Anatomy & Physiology
Review Article
Volume 1 Issue 5 - 2015
Shoulder Dystocia: The Frightening Emergencies
Tahmina Afrose1*, Farzana Afzal2, Nasrin Habib3, Mamunur Rashid4 and Anath Bondhu Chattopadhyay5
1,5Department of Obstetrics & Gynecology, AIMST University, Malaysia
2Department of Ophthalmology, AIMST University, Malaysia
3Department of Physiology, Quest International University Perak, Malaysia
4Department of Medicine, Quest International University Perak, Malaysia
Received:November 18, 2015 | Published: December 01, 2015
*Corresponding author: Tahmina Afrose, Department of Obstetrics & Gynaecology, AIMST University, Malaysia, Tel: +60149402614; Email:
Citation: Afrose T, Afzal F, Habib N, Rashid M, Chattopadhyay AB (2015) Shoulder Dystocia: The Frightening Emergencies. MOJ Anat Physiol 1(5): 00025. DOI: 10.15406/mojap.2015.01.00025


Shoulder dystocia is a condition where there is a difficulty in the delivery of the shoulder of the fetus occurs. This is an obstetric emergency. It happens when the fetalbiacromial diameter is larger than the biparietal diameter or the maternal pelvic brim is flat rather than gynecoid, If this frightening situation is not manage properly, in time and by expert hand it can cause severe fetal and maternal outcome. All doctors should require proper training and knowledge for the management of this emergency situation. Well-trained health professionals can improve the outcome of the delivery when shoulder dystocia occurs. There is no any strong evidence to prevent shoulder dystocia because it is so unpredictable. But good control of blood glucose level of diabetic mother will reduce the incidence of macrosomic baby. Elective caesarean section is recommended for suspected fetal macrosomia to prevent brachial plexus injury.

Keywords: Shoulder dystocia; Brachial Plexus nerve palsy; Clavicle fracture; Brain injury; Postpartum bleeding


According to the definition of the Royal College of Obstetricians and Gynaecologists for shoulder dystocia some specific manoeuvres are needed for the delivery of the shoulder of the baby [1]. All over the world both in developed and developing countries the incidence of this emergency situation is increasing [2]. Serious feto-maternal complications are associated with the improper management of shoulder dystocia.

Macrosomic baby are in high risk for the injury of the Brachial plexus in this situation [3,4]. Larger infant and Shoulder dystocia are interrelated [5], but there are some evidence Shoulder dystocia can occurs in infant with less than 4000gm birth weight [6]. Some mechanical causes are related for the development of Shoulder dystocia [7,8].

Risk factors for shoulder dystocia
Antenatalrisk factors for shoulder dystocia are listed below

  • Previous history of shoulder dystocia [9]
  • Macrosomic baby [10]
  • Gestational Diabetic mother [11]
  • Obesity (body mass index >25) [12,13]
  • Multiparty [13,14]
  • Elderly mother [12,13]

Intrapartum risk factors are as follows

  • Short labour(< 20 min) [11,15]
  • Instrumental vaginal delivery (vacuum, forceps) [10]
  • Prolonged second stage of labour [10]
  • Without local anaesthesia (>2 h for multiparous patients, or >1 h for multiparous patients) [11]
  • With local anaesthesia (>3 h for nulliparous patient, >2 h for others) [11]
  • Induction of labour for "impending macrosomia" [16]

In clinical practices a lot of patient having these risk factors do not face this complication but some other patient without these risk factors have the complication of shoulder dystocia. Sometimes the delivery of a small fetus can be complicated by Shoulder dystocia [17].

The accurate birth weight of a macrosomic baby cannot be diagnosed before the delivery [16]. Babies of diabetic mothers are in greater risk of Shoulder dystocia [5,18]. Prolonged second stage of labour is also associated with Shoulder dystocia.

Many of the elderly mothers having the higher BMI and there deliveries are complicated by Shoulder dystocia [19]. Shoulder dystocia is also associated with multiparty because most of them are dealing with obesity [20].

