{"id":1469,"date":"2020-01-02T13:00:00","date_gmt":"2020-01-02T18:00:00","guid":{"rendered":"https:\/\/obgconnect.com\/library\/?p=1469"},"modified":"2025-03-02T22:01:51","modified_gmt":"2025-03-03T03:01:51","slug":"shoulder-dystocia","status":"publish","type":"post","link":"https:\/\/obgconnect.com\/library\/2020\/01\/02\/shoulder-dystocia\/","title":{"rendered":"Shoulder Dystocia"},"content":{"rendered":"\n<ul class=\"wp-block-list\">\n<li><a href=\"#key-points\">Key Points<\/a><\/li>\n\n\n\n<li><a href=\"#background\">Background<\/a>\n<ul class=\"wp-block-list\">\n<li><a href=\"#risk-factors\">Risk Factors<\/a><\/li>\n\n\n\n<li><a href=\"#evaluation\">Evaluation<\/a><\/li>\n\n\n\n<li><a href=\"#maneuvers\">Maneuvers<\/a><\/li>\n\n\n\n<li><a href=\"#management\">Management<\/a><\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><a href=\"#primary-sources\">Primary Sources<\/a><\/li>\n\n\n\n<li><a href=\"#recommendations\">Professional Recommendations<\/a><\/li>\n\n\n\n<li><a href=\"#references\">References<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/obgconnect.com\/library\/2020\/03\/29\/labor-and-delivery-table-of-contents\/\"><strong>ObG L&amp;D<\/strong> Table of Contents<\/a><\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"key-points\">KEY POINTS:<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Defined as \u201cFailure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery&#8221; (ACOG PB 178)<\/li>\n\n\n\n<li>Shoulder dystocia is an obstetrical emergency<\/li>\n\n\n\n<li>While there are associated risk factors, they are poor at predicting shoulder dystocia<\/li>\n\n\n\n<li>The majority of cases will occur in women without diabetes whose offspring are within normal weight range | Nor is there any evidence that shoulder dystocia can be prevented<\/li>\n\n\n\n<li>Complications include PPH and brachial plexus injuries | Severe neonatal morbidity can occur if shoulder dystocia is not resolved in a timely manner<\/li>\n\n\n\n<li>Simulation of maneuvers been shown to improve use of maneuvers as well as teamwork and documentation<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"background\">BACKGROUND:<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"risk-factors\">Risk Factors<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Maternal\n<ul class=\"wp-block-list\">\n<li>Prior history of shoulder dystocia\n<ul class=\"wp-block-list\">\n<li>Universal prophylactic cesarean section is not recommended<\/li>\n\n\n\n<li>Due to recurrence risk (1% to 16.7%), evaluate EFW, GA, glucose and severity of previous event<\/li>\n\n\n\n<li>Patient discussion and careful delivery planning are recommended<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Diabetes: GDM and pre-gestational diabetes<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Fetal\n<ul class=\"wp-block-list\">\n<li>Macrosomia (see delivery recommendations below)<\/li>\n\n\n\n<li>Large fetal chest relative to biparietal diameter (seen with diabetes)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Note:<\/strong> Despite known risk factors \u201c\u2026shoulder dystocia cannot be accurately predicted or prevented\u201d (ACOG PB 178)<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"evaluation\">Evaluation<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>There are no ultrasound findings or labor patterns that are predictive of shoulder dystocia<\/li>\n\n\n\n<li>The classic \u2018turtle sign\u2019 at delivery is \u201c\u2026suggestive, but not diagnostic, of the presence of shoulder dystocia\u201d (ACOG PB 178)<\/li>\n\n\n\n<li>Diagnosis is based on clinical judgement when there is failure to deliver the fetal shoulders after initial traction attempts<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"maneuvers\">Maneuvers<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><em>See videos in \u2018References\u2019 below<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>McRoberts maneuver: Best first step (Level B Evidence)\n<ul class=\"wp-block-list\">\n<li>Maternal knees flexed and brought to chest while suprapubic pressure is applied<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Posterior Shoulder Delivery to reduce shoulder diameter (Level C Evidence)\n<ul class=\"wp-block-list\">\n<li>Next