Protocols for High-Risk Pregnancies, 7th Edition: Shoulder Dystocia

AUTHORS: George A. Macones, MD, Division of Maternal-Fetal Medicine, Dell Medical School-University of Texas at Austin and Robert B. Gherman, MD, Division of Maternal-Fetal Medicine, WellSpan Health System, York, PA.

SYNOPSIS: In this protocol, Macones and Gherman reviews the pathophysiology, diagnosis, and management of shoulder dystocia. Included are descriptions of extraordinary movements and a list of documentation suggested when a shoulder dystocia is encountered.

Protocols for High-Risk Pregnancies, 7th Edition

As the authors note, shoulder dystocia is unpredictable and reported incidence varies from 0.2% to 3.0%. Risk does increase with birth weight, but up to 60% of shoulder dystocias occur in infants weighing less than 4000 g and only 3.3% of births with weights greater than 4000 g involve this complication. Episiotomy alone will not release an impacted shoulder and cutting a generous episiotomy or proctoepisiotomy should be based on clinical circumstances.

Key Messages:

• Prior shoulder dystocia statistically increases risk of recurrence. However, there are no clinically useful positive predictive values for antenatal prediction of the condition.
• No randomized clinical trials exist to guide management of shoulder dystocia. Fetal injury is possible with all maneuvers that have been described to relieve it.
• Most shoulder dystocias can be relieved within several minutes. Permanent brain injury can occur with a delay as short as 3 to 4 minutes or as long as 15 to 20 minutes. The determining factor is the condition of the fetus at the time of the dystocia.
• It is key for the mother to stop pushing when shoulder dystocia is encountered.
• The first technique used to alleviate the condition is usually the McRoberts maneuver. Suprapubic pressure also can be applied in conjunction with or before it.
• If those techniques fail, delivery of the posterior arm is recommended, followed (if necessary) by rotation of the posterior shoulder.
• Fundal pressure should not be applied nor should rotation of the fetal head. Traction should be downward and axial, in alignment with the fetal cervico-thoracic spine.
• “Rescue” techniques for shoulder dystocia include the Gaskin maneuver, axillary traction, and the Zavanelli maneuver. Abdominal rescue should rarely be used.

Read the complete chapter on shoulder dystocia from Protocols for High-Risk Pregnancies, 7th Edition, edited by John T. Queenan, MD, Catherine Y. Spong, MD, and Charles J. Lockwood, MD, MHCM, here.

Buy the book on Wiley.com: Protocols for High-Risk Pregnancies: An Evidence-Based Approach, 7th Edition.