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Shoulder dystocia: Management and

documentation

Article in Seminars in Perinatology · June 2014

Impact Factor: 2.68 · DOI: 10.1053/j.semperi.2014.04.004 · Source: PubMed

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 SE M I N A R S I N P E R I N A T O L O G Y 38 (2014) 194–200

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Shoulder dystocia: Management and

documentation
Michael L. Stitely, MD, FACOG, FRANZCOGa, and Robert B. Gherman, MD,
FACOGb,n
a
Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
b
Division of Maternal/Fetal Medicine, Department of OB/GYN, Franklin Square Medical Center,
21636 Ripplemead Dr, Laytonsville, Baltimore, MD 20882

article info abstract

Keywords: Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become
Shoulder dystocia impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate
Brachial plexus palsy this impaction. A number of protocols and training mnemonics have been developed to
Management assist in managing shoulder dystocia when it occurs. This article reviews the evidence
Documentation regarding the performance, timing, and sequence of these maneuvers; reviews the
mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning
documentation of the care provided during this obstetric emergency.
& 2014 Elsevier Inc. All rights reserved.

Shoulder dystocia results from a size discrepancy between
the fetal shoulders and the pelvic inlet, which may be
absolute or relative (due to malposition). A persistent ante-
rior–posterior location of the fetal shoulders at the pelvic
brim occurs when there is increased resistance between the
fetal skin and the vaginal walls (with accelerated fetal
growth), with a large fetal chest relative to the biparietal
diameter, and when truncal rotation does not occur (precip-
itous labor). The overall goal of shoulder dystocia manage-
ment is to convert the fetal shoulders to an oblique diameter
in order to relieve the obstruction before the fetal brain
suffers irreversible hypoxic-ischemic injury.
For many years, long-standing opinions based solely on
empiric reasoning have dictated our understanding of the
detailed aspects of shoulder dystocia management. Recom-
mendations are essentially taken from non-randomized,
observational studies. A clear and undisputed stepwise
approach to shoulder dystocia management therefore does
not currently exist. Each individual provider must take
into account the resources available within his/her own
institution and community to design and implement a pro-
tocol that will assist in the optimal management of shoulder
dystocia. In this article, we present the current evidence for a
rational approach to shoulder dystocia management.
Diagnosis
Shoulder dystocia occurs when the fetal shoulders are
obstructed at the level of the pelvic inlet. The ultimate
diagnosis of this obstetric emergency, however, will not occur
until after the fetal head has emerged from the vagina. The
“turtle sign,” in which there is retraction of the fetal head
against the maternal perineum, is suggestive (but not diag-
nostic) of the presence of shoulder dystocia. Shoulder dysto-
cia is therefore most commonly diagnosed when there is
failure of delivery of the fetal shoulder(s) after initial attempts
at downward traction and ancillary obstetrical maneuvers are
required. Although other definitions have been reported in
the literature, these are not commonly employed in daily

n
Corresponding author.
E-mail address: ghermdoc@gmail.com (R.B. Gherman).