option if McRoberts unsuccessful<\/li>\n\n\n\n<li>Decreases the diameter of the fetal shoulder girdle<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Additional techniques to deliver the posterior shoulder include the following\n<ul class=\"wp-block-list\">\n<li>Rubin maneuver: Place hand on the back of the posterior fetal shoulder followed by anterior rotation towards the fetal face<\/li>\n\n\n\n<li>Woods Screw maneuver: Apply pressure to anterior surface of the posterior shoulder with fetal rotation until anterior shoulder disengages from behind the maternal symphysis<\/li>\n\n\n\n<li>Posterior axilla sling traction: Thread a size 12 or 14 French soft catheter around the posterior shoulder and apply moderate traction to the sling to deliver the shoulder<\/li>\n\n\n\n<li>Gaskin all-fours maneuver (for women without anesthesia): With patient on hands and knees, apply gentle downward traction on the posterior shoulder or upward traction on the anterior shoulder<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>\u2018Last Resort\u2019 maneuvers: Associated with significant maternal and\/or fetal morbidity and mortality\n<ul class=\"wp-block-list\">\n<li>Zavanelli maneuver: Head placed back in vaginal canal followed by cesarean section<\/li>\n\n\n\n<li>Abdominal rescue: shoulder dislodged from above via hysterotomy<\/li>\n\n\n\n<li>Intentional fetal clavicular fracture<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Do not apply fundal pressure due to risk for uterine rupture<\/li>\n\n\n\n<li>Instruct patient to stop pushing until dystocia is resolved<\/li>\n\n\n\n<li>Evidence does not support use of routine episiotomy\n<ul class=\"wp-block-list\">\n<li>Reserve for clinical situation where additional room may be needed for above maneuvers<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Documentation should be contemporaneous and include (Level B Evidence)\n<ul class=\"wp-block-list\">\n<li>Time of diagnosis<\/li>\n\n\n\n<li>Management<\/li>\n\n\n\n<li>Time of delivery<\/li>\n\n\n\n<li>Sequelae<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Simulation Programs\n<ul class=\"wp-block-list\">\n<li>Simulation is used to train healthcare personnel for particularly severe, high acuity events that are relatively infrequent<\/li>\n\n\n\n<li>Simulation is effective in the setting of shoulder dystocia and improves\n<ul class=\"wp-block-list\">\n<li>Communication | Use of maneuvers | Documentation (Level B Evidence)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"management\">Management for Suspected Fetal Macrosomia<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Delivery &lt;39 weeks gestation is not recommended without medical indication<\/li>\n\n\n\n<li>Elective cesarean delivery should be considered for the following\n<ul class=\"wp-block-list\">\n<li>Without diabetes: estimated fetal weight of \u22655,000 gm<\/li>\n\n\n\n<li>With diabetes: estimated fetal weight of \u22654,500 gm<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Induction\n<ul class=\"wp-block-list\">\n<li>Not suggested for suspected fetal macrosomia as induction has not been shown to improve maternal or fetal outcomes<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Trial of labor\n<ul class=\"wp-block-list\">\n<li>Suspected fetal macrosomia is not a contraindication to a trial of labor after cesarean delivery<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"primary-sources\">PRIMARY SOURCES:<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">Zhang et al. BJOG, 2018<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Meta-analysis to determine whether the maternal pre-pregnancy obesity has an impact on shoulder dystocia risk | 20 studies (2,153,898 participants)<\/li>\n\n\n\n<li>Results\n<ul class=\"wp-block-list\">\n<li>For obese versus nonobese: Pooled relative risk (RR) of shoulder dystocia was 1.63 (95% CI, 1.33\u20131.99)<\/li>\n\n\n\n<li>Significant association remained across different continents<\/li>\n\n\n\n<li>When adjusted for gestational diabetes the increased risk remained significant: RR 1.61 (95% CI, 1.05\u20132.47)<\/li>\n\n\n\n<li>Compared to nonobese women, the pooled RRs for multiple obesity classes were as follows\n<ul class=\"wp-block-list\">\n<li>Obesity