Shoulder dystocia is a condition that occurs when one or both of the baby’s shoulders get stuck during vaginal delivery. Reasons may include having a large baby, having a small pelvis, or being in the wrong position.

What is shoulder dystocia?

It occurs when one or both of the baby’s shoulders get stuck inside the pelvis during delivery. The word dystocia is derived from the Greek words “dys,” meaning difficult, and “tokos,” meaning birth.

Shoulder dystocia is a medical emergency. Babies with this condition are usually born easily, but it can cause serious complications for the mother and the baby.

The statistics of the incidence of this condition are very different. The average rate also varies depending on the baby’s birth weight. Shoulder dystocia occurs in 0.6% to 1.4% of infants weighing between 5 pounds, 8 ounces, and 8 pounds, 13 ounces at birth. This rate increases to 5 to 9 percent in babies who weigh more than 8 pounds, 13 ounces.

What are the signs of shoulder dystocia?

It is a condition that occurs when one or both of the baby’s shoulders become stuck during vaginal delivery. While there are no symptoms before delivery, the following signs can indicate shoulder dystocia:

• Turtle sign: The baby’s head emerges but then retracts back into the vagina, resembling a turtle pulling its head into its shell.
• Slow or stalled delivery: The baby’s head may take longer to deliver than usual, or there may be no progress in the second stage of labor.
• Failure to rotate: After the baby’s head emerges, it typically rotates to the side. This can be a sign of shoulder dystocia if it doesn’t rotate.
• Visible fetal shoulder: The baby’s shoulder can sometimes be seen or felt lodged behind the mother’s pubic bone.

What are the risk factors for shoulder dystocia?

Some women may be more at risk of developing shoulder dystocia than others. These include:

• Diabetes and gestational diabetes
• Birth history of a baby with high weight or macrosomia
• History of shoulder dystocia
• Induction delivery
• Being fat
• Delivery after the due date
• When the doctor uses forceps or a vacuum cleaner to guide the baby through the birth canal.
• Multiple pregnancies

What causes shoulder dystocia?

Shoulder dystocia is usually caused by a combination of factors, including:

• Large fetal size: Babies who are abnormally large or have a higher birth weight are more likely to develop shoulder dystocia.
• Maternal factors: Some maternal factors, such as a history of diabetes or previous delivery of shoulder dystocia, can increase the risk.
• Rapid delivery: A very rapid delivery can sometimes lead to shoulder dystocia, as the baby may not have enough time to rotate correctly.
• Maternal pelvic shape: A narrow or abnormally shaped maternal pelvis can sometimes contribute to shoulder dystocia.
• Fetal position: While less common, some fetal positions, such as the breech position, can increase the risk.

It is important to note that shoulder dystocia can occur even in women who have normal-sized babies without any known risk factors.

How is shoulder dystocia diagnosed?

The doctor diagnoses shoulder dystocia when they can visualize the baby’s head, but the baby’s body cannot be born even after performing some minor maneuvers. If the doctor sees that the child’s trunk does not come out easily, and as a result, he needs to take special measures, he diagnoses shoulder dystocia.

What is the treatment of shoulder dystocia?

If the mother has diabetes or if the fetus is very large, the gynecologist may recommend planning a cesarean section.

If the mother is at risk for shoulder dystocia and natural childbirth, the doctor will have a safety checklist ready. The safety checklist includes steps to be taken in case of shoulder dystocia.

If the obstetrician-gynecologist detects shoulder dystocia, everything happens quickly in the delivery room. The obstetrician-gynecologist and nursing team may try several interventions or maneuvers. They may want to move the mother into a better position for the pelvis to open, or they may want to move the baby into a better position for the fetal shoulders to move.

The HELPERR mnemonic is a tool the healthcare team may use to treat shoulder dystocia.

H — Help

The gynecologist will call for help. They use safety checklists and ask for additional help from other healthcare providers. These providers may include an anesthesiologist, a neonatologist, and additional labor and delivery specialists.

E- Evaluate for episiotomy

The obstetrician will decide whether the mother needs an episiotomy to help deliver the baby. An episiotomy is an incision (cut) in your perineum to enlarge the vaginal opening. The doctor will only perform this procedure if it is necessary to create room for rotational maneuvers.

L — legs

The gynecologist may use the McRoberts maneuver. In this maneuver, the obstetrician-gynecologist asks the mother to press her thighs against her stomach, which helps to rotate the pelvis.