http://dx.doi.org/10.1053/j.semperi.2014.04.004
0146-0005/& 2014 Elsevier Inc. All rights reserved.
 S E M I N A R S I N P E R I N A T O L O G Y
clinical practice. Two studies have proposed defining
shoulder dystocia as a prolonged head-to-body delivery
interval of 60 s (the mean þ two standard deviations) and/
or the use of ancillary obstetric maneuvers.1 In Hoffman's
multicenter study, however, there were only two instances
(0.01%) among the 2018 reported shoulder dystocias in which
the delivery note documented such a head-to-body time.2
Mnemonics/algorithms
Algorithms (Figs. 1 and 2) depicting a particular sequence in
which the maneuvers to manage shoulder dystocia should be
employed are not based on high-level scientific evidence. No
particular sequence of maneuvers has been shown to be more
effective than an alternative sequence. These flow diagrams
are, however, helpful from a planning and training perspective,
as the emergent nature of shoulder dystocia is a barrier to
performing interventional research. In addition, these proto-
cols have attempted to provide a simple standardized
approach to handling shoulder dystocia. Distinct features of
the protocol espoused by Inglis et al.3 include a “hands-off”
procedure (no traction on the fetal head) once shoulder
dystocia has been called and assessment of the position of
the anterior shoulder by the delivering provider. In Grobman
et al.'s protocol, the delivery provider first unambiguously
announces that a shoulder dystocia is present. The delivery
provider then proceeds to alleviating maneuvers, while the
patient's primary nurse uses an emergency call button to
summon other relevant staff (Fig. 2).4 Mnemomics such as BE
CALM5 and HELPERR6 (Fig. 3) have also been designed as
memorization tools.
First-line maneuvers (external manipulations)
The McRoberts' maneuver is commonly cited as the initial
immediate approach for alleviation of shoulder dystocia. This
maneuver is performed by having the gravida hyperflex her
thighs toward her abdomen. This straightens the sacrum
with respect to the lumbar spine and decreases the angle of
inclination of the pelvis.7
Suprapubic pressure is applied directly downward onto the
anterior presenting shoulder or using a rocking motion from
the fetal back toward the front. The aim of this maneuver is
to decrease the bisacromial diameter by adducting the ante-
rior shoulder and to deflect the bisacromial diameter to an
oblique plane. The combination of the McRoberts' maneuver
and suprapubic pressure will alleviate the majority of cases of
shoulder dystocia.1
Second-line maneuvers (internal manipulations)
Rotational maneuvers routinely performed include the Rubin
II maneuver and the Woods corkscrew maneuver. The Rubin
II maneuver is performed by placing a hand into the vagina
and applying pressure to the posterior aspect of the most
accessible fetal shoulder. The shoulder is then pushed toward
the anterior surface of the fetal chest. The mechanism of this
38 (2014) 194–200 195
maneuver is by adduction of the fetal shoulder, which
reduces the bisacromial diameter allowing for the anterior
shoulder to be rotated and dislodged from behind the pubic
symphysis.8 The Woods corkscrew maneuver is performed by
placing the fingers on the anterior aspect of the posterior fetal
shoulder and rotating the shoulder toward the fetal back.9
The mechanism for this maneuver is attempted rotation in a
1801 fashion to allow descent with rotation, much like the
movement of a threaded screw when rotated.
Several techniques to deliver the posterior shoulder have been
described. The most widely employed method is extraction of
the posterior fetal arm. To approach the posterior arm, the
delivering clinician's hand is placed in the vagina and the
humerus of the posterior fetal arm is traced from the shoulder
to the elbow. Once the forearm is grasped, it is swept across the
fetal chest and the arm is pulled out of the vagina. If the forearm
is not accessible, pressure can be placed on the antecubital fossa
to flex the elbow. If this allows access to the forearm, delivery of
the posterior arm is accomplished as described above. If the
forearm is still not accessible, attempts are then made to deliver
the posterior shoulder or to make the posterior arm accessible
using posterior axillary traction methods. Menticoglou10
described a technique of utilizing finger traction to accomplish
axillary traction. The technique starts by having an assistant
hold the fetal head upwards, avoiding traction. Then the
operator's two middle fingers are placed from each side of the
posterior fetal shoulder and into the axilla. Downward and
outward traction is then placed on the posterior shoulder to
follow the curve of the sacrum. As the shoulder comes into view,
the posterior arm is delivered as previously described. Another
method of performing axillary traction is the use of a sling.
Hofmeyr and Cluver11 described a technique of applying axillary
traction utilizing a sling fashioned from a size
12- to 14-Fr suction catheter. In this technique, the suction
catheter is passed over the shoulder and around the axilla. The
two free ends of the catheter are clamped, and downward
traction is utilized until the shoulder descends enough to allow
for delivery of the posterior arm.
Preferred maneuvers and sequence
McRoberts' maneuver and suprapubic pressure are appropriate
first-line techniques as they are non-invasive, easy to learn, and
can be performed quickly. We believe that it is reasonable to
consider performing delivery of the posterior shoulder/arm as
the next maneuver in this sequence. The ultimate decision for
this, however, should be based on provider experience and the
clinical situation. If delivery of the posterior arm is unsuccessful
or cannot be attempted, then rotational maneuvers such as
Rubin II or Woods corkscrew can be performed.
In Grimm's computer modeling evaluation, posterior arm
delivery required the least exogenous force to effect delivery
and resulted in the lowest brachial plexus stretch.12 This
decreases the impacted diameter from the bisacromial dia-
meter to the axillo-acromial diameter. The end point of posterior
arm extraction is to substitute the axilloacromial diameter for
the bisacromial diameter, with the former being approximately
3 cm shorter than the latter.13 Geometric analysis has revealed
196 SE M I N A R S I N P E R I N A T O L O G Y 38 (2014) 194–200

