There is no singularly agreed upon definition of shoulder dystocia, but it is generally defined as, after delivery of the fetal head, additional obstetric maneuvers beyond gentle guidance needed to enable delivery of the fetal shoulder. Shoulder dystocia occurs when there is a mechanical obstruction of the anterior fetal shoulder during the birthing process after the head is delivered. There can be several causes for this including the fetal shoulders being too broad to get through the pelvis, the fetus is not rotated properly to line up in the pelvis, a small maternal pelvic outlet, or the baby is too big to fit through the maternal pelvic outlet. The incidence varies in the literature to occur in 0.2-3% of all deliveries. 50% of all shoulder dystocias occur in infants less than 4,000 grams (8# 13 oz.) and without any associated risk factors. The basis of any litigation related to shoulder dystocia is – 1) Did they identify risk factors, and 2) Did they respond appropriately?
When a shoulder dystocia is identified, it is crucial for all team members to work together to effectuate a timely delivery. They should anticipate the potential need for a depressed newborn and additional staff should be called into the delivery to assist including providers skilled in advanced newborn resuscitation. If the baby is not delivered by the provider with GENTLE downward traction on the head/neck, then McRoberts Maneuver should be implemented. This includes lowering the head of the mother’s delivery bed and hyperflexing her legs toward her abdomen. This changes the shape of the maternal pelvis and 9 times out of 10, will allow the fetus to be delivered without additional maneuvers. If the shoulder dystocia persists, one of the nurses should then apply pressure from above and behind the pubic bone – suprapubic pressure – as directed by the delivering provider. This maneuver will help guide the anterior fetal shoulder down under the pubic bone while the mother pushes and the delivering provider applies gentle downward traction to the fetal head. The nurse and/or delivering provider should never apply fundal pressure at the top of the mother’s uterus, under ANY circumstances, in an attempt to deliver a baby in a shoulder dystocia situation. This will only impact the fetus further and increase the likelihood of additional injuries. If the fetus is not delivered after utilizing McRoberts Maneuvers, the delivering provider may then opt to use additional maneuvers such as cutting an episiotomy, Rubin’s maneuver, Woods corkscrew maneuver, delivery of the posterior arm, Gaskin maneuver, or intentional fracture of the fetal clavicle to facilitate a vaginal delivery.
A birth complicated by shoulder dystocia can lead to various fetal and maternal injuries. The fetus can suffer a fractured clavicle, fractured humerus, or even a dislocated or fractured cervical vertebrae resulting in permanent paralysis or even death. There is also the risk of umbilical cord entanglement while the fetus is stuck in the birth canal. The risk for brain damage from umbilical cord entrapment increases significantly after 5 minutes if there is a delay between delivery of the fetal head and the rest of the body. There is also the potential for maternal injuries such as lacerations, pubic bone separation, postpartum hemorrhage, increased pain, and PTSD due to traumatic delivery.
In any litigation matter involving shoulder dystocia, it is important to review the medical records of both the mother and the baby, or babies, to determine the following information:
Was the baby full-term or preterm?
When did active labor begin? (After 6 cm dilated)
When did the 2nd stage, pushing, begin? (Active pushing, not just 10 cm dilated)
What was the time of delivery of the fetal head?
What was the time of delivery of the fetal body? (Also known as Head-to-body delivery interval)
What did the fetal heart pattern look like in the 30 minutes prior to delivery?
What maneuvers were utilized, if any, in response to the shoulder dystocia?
Did the baby require resuscitation beyond “routine” interventions?
Who was in the delivery room assisting? (Healthcare personnel)
Shoulder dystocia cannot be prevented, but there are several risk factors associated with an increased risk of shoulder dystocia. These risk factors will be discussed in Shoulder Dystocia – Do You Have a Case? Part 2.