Shoulder Dystocia

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Chapter 222 Shoulder Dystocia

INTRODUCTION

Description: Shoulder dystocia is an obstruction to delivery caused by impaction of the fetal shoulder behind the maternal symphysis. Less commonly it can be due to impaction of the posterior fetal shoulder on the sacral promontory. Shoulder dystocia is most often an unpredictable and unpreventable obstetric emergency, usually defined as a delivery that requires additional obstetric maneuvers (following failure of gentle downward traction on the fetal head) to effect delivery of the shoulders.
Prevalence: 0.15% of fetuses weighing ≥2500 g (5 pounds 8 oz), 1% to 5% for ≥4000 g (8 pounds 13 oz), 19% ≥4500 g (9 pounds 15 oz); overall 0.6% to 1.4% of vertex deliveries.
Genetics: Tall or large parents are at higher risk.

ETIOLOGY AND PATHOGENESIS

Causes: A relative disproportion between fetus and the birth passage or a misalignment of normally sized structures (fetus and pelvis).
Risk Factors: Fetal macrosomia (risk proportional to weight), pelvic deformity, maternal obesity, diabetes mellitus, post-term pregnancy, prolonged second stage of labor, oxytocin induction, midforceps or vacuum extraction.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Poor descent during labor
• Retraction of the fetal head onto the perineum following delivery of the chin (“turtle sign”)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Fetal macrosomia
• Fetal malformation
• Soft-tissue tumor (maternal or fetal)
• Conjoined or locked twins

Associated Conditions: Diabetes, obesity, prolonged gestation (maternal), neurologic injury (brachial plexus), hypoxia, macrosomia (fetal), postpartum hemorrhage (11%), fourth-degree laceration (4%), labor induction, operative vaginal delivery.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: Ultrasonography to assess fetal weight (88% accuracy).
Special Tests: None indicated.
Diagnostic Procedures: Pelvic examination, ultrasonography (suggestive or risk), clinical assessment at the time of dystocia.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Risk factor analysis, rapid recognition, call for assistance.
Specific Measures: Move the shoulder to the oblique, suprapubic pressure, fundal pressure only after the shoulder is disimpacted, McRoberts maneuver, Woods maneuver (shoulder rotation), delivery of posterior arm, Zavanelli maneuver. A generous episiotomy is advisable.
Diet: Patients generally should have nothing by mouth during delivery.
Activity: Not applicable. (McRoberts maneuver requires flexion and abduction of the maternal hips.)

Drug(s) of Choice

None. (Maternal analgesia or anesthesia may be required if time permits.)

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: Identification of patients at risk (risk factors + ultrasonography—58% accurate, most not predictable), Cesarean delivery for fetuses ≥4500 g in diabetic pregnancies or ≥5000 g in other women. (Cesarean delivery for all suspected fetuses is not appropriate; operative delivery for ≥4000 g would result in 2345 procedures to prevent 1 permanent injury at a cost of $4.9 million annually.) The risk of recurrence is estimated to be between 1% and 17%, although good data are lacking.
Possible Complications: Maternal: uterine atony, hemorrhage (11%), uterine rupture, urinary tract or rectal trauma. Fetal/neonatal: asphyxia, death, brachial plexus injury (up to 40%, 10% persist). Data suggest that a significant proportion (34% to 47%) of brachial plexus injuries are not associated with shoulder dystocia (in fact, 4% occur after cesarean delivery); clavicle or humerus fracture, neurologic damage.
Expected Outcome: Delivery can generally be accomplished, but 10% to 30% of fetuses will experience long-term sequelae.

MISCELLANEOUS

ICD-9-CM Code: 660.4.

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REFERENCES

Level I

Gonen O, Rosen DJ, Dolfin Z, et al. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol. 1997;89:913.

Level II

Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol. 1985;66:762.

Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia in the average-weight infant. Obstet Gynecol. 1986;67:614.

Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol. 1995;86:14.

Gherman RB, Chauhan S, Ouzounian JG, et al. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006;195:657. Epub 2006 Apr 21

Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol. 1998;178:1126.

Ginsberg NA, Moisidis C. How to predict recurrent shoulder dystocia. Am J Obstet Gynecol. 2001;184:1427.

Gonik B, Stringer CA, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol. 1983;145:882.

Gross SJ, Shime J, Farine D. Shoulder dystocia: predictors and outcome. A five-year review. Am J Obstet Gynecol. 1987;156:334.

Gurewitsch ED, Johnson E, Hamzehzadeh S, Allen RH. Risk factors for brachial plexus injury with and without shoulder dystocia. Am J Obstet Gynecol. 2006;194:486.

Jakobovits A, Iffy L. Perinatal implications of shoulder dystocia. Obstet Gynecol. 1996;87:638.

Lewis DF, Raymond RC, Perkins MB, et al. Recurrence rate of shoulder dystocia. Am J Obstet Gynecol. 1995;172:1369.

McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynaecol Obstet. 1996;55:219.

Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol. 1993;168:1732.

O’Leary JA. Cephalic replacement for shoulder dystocia: present status and future role of the Zavanelli maneuver. Obstet Gynecol. 1993;82:847.

Smith RB, Lane C, Pearson JF. Shoulder dystocia: what happens at the next delivery? Br J Obstet Gynaecol. 1994;101:713.

Level III

American College of Obstetricians and Gynecologists. Shoulder dystocia. ACOG Practice Bulletin 40. Obstet Gynecol. 2002;100:1045.

Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus palsy: an in utero injury? Am J Obstet Gynecol. 1999;180:1303.

Naef RW3rd, Martin JNJr. Emergent management of shoulder dystocia. Obstet Gynecol Clin North Am. 1995;22:247.

O’Leary JA, Leonetti HB. Shoulder dystocia: prevention and treatment. Am J Obstet Gynecol. 1990;162:5.

Sandberg EC. The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol. 1999;93:312.

Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol. 1985;152:479.

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