Injuries: Shoulder Dystocia
When you are in labor, your baby moves downward through your birth canal, head first. Normally, baby’s posterior shoulder (shoulder closest to the floor) enters into your pelvis before the anterior shoulder (shoulder closest to the ceiling). The shoulders then rotate as baby’s head rotates. This allows the shoulder closest to the ceiling to slide under your pubic bone.
If baby’s shoulders do not rotate, or if both shoulders try to come through your pelvis at the same time, the shoulder closest to the ceiling can get stuck behind your pubic bone, or the posterior shoulder can get stuck under your tailbone. During a shoulder dystocia1, it is more common for baby’s anterior shoulder to be stuck. If baby’s head continues to move down, the nerves in the neck and shoulder area can cause nerve damage. For this reason, you will be asked to stop pushing, and your physician, or midwife should not place any increased traction (pulling) on baby’s neck.
A shoulder dystocia is an emergency situation and steps to free baby’s shoulder must be taken immediately. Your physician, or midwife, should alert the labor and delivery nurses that there is a shoulder dystocia. When this is announced, a labor and delivery nurse should take note of the time that it was announced. Additional health professionals from anesthesiology and nursery may be summoned to the room.
What happens next
During a delivery complicated by shoulder dystocia, many things may be happening at the same time. While others are alerted of the need for additional members of the healthcare team, you will be asked to stop pushing, and you will be assisted to bring your legs back so that your thighs are on your abdomen, and as wide apart as possible. This is called the McRoberts position.
Another member of the labor and delivery team will push down on an area in your lower abdomen called the suprapubic region. This is called suprapubic pressure. The purpose of suprapubic pressure is to free your baby’s shoulder from behind your pubic bone.
Your physician or midwife may also place their hands inside of your vagina to attempt to free the shoulder.2 There are specific maneuvers, or techniques, that your physician, or midwife, has been trained to perform when a shoulder dystocia occurs. To allow for more room for the maneuvers, your physician, or midwife, may perform an episiotomy.
There are several maneuvers that may be necessary to deliver a baby when a shoulder dystocia occurs. If one maneuver is not successful, your physician or midwife will move to the next one. Other maneuvers include:
- Gaskin Maneuver. Involves rolling the mother on to her hands and knees to allow for more room in the pelvis
- Rubin Maneuver. The physician, or midwife, places one hand behind baby’s anterior shoulder and rotates the shoulder forward toward baby’s chest.
- Wood Screw Maneuver. The physician, or midwife rotates baby’s shoulders, similar to turning a bolt so that it will fit into a nut, so that baby’s anterior shoulder can slide under the mother’s pubic bone.
- Reverse Wood Screw Maneuver. The physician, or midwife, rotates baby’s shoulders in the opposite direction of the Wood Screw Maneuver to allow baby’s
- Delivery of the baby’s posterior arm. The physician, or midwife finds baby’s elbow of the posterior arm and delivers it, allowing the anterior shoulder to slide under the mother’s pubic bone.
- Delivery of the baby’s posterior shoulder. If the physician, or midwife, cannot reach the elbow of baby’s posterior arm, it may be possible to deliver the posterior shoulder, allowing for the anterior shoulder to slide under the mother’s pubic bone.
- Posterior Axilla Sling Traction. If the above methods did not work to deliver baby’s posterior arm or shoulder Fracture (break) baby’s collar bone
Each maneuver should be attempted for 30 to 60 seconds before the next maneuver is attempted. If after performing the above maneuvers, the shoulder dystocia continues, your doctor or midwife may move on to:
- The Zavanelli Maneuver. This procedure is performed by pushing baby’s head back into the birth canal, then performing a cesarean section to deliver baby. In most cases, a shoulder dystocia is handled by performing maneuvers that do not require surgery.
- Abdominal surgery and hysterotomy. An incision is made into the abdomen, then into the uterus. The surgeon locates baby’s posterior arm and passes it through the vagina, where an assistant takes the hand. The surgeon applies pressure to the anterior shoulder to turn the shoulder. The baby is then delivered through the vagina. This procedure is done as a last resort when all of the other maneuvers did not work.
- Symphsiotomy. After injecting a local anesthetic, the cartilage is divided in the symphesis pubis. This will allow more room to deliver baby’s shoulders. This procedure is only performed if all other maneuvers do not work.
When a should dystocia occurs, fundal pressure (pushing on the top of the uterus) should never be done.
Risks of injury to the mother and child
A shoulder dystocia can pose risks to both the mother and the child, given the circumstances. A delivering mother is at risk of:
- Postpartum Hemorrhage
- Rectovaginal Fistula
- Separation of Symphesis or Diathesis (separation of the pubic bones)
- Third or fourth-degree tears
The baby, however, is put at risk of a brachial plexus injury. The brachial plexus refers to a group of nerves located in the spinal canal that send impulses from the spinal cord to the shoulder, arm, and hand.