class I: 1.29 (95% CI, 1.06\u20131.57)<\/li>\n\n\n\n<li>Obesity class II: 1.94 (95% CI, 1.26\u20132.98)<\/li>\n\n\n\n<li>Obesity class III: 2.47 (95% CI, 1.56\u20133.93)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Conclusion\n<ul class=\"wp-block-list\">\n<li>Maternal pre-pregnancy obesity is associated with increased risk of shoulder dystocia<\/li>\n\n\n\n<li>Higher the obesity class, the greater the risk<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"recommendations\">PROFESSIONAL RECOMMENDATIONS:<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">ACOG PB 178<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>The guideline states that Maneuvers may be repeated if not successful initially and in addition<\/li>\n<\/ul>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">\u2026clinicians should use the maneuver most likely to result in successful delivery<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">No randomized controlled trials have compared maneuvers for shoulder dystocia alleviation<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">However, it is clear that brachial plexus injury can occur regardless of the procedures used to disimpact the shoulder(s) because all maneuvers can increase the degree of stretch on the brachial plexus<\/p>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"references\">REFERENCES:<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.acog.org\/clinical\/clinical-guidance\/practice-bulletin\/articles\/2017\/05\/shoulder-dystocia\" target=\"_blank\" rel=\"noreferrer noopener\">ACOG Practice Bulletin 178: Shoulder Dystocia<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.hopkinsmedicine.org\/gynecology_obstetrics\/education\/training\/shoulder-dystocia\" target=\"_blank\" rel=\"noreferrer noopener\">Johns Hopkins Medicine | Gynecology &amp; Obstetrics: Shoulder Dystocia Simulation and Training Videos<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/28766922\" target=\"_blank\" rel=\"noreferrer noopener\">Maternal prepregnancy obesity and the risk of shoulder dystocia: a meta\u2010analysis (Zhang et a. BJOG, 2018)<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Shoulder dystocia is an obstetrical emergency, defined as \u201cFailure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery&#8221; (ACOG PB 178)<\/p>\n","protected":false},"author":6,"featured_media":931,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[11],"tags":[59,50,40,60],"class_list":["post-1469","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-labor-and-delivery","tag-diabetes","tag-gestational-diabetes","tag-labor-management","tag-lga"],"acf":[],"featured_image_urls_v2":{"full":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",150,99,false],"medium":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",300,199,false],"medium_large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"1536x1536":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"2048x2048":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"ultp_layout_landscape_large":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"ultp_layout_landscape":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"ultp_layout_portrait":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"ultp_layout_square":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"woocommerce_thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",300,199,false],"woocommerce_single":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured.jpg",400,265,false],"woocommerce_gallery_thumbnail":["https:\/\/obgconnect.com\/library\/wp-content\/uploads\/sites\/3\/2020\/04\/zachery-perry-ioIbdrdpLL4-unsplash-featured-100x100.jpg",100,100,true]},"post_excerpt_stackable_v2":"<p>Shoulder dystocia is an obstetrical emergency, defined as \u201cFailure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery&#8221; (ACOG PB 178)<\/p>\n","category_list_v2":"<a href=\"https:\/\/obgconnect.com\/library\/category\/labor-and-delivery\/\" rel=\"category tag\">ObG L&amp;D\u2122<\/a>","author_info_v2":{"name":"mharris","url":"https:\/\/obgconnect.com\/library\/author\/mharris\/"},"comments_num_v2":"0 comments","yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - 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