.
• Delivery of the posterior arm. The back arm is swept out, which reduces the width that has to pass.
• Rolling onto all fours, sometimes called the Gaskin maneuver.
• Last-resort maneuvers, including deliberately fracturing the collarbone.

Fundal pressure is discouraged. Pushing on the top of the uterus drives the shoulder harder against the pubic bone. ¹

What does standard care look like?

Recognition and a call for help. Shoulder dystocia is announced, help is called, and the time is noted.

A rehearsed sequence. Guidance describes the recognized maneuvers. Teams train for this as a drill, because the situation is rare and the response has to be immediate. ¹

No fundal pressure. ¹

Traction that is appropriate in amount and direction. Guidance addresses this directly, because excessive or wrongly directed traction on the head is the mechanism most associated with nerve injury. ¹

Documentation. The delivery note should record that a shoulder dystocia occurred, which maneuvers were used, in what order, the time from head to body, who was present, and the condition of the baby. ¹

On prediction. Guidance states that shoulder dystocia cannot be accurately predicted or prevented, and addresses when cesarean may be offered for suspected large baby, noting that ultrasound estimates of fetal weight carry substantial error. ^{1 3}

What can go wrong?

Fundal pressure applied. It is discouraged because it worsens the impaction. ¹

Excessive or downward traction on the head. This is the mechanism most associated with brachial plexus injury, and guidance addresses it. ¹

The recognized maneuvers not used, or used out of order. ¹

No documentation. A thin or absent shoulder dystocia note is a real problem for a family, because it removes the record of what was done.

Risk factors not considered. Guidance addresses gestational diabetes management and the discussion around suspected macrosomia. ^{4 3}

The baby not examined afterward for arm movement and for a clavicle fracture. ²

Referral for a persistent arm injury delayed past the window in which nerve surgery is an option. ²

Guidance is explicit that brachial plexus injury occurs even when shoulder dystocia is managed appropriately. ¹ Whether care met the standard in a particular case takes a physician expert reading the whole record.

Which injuries can follow?

For the baby

• Brachial plexus birth injury, including Erb's palsy, Klumpke's palsy and total plexus palsy. ²
• Clavicle fracture, sometimes deliberate as a maneuver. ¹
• Fracture of the upper arm bone.
• HIE, where the interval from head to body was prolonged. ⁵
• Spinal cord injury, which is rare. ⁶

For the mother

• Postpartum hemorrhage. ⁷
• Severe perineal tearing. ⁸

What does this look like in the records?

Ask for the shoulder dystocia note by name. Many units use a dedicated form. It should record:

• That shoulder dystocia was recognized, and the time.
• Which shoulder was anterior.
• Each maneuver used, in order, with times.
• Whether fundal pressure was used.
• The time from delivery of the head to delivery of the body.
• Who was present and when they arrived.
• The baby's condition at birth.

Also request

• The full delivery note and nursing notes.
• The fetal monitoring strip up to the delivery. ⁹
• The cord blood gas results and the Apgar score scores. ¹⁰
• The newborn examination, including arm movement.
• Any X-ray of the collarbone or arm.
• Your prenatal record, including any growth scans and diabetes screening. ⁴

If the shoulder dystocia note is missing or very brief, ask for it in writing. Your right of access covers the record set held by the provider. ^{11 12}

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.