II. Epidemiology

  1. Incidence of Shoulder Dystocia
    1. Incidence Overall: 0.3 - 1%
    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

III. Risk Factors

  1. Most cases occur without obvious predictors
  2. Assisted Vaginal Delivery (most common risk factor)
  3. Fetal Macrosomia (>4000 grams)
    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 or Short Stature
  8. History of prior Shoulder Dystocia
  9. Prolonged first or second stage of labor

IV. Signs: Warning signs suggestive of Shoulder Dystocia

  1. Prolonged second stage of labor
  2. Recoil of head on perineum (turtle's sign)

V. 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

VI. Complications of Shoulder Dystocia: Fetus

  1. Brachial Plexus Injury from Birth Trauma (10%)
    1. General
      1. Most resolve in first year, some persistent
      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. Clavicle Fracture
    2. Humerus Fracture
  3. Fetal Asphyxia
  4. Fetal Death
  5. Meconium Aspiration

VII. Complications of Shoulder Dystocia: Maternal

  1. Postpartum Hemorrhage (11% of cases)
  2. Fourth-degree perineal Laceration (Up to 4% of cases)
  3. Uterine Rupture
  4. Rectovaginal fistula
  5. Pubic symphysis separation with femoral Neuropathy

VIII. Prevention in anticipation of a Shoulder Dystocia

  1. Deliver at the start of the contraction
  2. Deliver head and Shoulders with the same push
  3. Suction airway after Shoulders are delivered
  4. Early induction or cesarean in macrosomia not supported
    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]

IX. Management

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Ontology: 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