Neonatal-Maternal Outcome of shoulder dystocia
Incidence of neonatal and maternal morbidity and mortality is higher in shoulder dystocia. Prompt action can reduce this incidence [21].
Maternal complication of shoulder dystocia [22]:

  • Hypovolumic shock due to profuse bleeding during post natal period
  • Cervical laceration
  • Injury to the birth canal
  • Separation of the Pubic symphysis
  • Lateral femoral cutaneous neuropathy
  • Rupture of the uterus

Fetal complication of shoulder dystocia [22]:

  • Brachial plexus palsy
  • Fetal death
  • Fetal distress
  • Fracture of the clavicle
  • Fracture of the humerus

One dangerous neonatal complication of shoulder dystocia is Brachial Plexus nerve palsy [23]. Majority of the cases resolve spontaneously. 10% of the infants with this complication may develop permanent disability [24]. Either excessive traction by the doctor during the delivery or maternal bearing down effort during the labour may be the cause of this type of injury [25].

Postpartum bleeding due to birth canal injury is one of the major causes of the maternal morbidity and mortality [26,27].

Prevention of shoulder dystocia
If fetal weight is normal for a Gestational diabetic mother, after 38 weeks her baby can be delivered either by vaginal delivery through Induction of labour or by caesarean section [28]. If the high risk mothers are identified during their antenatal period and their babies are being delivered by elective caesarean section, the incidence of Shoulder dystocia can be prevented [29,30].

Intrapartum management of shoulder dystocia
For the clinical diagnosis of Shoulder dystocia during intrapartum period the health care provider should routinely observe for the followings : (Evidence level IV, RCOG) [25]

  • Difficulties in delivery of the face and chin
  • “Turtle-neck sign”
  • Failure of restitution of the fetal head
  • There is the difficulty in descend of the shoulder

During the management of the Shoulder dystocia the birth attendants must be calm, confidant and have the ability to take prompt action [31]. The mother should be needed for the counselling of this emergency situation. Documentation is always necessary [30]. Systematically management of the Shoulder dystocia according to “the RCOG algorithm” may prevent some serious feto-maternal complication [32].
There are various techniques for the delivery of the anterior shoulder.

First-line manoeuvres [1]: These include

  • Call for additional help: In this emergency situation a team work is necessary. The must have an expert obstetrician, an experienced pediatrician and an anesthetist [33].
  • Discouraging Fundal pressure: For the management of this type of emergency it is always suggest to avoid fundal pressure [34]. Otherwise it can lead to fetal life in danger [35].
  • Episiotomy: It is given when necessary. The benefit of the episiotomy is that the doctor can get more space if they try for any internal manoeuvre [36-39].
  • McRoberts’ manoeuvre: [37,38] (Figure 1): In this type of manoeuvre maternal hips are being kept in flexed and abducted position with thighs on her abdomen. [39] This manoeuvrehelp to increase the anterior-posterior diameter of the maternal pelvis creating an adequate space for the delivery of the shoulder [40]. The success rates is high in this manoeuvre [41-44].
  • Suprapubic pressure: Both suprapubic pressure and the ‘McRoberts’ manoeuvre’can be tried simultaneously [41]. By applying suprapubic pressure the fetal biacromial diameter is reduced , facilitatingthe rotation of the anterior shoulder of the fetus into the wider pelvis [43].

Second-line manoeuvres [1]:These include

  • Internal rotation: This is done by giving pressure on the posterior aspect of either the anterior or the posterior shoulder of the fetus. This facilitates adduction of the shoulder and in turn decreases the biacromial diameter [45-48].
  • All-fours position [40] : In this type ofmanoeuvre Thesuccess rate is also good [49].
  • Third-line manoeuvres [1]: The maternal morbidity and mortality is high if this type of manoeuvres is not performed by expert hand. .Any of the following can be tried [1].
  • “The Zavanellimanoeuvre” [50]: Here vaginal delivery is avoided. In this manoeuvreat first the fetalhead is replaced into the vagina and the baby is deliveredby caesarean section [50,51].
  • “Symphysiotomy” [50,51]: In this manoeuvrethe anterior fibre of the pubic symphyseal ligaments are dissected . The success rate is also good [52].
  • “Cleidotomy”: This procedure is performed either by surgically or by manually [52].

