Shoulder dystocia occurs when an infant’s shoulder catches on the mother’s hip during child birth. This is a medical emergency that comes with little warning. There are several last-minute safety techniques to help prevent injury for the mother and infant. If there is a delay implementing shoulder dystocia procedures, severe brachial plexus injury may result.
Causes and Risk Factors
Approximately 1% of all deliveries experience shoulder dystocia complications. Shoulder dystocia is difficult to predict because it can only happen right when birth begins. Certain factors may increase risk of shoulder dystocia. Any increased risk should be discussed between the expecting parents and medical practitioner.
Some risk factors for shoulder dystocia include:
- Petite maternal stature or pelvis size
- Abnormal maternal pelvis shape
- Previous births with shoulder dystocia complications
- Gestational diabetes
- Maternal obesity
- Brachycephaly, or flattened back of fetal head
- Suspected macrosomia, or large fetal size for gestational age
- Assisted vaginal delivery, using forceps or vacuum
- Abnormally long labor time
Signs of Shoulder Dystocia
Obstetricians are taught to look for the “turtle” sign to be alerted to shoulder dystocia. The turtle sign occurs when the infant’s head surfaces and returns to the womb during child birth. It appears in a manner similar to a turtle retreating back into its shell. Another sign of shoulder dystocia is a red or puffy face on the infant during vaginal birth attempts.
Managing Shoulder Dystocia
If shoulder dystocia is suspected, the goal is to deliver the child in less than 5 minutes to minimize risk of injury. There are two mnemonic devices suggesting a similar order and type of action to take. They include the HELPERR and the ALARMER. Delaying the HELPERR or ALARMER process during a shoulder dystocia emergency can result in severe maternal or fetal injury. This can lead to the use of extreme procedures, such as a hysterotomy, or death.
Common procedures for managing shoulder dystocia are:
Rubin I – or pressure applied above the pubis.
Rubin II, or pressure applied to the fetal shoulder facing the maternal pubic symphysis. The goal of this procedure is to move the fetus in an oblique position with the head slightly angled toward the vagina.
McRoberts Maneuver is 42% effective. The mother pulls her legs tightly to her abdomen, allowing the spine to flatten and the pelvis to widen. Abdominal pressure may be applied by a nurse during this procedure. The head of the infant is lightly pulled.
Woods’ Screw Maneuver involves turning the fetal shoulder closest to the maternal pubic symphysis away from the pelvis. It can require turning the fetal shoulder farthest from the maternal pubic symphysis closer to the pelvis. Regardless of the method, this maneuver is the opposite of the Rubin II procedure.
Jacquemier’s Maneuver or Barnum’s Maneuver identifies the fetal forearm in the birth canal. The hand and forearm are delicately pulled, delivering the infant with the farthest shoulder first.
Gaskin Maneuver requires the mother to kneel on all fours. The mother arches her back, and the pelvis is widened.
Zavanelli’s Maneuver pushes the fetal head back in to the womb. A C-section must be performed, so it is only used for situations with severe shoulder dystocia.
Maternal Symphysiotomy involves breaking connective tissues between maternal pubes bones. This widens the birth canal, allowing the infant to pass through. It is only used for extreme shoulder dystocia cases.
Intentionally Fracturing the Fetal Clavicle is also an option for extreme shoulder dystocia complications. This reduces shoulder width, allowing the infant to pass through the birth canal.
Problems after Shoulder Dystocia
If a medical provider fails to adequately handle shoulder dystocia, these problems may result:
- Brachial plexus injury
- Fetal hypoxia, or fetal oxygen deprivation
- Klumpke’s palsy
- Erb’s palsy
- Cerebral palsy
- Fetal death
- Maternal hemorrhage after delivery