Obstetrics Book



Shoulder Dystocia

Aka: Shoulder Dystocia, Impacted Shoulders During Labor
  1. Also See
    1. Fetal Macrosomia
    2. Gestational Diabetes
  2. Definitions
    1. Shoulder Dystocia
      1. Birth complication in which the fetal anterior Shoulder impacts the maternal Symphysis Pubis and prevents fetal body delivery
      2. Potentially life-threatening condition requiring emergent maneuvers to relieve the impaction and deliver the fetal body
  3. Epidemiology
    1. Incidence of Shoulder Dystocia
      1. Incidence Overall: 0.3 - 1% of vaginal deliveries
      2. Birthweight >4000g: 5-7%
      3. Birthweight >4500g: 8-10%
    2. Shoulder Dystocia Cases by birthweight
      1. Infants over 4500 grams: 50%
      2. Infants 4000 to 4500 grams: 23%
      3. Infants 3500 to 4000 grams: 9%
      4. Normal birthweight infant: 50-66% in some studies
  4. Risk Factors
    1. Most cases occur without obvious predictors
    2. Assisted Vaginal Delivery (most common risk factor)
    3. Fetal Macrosomia (>4000 grams, OR>16)
      1. Estimated fetal weight of current pregnancy
      2. Prior macrosomic infant
      3. Family History of Fetal Macrosomia
    4. Gestational Diabetes
    5. Multiparity
    6. Postterm delivery
    7. Maternal abnormal Pelvic Anatomy, Short Stature or Obesity
    8. History of prior Shoulder Dystocia (OR>8)
    9. Prolonged first or second stage of labor
    10. Oxytocin use to augment labor
    11. Operative Vaginal Delivery (vacuum or forceps)
  5. Signs: Warning signs suggestive of Shoulder Dystocia
    1. Prolonged second stage of labor
    2. Recoil of head on perineum (turtle's sign)
  6. Diagnosis
    1. Time between delivery of head and delivery of body >60 seconds
    2. Additional delivery maneuvers required to deliver the body
  7. Management
    1. See Shoulder Dystocia Management
  8. Complications: Shoulder Dystocia Fetal Effects
    1. Brachial Plexus Injury from Birth Trauma (10%)
      1. General
        1. Most resolve in first year, but persistent in 10% of cases
        2. Palsy may be unrelated to disimpaction maneuvers
          1. Gherman (1998) Am J Obstet Gynecol 178:423-7 [PubMed]
          2. Sandmire (2000) Am J Obstet Gynecol 95:941-2 [PubMed]
      2. Types
        1. Erb-Duchenne Palsy
          1. Fifth and sixth cervical roots
        2. Klumpke's Paralysis
          1. Eighth cervical and first thoracic roots
    2. Fractures
      1. Humerus Fracture
      2. Clavicle Fracture from Birth Trauma
    3. Fetal Asphyxia and Fetal hypoxic ischemic encephalopathy
    4. Fetal Death
    5. Meconium Aspiration
  9. Complications: Shoulder Dystocia Maternal Effects
    1. Postpartum Hemorrhage (11% of cases)
    2. Fourth-degree perineal Laceration (Up to 4% of cases)
    3. Lacerations to other pelvic structures (Bladder, Urethra, vagina, anal sphincter, Rectum)
    4. Uterine Rupture
    5. Rectovaginal fistula
    6. Pubic Symphysis separation
    7. Lateral Femoral Cutaneous Neuropathy
  10. Prognosis
    1. Shoulder Dystocia results in cord compression
      1. Arterial pH drops 0.04 per minute
      2. Arterial pH drops 0.28 in seven minutes
      3. Arterial pH drops 0.14 per minute on trunk delivery
    2. Arterial pH below 7.0 makes Resuscitation difficult
  11. Prevention: Anticipation of a Shoulder Dystocia
    1. Advanced Life Support in Obstetrics (ALSO) course
      1. https://www.aafp.org/cme/programs/also.html
      2. Prepares providers for obstetrical emergencies including Shoulder Dystocia Management
    2. During delivery
      1. Deliver at the start of the contraction
      2. Deliver head and Shoulders with the same push
      3. Suction airway after Shoulders are delivered
    3. Cesarean delivery for fetal macrosmia indications
      1. ACOG recommends considering cesarean delivery for fetal weight >5000 g (11 lb)
      2. ACOG recommends considering cesarean delivery for Gestational Diabetes AND weight >4500 g (9 lb 15 oz)
      3. (2017) Obstet Gynecol 129(5): e123-33
    4. However, prior studies did not show benefit for induction or cesarean in macrosomia
      1. See Fetal Macrosomia
      2. Elective cesarean does not reduce dystocia cases
        1. Rouse (1996) JAMA 276:1480-6 [PubMed]
      3. Early induction does not reduce dystocia cases
        1. Kjos (1993) Am J Obstet Gynecol 169:611-5 [PubMed]
  12. References
    1. Acker (1986) Obstet Gynecol 67:614-8 [PubMed]
    2. Baskett (1995) Obstet Gynecol 86:14-7 [PubMed]
    3. Baxley (2004) Am Fam Physician 69:1707-14 [PubMed]
    4. Hill (2020) Am Fam Physician 102(2): 84-90 [PubMed]
    5. Lewis (1995) Am J Obstet Gynecol 172:1369-71 [PubMed]

Shoulder girdle dystocia (C0269825)

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, ケンコウナンザン, ケンコウジョウシタイナンザンブンベンチュウ
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
Derived from the NIH UMLS (Unified Medical Language System)

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