Post-partum Management of shoulder dystocia
Documentation should be comprehensive. Specially in keeping birth record the following information are required to look for [53,54].

  • The time interval between the head and the body of the fetus
  • The name of the manoeuvres that has been tried, their duration and the outcome.
  • Clinical findings of the vaginal and perineal examinations
  • About the amount of bleedings
  • About the team work
  • Neonatal condition including the Apgar score [53,54].

Figure 1: Somatotopical interpretation on the homunculus model of functionality [16].

Figure 2: SPosterior arm delivery.


The incidence of the Shoulder dystocia is increasing [2] due to higher rate of elderly mother and the obesity. Even after managed appropriately there can be significant perinatal mortality and morbidity associated with this condition [55], It can be managed systematically. It is frequently associated with permanent birth-related injuries and maternal complications. Calm and effective management of this frightening emergency with applying specified maneuvers will allow a spontaneous delivery of the infant. All healthcare providers attending pregnancies needed to be prepared with a high level of awareness and training to handle vaginal delivery complicated by Shoulder dystocia [56-58].

All the obstetricians should be prepared to manage this anxiety-provoking emergency. For this reason a team-oriented approach is necessary for the management of SD. For this purpose team-oriented approach is very much important. The key of success lies in managing shoulder dystocia includes constant preparedness, a confident team work and proper documentation [59].