Shoulder Dystocia Protocol

Summon Aida
Shoulder Hands off
Dystocia
Pressureb

d
Episiotomye

Assess
Shoulder
Position

Rotate to
Oblique

Change
Cork Screw Suprapubic Maternal
Maneuver Pressure Positionc

Deliver
Posterior
Arm

Replace Head-CSe
Fracture Clavicle
Symphysiotomy

Fig. 1 – Shoulder dystocia protocol. aExperienced obstetrician, nurse, anesthesiologist, and neonatologist. bNo fundal
pressure, no pushing, and no head traction. cMcRobert, knee chest position, lateral position, and squat. dMandatory part of
protocol. eOption or choice in protocol. fProceed with cesarean delivery. (Adapted with permission from Inglis et al.3)

that using posterior arm delivery reduced shoulder dystocia
more than twice as often relative to McRoberts' maneuver.14
Hoffman et al.2 completed a cohort study in which 2018
patients delivered with a shoulder dystocia had their
records analyzed by trained abstractors for the maneuvers
performed. Delivery of the posterior shoulder was the most
successful (84.4%) maneuver to alleviate the shoulder dysto-
cia, with the Woods maneuver (72%), Rubin II maneuver
(66%), and suprapubic pressure (62.2%) also showing high
rates of delivery. Multiple logistical regression analysis
revealed that there was a higher risk of neonatal injury
with the Rubin maneuver (OR ¼ 1.54) and Woods maneuver
(OR ¼ 2.22) than with delivery of the posterior shoulder (OR ¼
1.36). Leung et al.15 likewise found that among cases in which
the McRoberts' maneuver was unsuccessful, subsequent rota-
tional methods and posterior arm delivery were similarly
successful (72% vs 63.6%), without a statistically significant
increase in the rate of brachial plexus injury.
Episiotomy
The use of routine episiotomy in the management of all
shoulder dystocia cases has been advocated in the past, but
 S E M I N A R S I N P E R I N A T O L O G Y 38 (2014) 194–200 197

OB Provider Triggers L&D Nurses

Announce shoulder RN response
dystocia Employ TEAM approach:
Communicate with
Time
patient/family
- Note delivery of head using fetal
Direct nurses to perform monitor event marker
maneuvers as appropriate
- Call out 30-second intervals
- McRoberts
Emergency call light button
- Suprapubic pressure
- We have a shoulder in LDR #
Perform secondary and need a nurse and resident
maneuvers as necessary
- Rotational Activate shoulder dystocia page
- Deliver posterior arm Perform Maneuvers
Upon arrival, third nurse retrieves
worksheet and acts as Documenter:
- Observe & record key information

