Shoulder Dystocia

What Is Shoulder Dystocia?

Shoulder dystocia is a complication during a vaginal birth in which the fetal shoulders fail to deliver spontaneously after the head emerges. In other words, one or both of the baby’s shoulders get stuck inside the mother’s pelvis during delivery.

Although uncommon, shoulder dystocia is potentially treacherous. How often it occurs is difficult to ascertain, but estimates are that it occurs between in 0.15 and 2.0% of births. The rate increases to 5-9% of births in babies weighing more than 8 pounds 13 ounces.

The obstetrician should diagnose shoulder dystocia if all these factors occur: the baby’s head is delivered but the mother is unable to push the shoulders out, it takes more than one minute for the baby’s body to emerge after the head, and intervention is required by the physician to deliver the baby successfully.

Shoulder dystocia can be relieved without permanent injury to the baby. The condition is frequently associated with permanent birth-related injuries such as brachial plexus injuries and complications for the mother.

What Are Common Causes Of Shoulder Dystocia?

Risk factors for shoulder dystocia and brachial plexus injury (BPI) can be usefully categorized into those identifiable in the patient’s history, and those that arise or are identified during prenatal care or labor. Although a number of recognized conditions can cause shoulder dystocia, many cases develop without recognized antecedent risk factors. In those latter cases, there are no warning signs in advance.

Among the common causes of shoulder dystocia are a mother’s history of a prior shoulder dystocia birth, maternal diabetes, gestational diabetes (which develops during pregnancy), and maternal obesity. Fetal macrosomia (large baby), a mother with a small pelvis, or the mother in a position that limits pelvic room also increase the risk of shoulder dystocia. Other intrapartum risk factors include arrested labor, precipitous second stage, and instrumental delivery.

The ability to predict the occurrence in an individual delivery is limited but can and should be done by the obstetrician. Shoulder dystocia should not be an unexpected complication. Obstetricians must use the proper maneuvers to release a “stuck shoulder”; otherwise, improper traction will cause a brachial plexus injury.

There is limited evidence that BPI can occur in the absence of shoulder dystocia. The weight of the available information suggests, however, that improper medical intervention is probably a factor in most injuries.

What Tre The Symptoms Of Shoulder Dystocia?

For the obstetrician, the symptoms of shoulder dystocia appear when the baby’s shoulders do not smoothly exit after the head during delivery. Sometimes, the baby’s shoulder is stuck and the head will appear and then retract like that of the head of a turtle, something called the “turtle sign.” The baby simply cannot exit the birth canal unless the shoulder entrapment is relieved.

Postpartum symptoms of shoulder dystocia with a brachial plexus injury may present as a limp or paralyzed arm; have poor or no muscle control in the arm, hand, or wrist; or lack of sensation in the arm or hand. The severity of the injury is determined by the type of damage done to the nerves.

Most BPIs associated with shoulder dystocia are Erb’s palsies, and result from overstretching of the C5-6 nerve roots during childbirth, particularly in the presence of difficult shoulder delivery.

Are There Lasting Effects Or Complications With Shoulder Dystocia-Related Injuries?

Severe complications from shoulder dystocia can occur.

Complications from unrecognized and/or improperly treated shoulder dystocia include various degrees of brachial plexus injury and, less commonly, hypoxic injuries caused by lack of oxygen. Traumatic central nervous system damage, damage to the baby’s collarbone and arms, and long bone fractures can also occur. Injuries and deficits can unfortunately be lifelong.

Some BPIs may heal without treatment. Mild cases that occur during birth improve or recover within the baby’s first 3 to 4 months. In cases with more severe nerve injury, recovery of arm and hand function may not be possible. An MRI examination of the brachial plexus is an excellent way to identify the extent of the BPI. In the most severe avulsion cases, nerve graft surgery is performed to try reconnecting the nerve to the spinal cord. Nonsurgical treatments for brachial plexus injuries as a complication of shoulder dystocia include physical and occupational therapy.

The mother may also suffer complications from the force of the impact of a shoulder dystocia birth—tearing or bruising around the cervix, rectum, and vagina can occur. In rare cases, the mother may experience severe bleeding and require immediate medical attention.

An Experienced Birth Injury Attorney Is Important

An experienced birth injury attorney can help parents find out whether their child’s injury was a result of the physician’s improper management of shoulder dystocia. Errors in recognizing the risk factors for shoulder dystocia during prenatal care and failing to utilize appropriate maneuvers in the delivery room are often subtle. Knowing how to look for these risk factors that could have predicted shoulder dystocia or whether the correct maneuvers were used to relieve shoulder dystocia makes a difference in determining if negligence caused a baby’s birth injury.