  1. Royal College of Obstetricians and Gynaecologists RCOG. Shoulder dystocia. (2005) Clinical Green Top Guideline No. 42. London.
  2. MacKenzie IZ, Shah M, Lean K, Dutton S, Newdick H, et al. (2007) Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol 110(5): 1059-1068.
  3. Gherman RB, Ouzounian JG, Satin AJ, Goodwin TM, Phelan JP (2003) A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies. Obstet Gynecol 102(3): 544-548.
  4. Pondaag W, Allen RH, Malessy MJ (2011) Correlating birthweight with neurological severity of obstetric brachial plexus lesions. BJOG 118(9): 1098-1103.
  5. Acker DB, Sachs BP, Friedman EA (1985) Risk factors for shoulder dystocia. Obstet Gynecol 66(6): 762-768.
  6. Baskett TF, Allen AC (1995) Perinatal implications of shoulder dystocia. Obstet Gynecol 86(1): 14-27.
  7.  Woods CE, Westburg NY (1943) A principle of physics as applicable to shoulder dystocia. Am J Obstet Gynecol 45796-45804.
  8. Allen RH (2007) On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol 50(3): 607-623. 
  9. Smith RB, Lane C, Pearson JF (1994) Shoulder dystocia: what happens at the next delivery?. Br J Obstet Gynaecol 101(8): 713-725.
  10.  Benedetti TJ, Gabbe SG (1978) Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstet Gynecol 52(5): 526-529.
  11. Acker DB, Sachs BP, Friedman EA (1985) Risk factors for shoulder dystocia. Obstet Gynecol. 66(6): 762-768.
  12. Cedergren MI (2004) Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet Gynecol 103(2): 219-224. 
  13. Mazouni C, Menard JP, Porcu G, Cohen-Solal E, Heckenroth H, et al. (2006) Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia. Eur J Obstet Gynecol Reprod Biol 129(1): 15-28.
  14. Overland EA, Vatten LJ, Eskild A (2012) Risk of shoulder dystocia: associations with parity and offspring birthweight. A population study of 1 914 544 deliveries. Acta Obstet Gynecol Scand 91(4): 483-488.
  15. Poggi SH, Stallings SP, Ghidini A, Spong CY, Deering SH, et al. (2003) Intrapartum risk factors for permanent brachial plexus injury. Am J Obstet Gynecol 189(3): 725-729. 
  16. Gonen O, Rosen DJ, Dolfin Z, Tepper R, Markov S, et al. (2006) Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol 89(6): 913-917.
  17. Dyachenko A, Ciampi A, Fahey J, Mighty H, Oppenheimer L, et al. (2006) Prediction of risk for shoulder dystocia with neonatal injury. Am J Obstet Gynecol 195(6): 1544-1549.
  18. Nesbitt TS, Gilbert WM, Herrchen B (1998) Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 179(2): 476-480.
  19. Bahar AM (1996) Risk factors and fetal outcome in cases of shoulder dystocia comparedwith normal deliveries of a similar birthweight. Br J Obstet Gynaecol 103(9): 868-872.
  20. Rajan PV, Chung JH, Porto M, Wing DA (2009) Correlation of increased fetal asymmetry with shoulder dystocia in the nondiabetic woman with suspected macrosomia. J Reprod Med 54(8): 478-482.
  21. Ouzounian JG, Korst LM, Ahn MO (1998) Shoulder dystocia and neonatal brain injury: Significance of the head-shoulder interval. Am J Obstet Gynecol 178.
  22. (2010) Clinical Negligence Sscheme for Trusts. Maternity: Clinical Risk Management Standards. NHS Litigation Authority, London.
  23. (2005) Royal College of Obstetricians and Gynaecologists RCOG. Shoulder dystocia. Clinical Green Top Guideline No. 42. London.
  24. Gottlieb AG, Galan HL (2007) Shoulder dystocia: an update. Obstet Gynecol Clin N Am 34(3): 501-531.
  25. Benjamin K (2005) Part 1. Injuries to brachial plexus: mechanisms of injury and identification of risk factors. Adv Neonatal Care 5(4): 181-189. 
  26. Gherman RB, Goodwin TM, Souter I, Neumann K, Ouzounian JG, et al. (1997) The McRoberts’ maneuver for the alleviation of shoulder dystocia: how successful is it?. Am J Obstet Gynecol 176(3): 656-661.
  27. Mazouni C, Menard JP, Porcu G, Cohen-Solal E, Heckenroth H, et al. (2006) Maternal morbidity associated withobstetrical maneuvers in shoulder dystocia. Eur J Obstet Gynecol Reprod Biol 129(1): 15-18.
  28. (2008) National Institute for Health and Clinical Excellence. Diabetes in pregnancy. Management of diabetes and its complications from pre-conception to the postnatal period. NICE, Clinical Guideline 63. London.
  29. ACOG Committee on Practice Bulletins (2005) ACOG practice bulletin clinical management guidelines for obstetrician gynecologists. Number 60. Obstet Gynecol 105(3): 675-685.