Fig. 2 – Shoulder dystocia protocol. OB, obstetric; L&D, labor and delivery; RN, registered nurse. (Adapted with permission
from Grobman et al.4)

with little scientific evidence in support of this practice. From
a theoretical standpoint, it does not seem probable that an
incision into the soft tissue of the vagina and perineum
would be helpful in resolving an impaction of the bony
structures of the fetal shoulders in the bony construct of
the maternal pelvis. The need for cutting a generous epis-
iotomy or proctoepisiotomy must be based on clinical cir-
cumstances, such as a narrow vaginal fourchette in a
nulliparous patient. Episiotomy can allow for greater access
to the vagina for the performance of the internal manipu-
lations necessary for the rotational maneuvers or for delivery
of the posterior shoulder.
Brachial plexus injuries do not appear to be increased when
episiotomy is not performed in the management of shoulder
dystocia. Gurewitsch published a cohort study that included
cases of severe shoulder dystocia (defined as cases requiring
greater than 90 s for resolution, intentional performance of a
proctoepisiotomy, and/or fetal manipulations, umbilical
artery pH r 7.10 or 5-min Apgar score of o7) and then
stratified the cases into three groups: delivery by episiotomy
only (allowed for external maneuvers also); fetal manipula-
tion without episiotomy; and delivery by both episiotomy and
fetal manipulation. The performance of an episiotomy (with
and without fetal manipulation) was associated with brachial
plexus palsy with an odds ratio of 2.1, while the lack of an
episiotomy did not correlate with such injuries. The perform-
ance of an episiotomy was also positively associated with
anal sphincter injuries.16 In another retrospective study, Paris
analyzed for trend including episiotomy rates over time
compared with rates of shoulder dystocia and brachial plexus

