II. Definitions
- Shoulder Dystocia
- Birth complication in which the fetal anterior Shoulder impacts the maternal Symphysis Pubis and prevents fetal body delivery
- Potentially life-threatening condition requiring emergent maneuvers to relieve the impaction and deliver the fetal body
III. Epidemiology
-
Incidence of Shoulder Dystocia
- Incidence Overall: 0.3 - 1% of vaginal deliveries
- Birthweight >4000g: 5-7%
- Birthweight >4500g: 8-10%
- Shoulder Dystocia Cases by birthweight
- Infants over 4500 grams: 50%
- Infants 4000 to 4500 grams: 23%
- Infants 3500 to 4000 grams: 9%
- Normal birthweight infant: 50-66% in some studies
IV. Risk Factors
- Most cases occur without obvious predictors
- Assisted Vaginal Delivery (most common risk factor)
-
Fetal Macrosomia (>4000 grams, OR>16)
- Estimated fetal weight of current pregnancy
- Prior macrosomic infant
- Family History of Fetal Macrosomia
- Gestational Diabetes
- Multiparity
- Postterm delivery
- Maternal abnormal Pelvic Anatomy, Short Stature or Obesity
- History of prior Shoulder Dystocia (OR>8)
- Prolonged first or Second Stage of Labor
- Oxytocin use to augment labor
- Operative Vaginal Delivery (vacuum or forceps)
V. Signs: Warning signs suggestive of Shoulder Dystocia
- Prolonged Second Stage of Labor
- Recoil of head on perineum (turtle's sign)
VI. Diagnosis
- Time between delivery of head and delivery of body >60 seconds
- Additional delivery maneuvers required to deliver the body
VII. Management
VIII. Complications: Shoulder Dystocia Fetal Effects
-
Brachial Plexus Injury from Birth Trauma (10%)
- General
- Most resolve in first year, but persistent in 10% of cases
- Palsy may be unrelated to disimpaction maneuvers
- Types
- Erb-Duchenne Palsy
- Fifth and sixth cervical roots
- Klumpke's Paralysis
- Eighth cervical and first thoracic roots
- Erb-Duchenne Palsy
- General
- Fractures
- Fetal Asphyxia and Fetal hypoxic ischemic encephalopathy
- Fetal Death
- Meconium Aspiration
IX. Complications: Shoulder Dystocia Maternal Effects
- Postpartum Hemorrhage (11% of cases)
- Fourth-degree perineal Laceration (Up to 4% of cases)
- Lacerations to other pelvic structures (Bladder, Urethra, vagina, anal sphincter, Rectum)
- Uterine Rupture
- Rectovaginal fistula
- Pubic Symphysis separation
- Lateral Femoral Cutaneous Neuropathy
X. Prognosis
- Shoulder Dystocia results in cord compression
- Arterial pH drops 0.04 per minute
- Arterial pH drops 0.28 in seven minutes
- Arterial pH drops 0.14 per minute on trunk delivery
- Arterial pH below 7.0 makes Resuscitation difficult
XI. Prevention: Anticipation of a Shoulder Dystocia
- Advanced Life Support in Obstetrics (ALSO) course
- https://www.aafp.org/cme/programs/also.html
- Prepares providers for obstetrical emergencies including Shoulder Dystocia Management
- During delivery
- Cesarean delivery for fetal macrosmia indications
- ACOG recommends considering cesarean delivery for fetal weight >5000 g (11 lb)
- ACOG recommends considering cesarean delivery for Gestational Diabetes AND weight >4500 g (9 lb 15 oz)
- (2017) Obstet Gynecol 129(5): e123-33
- However, prior studies did not show benefit for induction or cesarean in macrosomia
- See Fetal Macrosomia
- Elective cesarean does not reduce dystocia cases
- Early induction does not reduce dystocia cases
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Related Studies
| Definition (NCI) | A birth complication caused by impaction of the anterior shoulder against the maternal symphysis pubis that requires additional maneuvers to relieve impaction of the fetal shoulder and allow for delivery.(NICHD) |
| Concepts | Disease or Syndrome (T047) |
| ICD9 | 660.4 |
| ICD10 | O66.0 |
| SnomedCT | 199782009, 199785006, 89700002 |
| English | Shoulder (girdle) dystocia during labor and delivery, Shoulder dystocia NOS, Shoulder dystocia unspecified, shoulder dystocia (diagnosis), shoulder dystocia, Shoulder Dystocia, dystocia shoulder, shoulder impact, dystocia shoulders, Shoulder dystocia unspecified (disorder), Shoulder dystocia NOS (disorder), Shoulder (girdle) dystocia during labour and delivery, Impacted shoulders, Shoulder girdle dystocia, Shoulder dystocia, Shoulder girdle dystocia (disorder), dystocia; shoulder, impaction; shoulder, shoulder; dystocia, shoulder; impaction, Impacted shoulders during labor |
| Italian | Distocia di spalla, Distocia di spalla (cingolo) durante il travaglio e il parto, Distocia della spalla (cingolo) durante il travaglio ed il parto |
| Dutch | schouder(gordel) dystocie tijdens bevalling en geboorte, dystocie; schouder, inklemming; schouder, schouder; dystocie, schouder; inklemming, schouder dystocie |
| French | Dystocie des épaules (ceinture) pendant le travail et l'accouchement, Dystocie de l'épaule |
| German | Schulter-(Guertel) Lage waehrend Wehen und Entbindung, Schulterlage |
| Portuguese | Distocia de ombro durante o trabalho de parto e expulsão, Distocia de ombro |
| Spanish | Distocia de hombros durante el parto y el alumbramiento, Distocia de hombros durante el trabajo de parto y la expulsión, distocia de hombros, SAI, distocia de hombros, SAI (trastorno), distocia de hombros no especificada, distocia de hombros no especificada (trastorno), distocia de hombro (trastorno), distocia de hombro, hombros impactados, Distocia de hombros |
| Japanese | 肩甲（上肢帯）難産、分娩中, 肩甲難産, ｹﾝｺｳﾅﾝｻﾞﾝ, ｹﾝｺｳｼﾞｮｳｼﾀｲﾅﾝｻﾞﾝﾌﾞﾝﾍﾞﾝﾁｭｳ |
| Czech | Dystokie ramének, Dystokie ramének (pletence) během porodu |
| Hungarian | Váll elakadása, Váll(övi) dystocia vajúdás és szülés idején, Váll (öv) dystocia vajúdás és szülés idején |