Diagnosing shoulder dystocia
It is often impossible to predict when a shoulder dystocia will happen; however, there are warning signs that alert your physician, or midwife, that you are at a higher risk for it to occur:
You had a shoulder dystocia with a previous delivery. If it has happened before, you have a greater risk of another shoulder dystocia occurring. Based on this, it is recommended that your physician discuss the risk with you, as well as the option of having a planned, prophylactic cesarean section. If your baby suffered a serious injury due to the shoulder dystocia, it is especially recommended that you deliver by prophylactic cesarean section.2
When your baby is expected to be much larger than normal. Due to the increased risk of a shoulder dystocia happening, The American College of Obstetricians and Gynecologists recommends:
- If you are not a diabetic, or gestational diabetic, and your baby’s estimate weight is 5000 grams (11 pounds), or greater, your physician, or midwife, discusses the risk of shoulder dystocia with you, as well as the option of having a prophylactic cesarean section instead of attempting a vaginal delivery. Your physician, or midwife, will provide you with information necessary for you to make an informed decision about the risks and benefits for each type of delivery.2
- If you are a diabetic, or a gestational diabetic, the risk of shoulder dystocia is much greater than that of women who are not diabetic. This is due to the fact that babies of diabetic mothers tend to be larger, and more likely to have a birth weight greater than the 90th Glucose (blood sugar) crosses the placenta to baby, which causes baby’s blood sugar to be higher than usual. Because of this risk, the American College of Obstetricians and Gynecologists recommends that your physician, or midwife, discuss the risk of shoulder dystocia with you, as well as the option of having a prophylactic cesarean section instead of attempting a vaginal delivery if your baby’s estimated weight is greater than 4500 grams (9 pounds, 9 ounces).2
If you are a diabetic, your baby’s growth should be monitored closely. Although there is no fool-proof method to determine the exact weight of your baby before birth, there are warning signs that suggest that your baby is larger than normal. Babies born to diabetic mothers do not grow in the same way that babies of non-diabetic mothers do. They tend to have more body fat and skin folds in the top part of their bodies, so they have larger shoulders, chests, and abdomens.3
If the fundal height measurement is higher than usual. By your 8th week of pregnancy, your physician or midwife can feel your uterus at the level of your symphysis pubis. By the 12th week of pregnancy, your uterus is high enough to actually be considered one of the organs in your abdomen. By the 16th week, the top of your uterus can be palpated halfway between your symphysis pubis and your umbilicus (belly button). From your 18th week, until the 34th week of pregnancy, the size of your uterus is measured, with a tape measure, in centimeters from your symphysis pubis to the top of your uterus (upper part of the uterine corpus). The measurement usually goes along with the weeks of pregnancy. When you reach the 20th week of pregnancy, the top of your uterus should be at the same level as your belly button. After you reach your 36th week, the measurements may actually be less. This is due to the fact that baby’s head is moving downward into your pelvis.6
If your physician or midwife feels that baby is not growing as he should be, an ultrasound may be done to provide a more detailed of specific measurements of baby’s body. Sometimes in pregnancy, a mother will have more, or less, than the normal amount of amniotic fluid, which could cause the measurement of the size of your uterus to be inaccurate. An ultrasound will also measure the amount of amniotic fluid. In other situations, the due date of your baby may not be accurate. This occurs more in women who are not sure of when the first day of her last normal monthly period was, and did not begin her prenatal care until after her first trimester (first 12 weeks).
If the baby seems “reluctant” to leave. While you are pushing, your physician, midwife, or labor and delivery nurse observes the “turtle sign,” which means that baby’s head moves back toward the vagina when you stop pushing.4
If you or your loved one was seriously injured by an act of medical negligence, Crandall & Pera Law may be able to help. We are a nationally recognized team of medical malpractice and birth injury attorneys serving clients throughout Ohio and Kentucky. To learn more about who we are, or to schedule a consultation with an experienced birth injury attorney, please call 877-955-0020 or fill out our contact form.
- Rodis, J. (2016). Shoulder dystocia: Intrapartum diagnosis, management, and outcome. UpToDate. Retrieved from http://www.uptodate.com/contents/shoulder-dystocia-intrapartum-diagnosis-management-and-outcome
- Russman, B. (2016). Neonatal brachial plexus palsy. UpToDate. Retrieved from http://www.uptodate.com/contents/neonatal-brachial-plexus-palsy
- Ecker, J. (2015). Pregestational diabetes mellitus: Obstetrical issues and management. UpToDate. Retrieved from http://www.uptodate.com/contents/pregestational-diabetes-mellitus-obstetrical-issues-and-management
- Rahimian, J. (2013). Chapter 16. Disproportionate Fetal Growth. In DeCherney, A., Nathan, L., Laufer, N. & Roman, A. (Eds). CURRENT diagnosis & treatment: Obstetrics & gynecology (11th ed.). New York, NY: McGraw-Hill
- DeCherney, A., Nathan, L., Laufer, N., & Roman A. (2013). CURRENT diagnosis & treatment: Obstetrics & gynecology (11th ed.). New York, NY: McGraw-Hill
- Bernstein, H., & VanBuren, G. (2013). Chapter 6. Normal Pregnancy and Prenatal Care. In Decherney, A., Laufer, N., Roman, A. (Eds). CURRENT diagnosis & treatment: Obstetrics & gynecology, 11e. Retrieved from http://accessmedicine.mhmedical.com/content.aspx?bookid=498§ionid=41008595