Fig. 3 – Useful Mnemonics used in team training and courses. (BE CALM mnemonic adapted with permission from ACOG
Optimizing Obstetric Protocols.2) (HELPERR mnemonic adapted with permission from AAFP ALSO course syllabus.3)
198 SE M I N A R S I N P E R I N A T O L O G Y
injury.17 Despite a decline in the episiotomy rate in shoulder
dystocia deliveries from 40% to 4% over the 10-year study,
there was no change in the rate of brachial plexus injuries.
Extraordinary measures
If delivery has not occurred within 4–5 min, plans for heroic
measures should be implemented. This may include moving
the patient to the operating room to prepare for cesarean
delivery in conjunction with the Zavanelli maneuver.
Employment of the Zavanelli maneuver may be considered
when there is impaction of the fetal shoulder upon the sacral
promontory, for bilateral shoulder dystocia, or when the
posterior shoulder is not in the pelvis. Cephalic replacement
may be used to relieve a shoulder dystocia resulting from the
occiput posterior position.
The Zavanelli maneuver is initiated by rotating the fetal
head back to the pre-restitution attitude. The head is then
flexed and pressure is applied to replace the head into the
vagina. Once the head is pushed back into the vagina,
delivery is by cesarean section.18 Tocolytic medications such
as halogenated inhalational anesthetics, terbutaline, or nitro-
glycerin can be used to assist in replacing the fetal head into
the vagina.
Sandberg19 published a review of cases of the Zavanelli
maneuver found in the medical literature. He reported that
cephalic replacement was successful in 84 of 92 cases in
which it was attempted. There were seven neonatal deaths in
the cephalic replacement cases and fetal injuries were com-
mon, but the injuries could not be causally related to the
procedure itself.
Zelig and Gherman20 reported a case where the fetal head
descended out of the introitus after successful cephalic
replacement. It was observed that the shoulder was no longer
impacted and vaginal delivery ensued. It is reasonable to
attempt vaginal delivery if this situation is encountered while
preparations for cesarean delivery are undertaken.
If cephalic replacement is not possible or in situations
where immediate access to an operating room facility is not
available, symphysiotomy can be performed. Symphysiotomy
was initially described as a treatment for cephalopelvic
disproportion. In cases of shoulder dystocia, symphysiotomy
is performed by placing the patient in the lithotomy position
and inserting a Foley catheter into the bladder (if possible).
The urethra is then retracted laterally by the operator's hand
to protect the urinary tract from injury. The overlying skin
and subcutaneous adipose is incised with a scalpel down to
the level of the symphysis pubis. The anterior fibers of the
symphysis pubis are incised with the scalpel. The separation
of the symphysis usually relieves the dystocia. In two cases
described by Reid and Osuagwu,21 this technique was used
with rapid resolution of the dystocia after attempts of other
maneuvers had failed.
Traction
The use of an exogenous force (traction) by the delivering
provider is inherent in the management of every vaginal
38 (2014) 194–200
delivery and in the management of shoulder dystocia.
Clinical diagnosis of shoulder dystocia results from failure
of delivery of the fetal shoulder(s) after an initial traction
attempt. A few authors have empirically advocated pro-
ceeding directly to maneuvers for attempted delivery of the
fetal shoulders (ie, avoidance of initial diagnostic traction),
in order to maintain the forward momentum of the fetus.
Others support a short delay in the delivery of the shoulders
(ie, observation alone), arguing that the endogenous rota-
tional mechanics of the second stage may spontaneously
alleviate the obstruction. When shoulder dystocia is clin-
ically diagnosed, the first order of business should be to stop
all endogenous and exogenous forces until an attempt is
made to alleviate the obstruction. The patient should be
instructed to stop pushing; however, it must be recognized
that, most likely, the gravida will continue to involuntarily
exert endogenous expulsive forces as uterine contractions
do not spontaneously abate once the head emerges from
the vagina. Maternal expulsive efforts will need to be
started after the fetal shoulders have been converted to
the oblique diameter (ie, as a diagnostic step to prove that a
maneuver has been successful) in order to complete the
delivery.
Textbooks have sparingly described the direction and
degree of traction that should be employed during normal
vaginal deliveries. In Gabbe's Obstetrics, it is stated: “Once the
fetal head is delivered, external rotation (restitution) is
allowed; if shoulder dystocia is anticipated, it is appropriate
to proceed directly with gentle downward traction of the fetal
head before restitution occurs. The anterior shoulder should
then be delivered by gentle downward traction in concert
with maternal expulsive efforts. The posterior shoulder is
then delivered by upward traction.”22
Williams Obstetrics likewise notes: “The sides of the head
are grasped with two hands, and gentle downward traction is
applied until the anterior shoulder appears under the pubic
arch. Next, by an upward movement, the posterior shoulder
is delivered. The rest of the body almost always follows the
shoulders without difficulty. With prolonged delay, however,
its birth may be hastened by moderate traction on the head
and moderate pressure on the uterine fundus.”23
Whenever extraction (exogenous) forces are applied by the
delivering clinician, the fetal head should be maintained in
an axial position and rotation of the fetal head should be
avoided.
Axially derived traction, by following the natural curve of
the maternal pelvis, does by definition have a downward
component. Axial traction is the traction applied in align-
ment with the fetal cervico-thoracic spine. Traction applied
