What Is Shoulder Dystocia?
Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become lodged against the pubic bone during delivery. This can extend the second stage of labor and may cause traumatic injury to both the mother and baby.
A rare and frightening complication, shoulder dystocia has a high rate of maternal and fetal morbidity. Clinicians must move quickly to assess the situation and resolve the issue to prevent permanent consequences.
Quick Facts About Shoulder Dystocia
- Shoulder dystocia occurs in roughly 0.6-3% of vaginal deliveries.
- One of the most common injuries is damage to the brachial plexus nerves, which occurs in 4-16% of shoulder dystocia cases.
- Most brachial plexus injuries heal without permanent disability if proper treatment is given. However, in about 10% of cases, the child may face lifelong consequences.
- Shoulder dystocia cases account for about 11% of all obstetric malpractice litigation.
Causes of Shoulder Dystocia
The incidence of shoulder dystocia can be difficult to predict and often occurs in deliveries with mothers and babies who have none of the common risk factors.
While some risks may stem from health conditions affecting the mother or the fetus, others can be environmental. The type of medications used and the techniques applied by the doctor during delivery can contribute to injuries sustained by mother and baby.
Common risk factors include:
- Abnormal pelvic anatomy
- Being overweight
- Diabetes/gestational diabetes
- Fetal macrosomia (unusually large fetus)
- History of shoulder dystocia in previous pregnancies
- Oxytocin induced labor
- Twins/multiple births
- Unusually long or short second stage labor
- Use of forceps or vacuum extraction
Doctors should discuss all relevant risk factors with their patients and — in cases where the risk is significant — must be prepared to act decisively to prevent injuries.
Symptoms of Shoulder Dystocia
Shoulder dystocia can have serious physical consequences for both the mother and baby. Complications from this vaginal birth injury can last a lifetime.
It isn’t just the child who can be injured during a difficult birth. Women who suffer from shoulder dystocia during birth may also experience serious symptoms.
Maternal symptoms of shoulder dystocia include:
- Postpartum hemorrhage (PPH)/heavy bleeding
- Tearing of the perineum
- Uterine rupture
About 12% of women who have experienced shoulder dystocia have a high risk of experiencing it again during subsequent pregnancies. Doctors will often recommend a cesarean delivery if there is a history of shoulder dystocia.
Shoulder dystocia can leave infants with a wide range of physical — and potentially intellectual — disabilities. Some of these ailments may be temporary or treatable with medical care and physical therapy, while others may last a lifetime.
Fetal symptoms of shoulder dystocia include:
- Broken arms/collarbone
- Damage to brachial plexus nerves resulting in Erb’s palsy
- Asphyxia leading to brain damage or death
Although most babies eventually recover from shoulder dystocia symptoms, more severe cases can leave them with long-term health problems that persist for years. Quick, decisive action by doctors is necessary to avert disaster and prevent more serious outcomes.
Treatment of Shoulder Dystocia
There is no one correct way to treat shoulder dystocia. Every case is a little different, and doctors must be prepared to deploy a variety of strategies to combat complications.
In cases where there is a known risk of shoulder dystocia, preparation is key. Women who have experienced shoulder dystocia before or who have fetuses with macrosomia (birth weight of over 8 pounds and 13 ounces) may be encouraged to consider a C-section birth. If the parents choose a natural birth, the birthing room should be cleared of clutter to make space for any extra personnel who may be needed.
The most common procedure for treating cases of shoulder dystocia is called HELPERR, a mnemonic device listing the maneuvers doctors should attempt when faced with shoulder dystocia.
- Help: Doctors should alert their team of the shoulder dystocia immediately and ask for extra assistance, calling in other doctors and nurses as needed.
- Evaluate for episiotomy: An episiotomy is an incision in the perineum — the skin between the vagina and the anus — which may be necessary to make room for future maneuvers. An episiotomy alone is not enough to free an infant from shoulder dystocia since the impaction occurs against the pelvic bone. Some women may not require it.
- Legs (the McRoberts maneuver): The mother’s legs are brought up toward the stomach, flattening and rotating the pelvis, which can free the baby’s head and allow it to pass through the gap more easily.
- Suprapubic pressure: External pressure is applied by an assistant to the mother’s pelvis to encourage the baby’s shoulders to rotate. If rotation is achieved, the baby may be freed.
- Enter maneuvers (internal rotation): The doctor attempts to manually rotate the fetus in an attempt to dislodge the shoulders. The doctor may need to push the fetus back up into the pelvis slightly to accomplish these maneuvers.
- Remove posterior arm: Removing one of the baby’s arms from the birth canal can help the baby pass through it more easily. This must be done very carefully to avoid fracturing the arm.
- Roll the patient: The mother is maneuvered on to her hands and knees. This changes the shape of the pelvis and may help dislodge the baby.
There is no specific order in which these maneuvers should be attempted. Doctors choose what to try first based on the position of the baby and their past experience. If none of these methods work, there are others — commonly called maneuvers of last resort — which may also be attempted.
Is Shoulder Dystocia Preventable?
Shoulder dystocia can be difficult to predict and prevent. Since it is a very rare occurrence, it is generally only handled by the most experienced obstetricians in the healthcare field.
Studies have shown that simulation training in a systematic approach can improve outcomes for both mother and baby.
A new device called the Yaari Extractor began clinical testing in the United States in the fall of 2023. The device shows promise for freeing babies from shoulder dystocia and saving both mother and child from injury.
Doctors and nurses have a duty to their patients to provide the best possible care even in unpredictable situations or high-stress environments. Poor preparation or a lack of necessary training can have serious physical and financial consequences for families.
Shoulder Dystocia and Medical Negligence
A birth involving shoulder dystocia can be a terrifying and traumatic experience. When improperly handled by medical staff, it can have serious long-term consequences physically, financially, and emotionally for everyone involved.
If you or a loved one has been affected by shoulder dystocia and you’re interested in pursuing legal action, get a free case review today.