Shoulder dystocia is a dangerous event that may occur during childbirth. When shoulder dystocia happens, the infant’s shoulder gets caught on the mother’s pubic symphysis, or hip bone. This causes new risks for both the maternal and fetal health during delivery. Shoulder dystocia is considered a medical emergency.
Many doctors are unable to predict whether shoulder dystocia will occur. However, there are risk factors that may help identify patients who are more likely to experience shoulder dystocia problems. In addition, there are last-minute safety techniques that doctors can use to minimize the risk of serious birth injury, such as brachial plexus injuries.
Causes of Shoulder Dystocia
Shoulder dystocia is not very common. Roughly 1% of infants experience shoulder dystocia during birth. The majors risks involved with shoulder dystocia come from the fact that it is difficult to predict or prepare for. Shoulder dystocia is a birth complication that can occur very suddenly during delivery.
Despite being difficult to predict, medical guidelines are in place for how a doctor should respond to this emergency. If these medical guidelines are not followed correctly, shoulder dystocia can lead to problems such as complete brachial plexus palsy, Erb’s palsy, and Klumpke’s palsy. As a result, any increase is shoulder dystocia risk must be discussed with the expecting parents, prior to delivery. Failure to follow these guidelines may result in medical malpractice or medical negligence.
Shoulder Dystocia Risk Factors
Risk factors for shoulder dystocia may involve:
- Abnormal maternal pelvic shape
- Petite maternal stature
- Petite maternal pelvic size
- Maternal obesity
- Gestational diabetes
- Shoulder dystocia complications during previous births
- Macrosomia, or large fetal size for the gestational age
- Brachycephaly, or flattened back of the fetal head
- Forceps- or vacuum-assisted delivery
- Abnormally long labor time
Shoulder Dystocia Warning Signs
Doctors are taught to look for the “turtle” sign as a warning that shoulder dystocia may be occurring. The turtle sign happens as the infant’s head surfaces, but then it returns back into the mother’s womb during child birth. Another warning sign of shoulder dystocia is a puffy, red-colored face of an infant during attempts at vaginal birth.
Shoulder Dystocia Treatment
In the event of suspected shoulder dystocia, the obstetrician’s goal is to deliver the infant within 5 minutes or less, to minimize the risk of permanent nerve damage. Doctors refer to two mnemonic devices that suggest a similar series of actions to take. They include the ALARMER and the HELPERR. Delaying the start of an ALARMER or HELPERR procedure will increase the risk of severe fetal or maternal injury.
Common medical maneuvers or procedures for shoulder dystocia management include:
- Rubin I, which is a maneuver where pressure is applied above the maternal pubis.
- Rubin II, which is a maneuver where pressure is applied to the fetal shoulder while facing the mother’s pubic symphysis.
- McRoberts Maneuver, which is believed to be 42% effective. During the McRoberts Maneuver, the mother pulls her legs in tightly to her stomach, allowing her spine to flatten while her pelvis widens. A nurse may apply abdominal pressure while the infant is gently pulled.
- Woods’ Screw Maneuver, which requires the fetal shoulder to be turned closer to the mother’s pubic symphysis and away from the maternal pelvis. It is essentially the opposite of the Rubin II maneuver.
- Jacquemier’s Maneuver or Barnum’s Maneuver, which involves gently pulling the fetal forearm through the birth canal. The goal of this maneuver is to deliver the infant’s farthest shoulder first.
- Gaskin Maneuver, which requires the mother to attempt birth on her hands and knees. Then, she arches her back to widen the pelvis.
- Zavanelli’s Maneuver, during which the fetal head is pushed back into the womb. An emergency C-section is performed, so this method of shoulder dystocia management is reserved for very severe cases.
- Maternal Symphysiotomy, which requires breaking of the connective tissue between the maternal pubic bones, allowing the birth canal to widen. Due to the maternal health risks, this method is also only used for severe cases of shoulder dystocia.
- Intentional Fracturing of the Fetal Clavicle is another last-resort option for severe shoulder dystocia cases. It works by reducing the width of the infant’s shoulders.
Permanent Nerve Damage
If a medical professional fails to correctly manage shoulder dystocia, the infant or mother may suffer from the following:
- Fetal hypoxia, or fetal oxygen deprivation
- Brachial plexus injury
- Erb’s palsy
- Klumpke’s palsy
- Cerebral palsy
- Maternal hemorrhage after delivery
- Fetal death
Baxley, E., and R. Gobbo. “Shoulder Dystocia.” National Center for Biotechnology Information. 2004. http://www.ncbi.nlm.nih.gov/pubmed/15086043
Draycott, T., J. Crofts, et al. “Improving neonatal outcome through practical shoulder dystocia training..” National Center for Biotechnology Information. 2008. http://www.ncbi.nlm.nih.gov/pubmed/18591302