Shoulder Dystocia

During childbirth, an obstetrical emergency called “shoulder dystocia” can occur when the baby’s shoulder becomes stuck behind the mother’s pubic bone or sacrum (the bone at the back of the pelvis above the tailbone). When this happens, it prevents the baby from continuing through the birth canal and the baby becomes stuck inside the pelvis. This can cause serious complications for the baby and the mother if not handled properly.

Causes and Risk Factors

Shoulder dystocia is a relatively rare delivery complication. There are several common, interrelated risk factors, but there is no one certain cause. Factors that may increase the risk of shoulder dystocia include:

• Fetal macrosomia: when the baby weighs more than 8 pounds, 13 ounces
• A small birth canal/pelvic opening
• The baby is in the wrong position or angle inside the birth canal
• The position of the mother which limits the room in the pelvis
• Maternal diabetes
• Excessive prenatal weight gain and maternal obesity
• Protracted labor
• Assisted vaginal delivery with the use of a vacuum extractor or forceps
• History of shoulder dystocia in a previous pregnancy
• Giving birth to twins or other multiples
• The use of oxytocin to induce labor

Shoulder dystocia is more common in male babies delivered full-term due to their tendency to be comparatively larger.

There are generally no symptoms that predict that shoulder dystocia will occur. If any of the risk factors are present and the mother is having a vaginal delivery, the healthcare provider should have a safety checklist prepared that includes steps to be taken in the event that shoulder dystocia occurs. An obstetrician may recommend scheduling a c-section if the mother has diabetes or if the baby is relatively large or has suspected fetal macrosomia.

Diagnosis

Although factors have been identified which are associated with a higher risk of shoulder dystocia, most cases occur with no warning. Since there are no definite symptoms of shoulder dystocia present in the mother prior to delivery, the obstetrician may only notice the condition after the mother delivers the baby’s head.  If the baby’s head emerges and then pulls back in against the perineum (the area between the vagina and rectum), it is referred to as the “turtle sign,” and is a clear indication of shoulder dystocia.

An obstetrician will typically diagnose shoulder dystocia if three factors are met:

• The baby’s head has been delivered but the mother is unable to push the baby’s shoulders out.
• At least one minute has passed since the baby’s head emerged but the body still has not.
• The baby needs medical intervention to be delivered successfully.

Treatment and Management

Shoulder dystocia can immediately threaten the safety of the mother and the baby. OB/GYNs have a very narrow window of time to act once shoulder dystocia occurs. If it is not properly identified and managed, the baby and/or mother can be seriously injured. In rare cases, the baby may even die or suffer serious brain damage from oxygen deprivation.

When shoulder dystocia occurs, fundal pressure must be avoided and excessive force must not be applied to the fetal head or neck. These maneuvers are unlikely to free the baby and may cause more damage to the baby and mother. Instead, the healthcare team my try several interventions or maneuvers to position the mother in a better position to widen the pelvis, or to move the baby into a better fetal position to move the baby’s shoulders. The mnemonic, “HELPERR,” is a tool healthcare providers may use as a framework for dealing with shoulder dystocia:

• H – Help: The obstetrician will call for help and implement the pre-arranged safety checklist or protocol. They may request the assistance of appropriate personnel and the necessary equipment.
• E – Evaluate for Episiotomy: This step should be considered throughout the management of the shoulder dystocia but is only necessary if the obstetrician needs to make room for a rotation maneuver. An episiotomy is an incision in the perineum that makes the opening to the vagina larger. However, shoulder dystocia implies the baby’s shoulder is stuck behind bone, so this incision alone will not release the baby’s shoulder. This incision can typically be avoided using the McRoberts maneuver and suprapubic pressure to release the baby’s shoulder.
• L – Legs (McRoberts Maneuver): This maneuver helps flatten and rotate the mother’s pelvis by positioning the mother’s thighs up against her abdomen.
• P – Pressure: Suprapubic pressure may be used to put pressure on the baby’s shoulder in an attempt to rotate and deliver the baby. The obstetrician or an assistant will press on the mother’s lower abdomen above the pubic bone while continuing downward traction to deliver the baby.
• E – Enter Maneuvers: Enter maneuvers, also referred to as internal rotation, require the obstetrician to reach up into the vagina and attempt to rotate the baby to free the shoulder.
• R – Remove the Posterior Arm (Jacquemier’s Maneuver): This maneuver requires the obstetrician to remove one of the baby’s arms from the birth canal to make it easier for the shoulder to pass through.
• R – Roll the Patient (Gaskin Maneuver): The mother will be repositioned and asked to roll over onto her hands and knees using this maneuver. Often, this rolling movement alone is sufficient to dislodge the baby’s shoulder.