  30. ACOG Committee on Practice Bulletins-Gynecology, The American College of Obstetrician and Gynecologists (2002) ACOG practice bulletin clinical management guidelines for obstetrician gynaecologists. Number 40. Obstet Gynecol 100(5 Pt 1): 1045-1050.
  31. Gherman RB (2002) Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol 45(2): 345-362.
  32. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, et al. (2008) Improving neonatal outcome through practicalshoulder dystocia training. Obstet Gynecol 112(1): 14-20.
  33.  Hope P, Breslin S, Lamont L, Lucas A, Martin D, et al. (1998) Fatal shoulder dystocia:a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol 105(12): 1256-1261.
  34. (1998) Focus Group Shoulder Dystocia. In: Confidential Enquiries into Stillbirths and Deaths in Infancy. 5th Annual Report. Maternal and Child Health Research Consortium, London, pp. 73-79.
  35. Metaizeau JP, Gayet C, Plenat F (1979) Les Lesions Obstetricales du Plexus Brachial. Chir Pediatr 20(3): 159-163.
  36. Hinshaw K (2003) Shoulder dystocia. In: Johanson R, et al. (Eds.), Managing Obstetric Emergencies and Trauma: The MOET Course Manual. RCOG Press, London, pp. 165-174.
  37. Stallard TC, Burns B (2003) "Emergency delivery and perimortem C-section". Emerg Med Clin North Am 21(3): 679-693. 
  38. Kish & Collea (2003) p. 382.
  39. Gonik B, Stringer CA, Held B (1983) An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol 145(7): 882-884.
  40. Buhimschi CS, Buhimschi IA, Malinow A, Weiner CP (2001) Use of McRoberts’ position during delivery and increase in pushing efficiency. Lancet 358(9280): 470-471.
  41. Gherman RB, Goodwin TM, Ouzounian JG, Miller DA, Paul RH (1998) Spontaneous vaginal delivery: a risk factor for Erbʼs palsy? Am J Obstet Gynecol 178(3): 423-427. 
  42. McFarland MB, Langer O, Piper JM, Berkus MD (1996) Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynaecol Obstet 55(3): 219-224.
  43. Lurie S, Ben-Arie A, Hagay Z (1994) The ABC of shoulder dystocia management. Asia Oceania J Obstet Gynaecol 20(2): 195-197.
  44.  O’Leary JA, Leonetti HB (1990) Shoulder dystocia: prevention and treatment. Am J Obstet Gynecol 162(1): 5-9.
  45. Gurewitsch ED, Donithan M, Stallings SP, Moore PL, Agarwal S, et al. (2004) Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol 191(3): 911-916.
  46. Woods CE, Westbury NYA (1943) A principle of physics as applicable to shoulder delivery. Am J Obstet Gynecol 45(5): 796-804.
  47. Rubin A (1964) Management of shoulder dystocia. JAMA 189: 835-837.
  48. Hinshaw K (2003) Shoulder dystocia. In: Johanson R, Cox C, Grady K,Howell C (Eds.), Managing Obstetric Emergencies and Trauma: The MOET Course Manual. RCOG Press, London, pp.165-174.
  49. Bruner JP, Drummond SB, Meenan AL, Gaskin IM (1998) All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 43(5): 439-443.
  50. Sandberg EC (1985) The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol 152(4): 479-484.
  51. Vaithilingam N, Davies D (2005) Cephalic replacement for shoulder dystocia: three cases. BJOG 112(5): 674-675.
  52. Wykes CB, Johnston TA, Paterson-Brown S, Johanson RB (2003) Symphysiotomy: a lifesaving procedure. BJOG 110(2): 219-221.
  53. Crofts JF, Bartlett C, Ellis D, Fox R, Draycott TJ (2008) Documentation of simulated shoulder dystocia: accurate and complete?. BJOG 115(10): 1303-1308.
  54. (2003) National Health Service Litigation Authority: Summary of sub standard care in cases in brachial plexus injury. NHSLA J.
  55. Gherman RB, Ouzounian JG, Goodwin TM (1998) Obstetric maneuvres for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 178(6): 1126-1130.
  56. Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, et al. (2006) Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 195(3): 657-672.
  57. Mavroforou A, Koumantakis E, Michalodimitrakis E (2005) Physiciansʼ liability in obstetric and gynecology practice. Med-Law 24(1): 1-9.
  58. (1998) Focus Group Shoulder Dystocia. In: Confidential Enquiries into Stillbirths and Deaths in Infancy. 5th Annual Report. Maternal and Child Health Research Consortium, London 73-79.
  59. Gottlirb AG, Galan HL (2007) Shoulder dystocia: an update. Obstet Gynecol Clin N Am 34(3): 501-531.
© 2014-2018 MedCrave Group, All rights reserved. No part of this content may be reproduced or transmitted in any form or by any means as per the standard guidelines of fair use.
Creative Commons License Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at
Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version | Opera |Privacy Policy