P — Pressure

Obstetricians and gynecologists may use suprapubic pressure. With suprapubic pressure, the gynecologist puts pressure on the abdomen above the pubic bone, which presses on the baby’s shoulder so that it can be turned and delivered.

E — enter maneuvers

The obstetrician may perform entry or internal rotation maneuvers. The gynecologist goes to the vagina to turn the baby.

R – remove the rear arm

Gynecologists and obstetricians may use Jacquemier’s maneuver. The gynecologist removes one of the baby’s arms from the birth canal. This may make it easier for their shoulders to pass.

R – roll the patient

An obstetrician-gynecologist may use the Gaskin maneuver. In this maneuver, the obstetrician-gynecologist asks the mother to roll over her hands and knees to enter a new position.

Clavicle fracture

Obstetricians and gynecologists break the child’s clavicle to free his shoulders.

Zavanelli maneuver

The obstetrician turns the baby’s head back into the uterus and performs a cesarean section.

Symphysiotomy

The obstetrician-gynecologist makes an incision in the cartilage between the pubic bones to enlarge the opening of the pelvis.

What are the complications of shoulder dystocia?

Complications caused by shoulder dystocia during childbirth that can affect the mother and the fetus include:

• Heavy bleeding after childbirth (postpartum hemorrhage).
• Severe tearing of the area between the vagina and the anus (perineum).
• Rectovaginal fistula: A rectovaginal fistula is an abnormal connection between the vagina and the rectum.
• Uterine rupture: Uterine rupture means the rupture of the uterus during childbirth.
• Separation of pubic bones

Can shoulder dystocia be prevented?

Yes, some steps can be taken to reduce the risk of shoulder dystocia. While it can’t always be prevented, these strategies can help:

• Manage gestational diabetes: If you have gestational diabetes, careful blood sugar control can help prevent your baby from getting too big.
• Monitor fetal size: Regular prenatal ultrasounds can help determine if the baby grows larger than expected.
• Avoid excessive weight gain during pregnancy: Maintaining a healthy weight can reduce the risk of having a large baby.
• Consider a planned delivery: If the mother has a history of shoulder dystocia or other risk factors, the doctor may recommend a planned delivery, such as an induction or cesarean section.
• Follow your healthcare provider’s advice: Following your doctor’s advice about prenatal, labor, and delivery care can help minimize the risk of complications.

The bottom line

Shoulder dystocia is an injury that can occur during childbirth. It can be worrying to think about what could go wrong during labor and delivery, but it’s important to remember that these conditions are rare. The obstetrics and gynecology team is trained in what to do. In case of any rare complications, try to stay calm and trust your team of specialists. They do everything they can to deliver the baby safely without any long-term complications.

Additional questions

1. What is the main cause of shoulder dystocia?

The main cause of shoulder dystocia is the continuous anterior-posterior position of the fetal shoulders, which enter at the same time as entering the pelvis or lowering the fetal shoulders.

2. What is the best position for shoulder dystocia?

Using the hand and knee position as the first approach to solving shoulder dystocia reduces the baby’s injury.

3. What is a late delivery after the due date?

While it’s common for babies to be born a few days before or after their due date, if a pregnancy continues past 42 weeks, it’s considered post-term. This can sometimes increase the risks for both the mother and baby.

4. What is the normal fetal position?

The normal fetal position is called cephalic presentation. The baby’s head is down and facing towards the mother’s pelvis in this position. This is the ideal position for a vaginal birth.

5. What is a postpartum hemorrhage?

Postpartum hemorrhage (PPH) is a serious complication that occurs after childbirth when a woman loses a significant amount of blood. It can happen immediately after birth or within the first 24 hours. While PPH can be a medical emergency, it’s usually preventable or treatable.

References

https://my.clevelandclinic.org/health/diseases/22311-shoulder-dystocia

https://www.rcog.org.uk/for-the-public/browse-our-patient-information/shoulder-dystocia/

https://www.webmd.com/baby/what-is-shoulder-dystocia

https://www.pregnancybirthbaby.org.au/shoulder-dystocia

https://brochures.mater.org.au/brochures/mater-mothers-hospital/shoulder-dystocia

https://www.healthline.com/health/pregnancy/delivery-shoulder-dystocia#prevention