There is no one superior maneuver and clinical judgment is needed to determine which procedures should be used. The order of the steps in HELPERR are not as important as ensuring the steps are employed appropriately. If a maneuver is ineffective, persistence in attempting that maneuver should be avoided.

In more severe cases when none of the above maneuvers and techniques are working, the obstetrician may use one of the following maneuvers as a last-resort:

• Deliberate Clavicle Fracture: the obstetrician may deliberately break the baby’s collarbone to release the shoulder.
• Zavanelli Maneuver: the obstetrician will push the baby’s head back into the mother’s uterus and perform a c-section. An operating team, anesthesiologist, and physicians capable of performing a c-section must be present to perform this method. This maneuver should never be attempted if a nuchal cord has been previously clamped and cut.
• General Anesthesia: general anesthesia, such as halothane (Fluothane), may be used to bring enough musculoskeletal or uterine relaxation to affect delivery.
• Abdominal Surgery with Hysterotomy: under general anesthesia, a c-section incision is made, allowing the surgeon to rotate the baby transabdominally through the hysterotomy incision. The baby’s shoulders are rotated and vaginal extraction is completed by another physician.
• Symphysiotomy: this maneuver should only be used once all other maneuvers have failed and a c-section is not an option. It involves making an incision in the cartilage between the pubic bones to enlarge the pelvic opening.

Complications

The risk of a birth injury is extremely high in cases of shoulder dystocia. A high level of skill must be utilized by physicians in order to handle shoulder dystocia and deliver the baby without injuring the mother or child. However, shoulder dystocia does not happen often enough for most physicians to develop expertise on the condition. This lack of experience may cause a physician to make panicked or rushed decisions resulting in overly aggressive manipulation, excessive force, or hyperflexion of the baby’s neck which routinely causes injuries to the baby.

The most common complication of shoulder dystocia in the baby is branchial plexus palsy, also called “Erb’s Palsy.” Erb’s Palsy occurs when there is damage to the brachial plexus nerves. These nerves run through the spinal cord, neck, and arm of the baby and are ultimately responsible for providing feeling and movement in the baby’s shoulder, arm, and hand. When the brachial plexus nerves are damaged, it can cause paralysis in the arm and hand. Other complications may include the following:

• Horner Syndrome: A rare neurological disorder affecting the baby’s eye and surrounding tissues on the affected side of the face.
• Compressed Umbilical Cord: Shoulder dystocia can sometimes trap the umbilical cord between the baby’s arm and the mother’s pubic/pelvic bone. This compression of the umbilical cord can cut off the blood flow and oxygen to the baby. Although it is rare, the resulting oxygen deprivation can cause serious brain injuries such as cerebral palsy (a condition that impairs the baby’s ability to control movement of the body), or even death.
• Babies can also suffer physical traumas such as broken bones and facial damage due to shoulder dystocia or the mismanagement of shoulder dystocia.

Complications from shoulder dystocia can also arise which affect the mother. These complications include the following:

• Postpartum Hemorrhage: extreme heavy bleeding after giving birth
• Rectovaginal Fistula: an abnormal connection between the vagina and rectum.
• Uterine Rupture: a tearing of the uterus during labor
• Separation of the pubic bones
• Severe tearing of the perineum

Filing a Medical Malpractice Claim or Lawsuit

If you or your baby have suffered complications from shoulder dystocia that was negligently managed or diagnosed, you may be entitled to compensation for your damages. Call Bonner Law at 1-800-4MEDMAL or visit our page for a free consultation.

Medical malpractice cases are complex and can be emotionally challenging for the patients involved. Finding the right attorney can make the process much easier. Michael P. Bonner has over 30 years of experience representing patients in medical malpractice cases all over Florida. Bonner Law has the knowledge and experience to represent you and navigate the legal and medical landscape to ensure that you receive compensation for damages, including medical bills, lost wages, and pain and suffering that you are entitled to. For more information on medical malpractice claims you can also visit our Medical Malpractice page.