in the plane of the fetal cervico-thoracic spine is typically
along a vector estimated to be 201–251 below the horizontal
plane when the woman in labor is in a lithotomy position.
Thus, while axial traction is also “downward,” it is applied
without lateral bending of the fetal neck (ie, bending the neck
toward the floor or the ceiling). Laterally derived traction only
should not be employed as the sole maneuver to effect
delivery in the absence of ancillary obstetric maneuvers.
Among four cases in which this occurred in Leung's series,
there were three (75%) brachial plexus injuries and one (25%)
clavicular fracture.15
 S E M I N A R S I N P E R I N A T O L O G Y
Length of time for alleviation
Shoulder dystocia should be viewed as an obstetric emergency
due to the short period of time required to relieve the
obstruction prior to the onset of hypoxic brain injury. Not all
fetuses have the same baseline reserve during second-stage
labor, so it is difficult to state an exact length of time in which
hypoxic-ischemic encephalopathy will occur if delivery is not
completed. Given the considerable overlap in delivery timing
for neonates with and without injuries or depression, it is
difficult to pinpoint an exact time in which delivery should
ideally occur. Based on the current literature, it seems reason-
able to consider extraordinary measures to effect delivery once
4–5 min have elapsed and the fetus is still undelivered.1
The exact mechanism behind fetal acidemia and subse-
quent hypoxia is currently unknown. Plausible hypotheses
include umbilical cord compression or compression of the
fetal neck and subsequent cerebral venous obstruction. In
Hoffman's series, no cases of neonatal death attributable to
shoulder dystocia occurred, although six of 101 (5.9%, 95% CI:
1.2–10.7%) had hypoxic-ischemic encephalopathy. The mean
head-to-body time interval was 10.75 min, but a significant
range was described (3–20 min).2 Among cases from the 1998
United Kingdom Confidential Enquiry into Stillbirths and
Deaths in Infancy report the median head-to-body delivery
time interval was just 5 min among the 45 reported cases of
fatal shoulder dystocia.24 Leung showed a 0.5% risk of pH o 7
and hypoxic-ischemic encephalopathy with head-to-body
delivery intervals of less than 5 min and a 5.9% risk of
pH o 7 and 23.5% risk of hypoxic-ischemic encephalopathy
when the head-to-body delivery interval was 5 min or greater.
They also demonstrated that for each additional minute of
delay between delivery of the head and the body, there was a
decrease in the umbilical cord pH of 0.011.25 Lerner compared
cases of uncomplicated shoulder dystocia deliveries to cases
of shoulder dystocia with persistent brachial plexus palsies
and cases of neonatal depression (defined as death, requiring
CPR or intubation in the delivery room, umbilical artery pH o
7 or 5-min Apgar score of 5 or less) and brachial plexus
palsy.26 They found that all uncomplicated cases of shoulder
dystocia had been delivered by 4 min, with a median time of
1 min. In contrast, neonates with depression and a brachial
plexus injury were delivered with a median time of 5.3 min
(range: 1–25 min). When grouping the deliveries with respect
to head-to-body time intervals, by 4 min, all uncomplicated
cases had delivered, and by 5 min, 93% of cases with persis-
tent brachial plexus injuries without neonatal depression had
delivered. There was considerable overlap in the distribution
of groups prior to 4 min time. By 4 min time, 43% of neonates
with persistent brachial plexus injuries and neonatal depres-
sion had already been delivered, and 85% of neonates with
persistent brachial plexus palsies without neonatal depres-
sion had delivered.
Documentation
Any shoulder dystocia that involves injury to the neonate,
whether temporary or permanent, holds significant potential
38 (2014) 194–200 199
to result in litigation. As most states allow medical malprac-
tice claims to be filed on behalf of a child as late as 2 years
after the child reaches the age of majority, a shoulder
dystocia case can take a significant period of time to work
its way through the legal system. In Clark's series, payment
was driven by lack of clear documentation in 54% of cases.27
This lack of clear documentation allows for missing data to
be supplied by non-medical personnel in attendance and
assumptions by expert witnesses. Contemporaneous docu-
mentation of the management of shoulder dystocia is there-
fore recommended to record significant facts, findings, and
observations about the shoulder dystocia event and its
sequelae. Consideration can be given to calling a nurse or
staff member into the room for the purpose of documenta-
tion once shoulder dystocia is diagnosed. In addition, team
debriefing to allow for an exact determination of the
sequence and timing and events has been advocated.28 There
is, however, no clearly defined standard of exactly what
should be documented in either a handwritten or a dictated
delivery note. Examples of checklists that contain the rec-
ommended information suggested for documentation are
ACOG's Patient Safety Checklist for shoulder dystocia or the
Royal College of Obstetrician and Gynecologist's Green-top
Guideline No. 42. Suggested items include the following:
 Type of delivery (spontaneous vs instrumental): if instru-
mental, document station and indication
 Time interval between delivery of the fetal head and body
 Which shoulder was anterior or posterior
 Timing and sequence of maneuvers performed
 Medical and nursing personnel in attendance
 Neonatal assessment of the baby
 Presence or absence of episiotomy
 Timing, duration, and angle of traction applied
 Condition of the infant: Apgar scores, umbilical cord blood
gases, evidence of fractures, and/or reduced movement of
either arm
 Information given to the patient or family
Pertinent negatives (lack of fundal pressure)
refere nces
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