Shoulder Dystocia

What is shoulder dystocia?

Shoulder dystocia occurs when one or both of your baby’s shoulders get stuck inside your pelvis during childbirth. The word dystocia comes from the Greek words “dys,” meaning difficult, and “tokos,” meaning birth.

Shoulder dystocia is a medical emergency. Babies with this condition are usually born safely. But it can cause serious complications for you and your baby.

How common is shoulder dystocia?

Shoulder dystocia is a rare condition. Statistics vary widely because the condition is sometimes over-diagnosed or underdiagnosed. The average rate also varies depending on the baby’s birth weight. Shoulder dystocia occurs in 0.6% to 1.4% of babies weighing between 5 pounds, 8 ounces and 8 pounds, 13 ounces at birth. The rate increases to 5% to 9% of babies born weighing more than 8 pounds, 13 ounces.

What are the signs of shoulder dystocia?

While there are risk factors that can lead to shoulder dystocia, the condition can happen to anyone. There are no symptoms, and there’s no way to predict if shoulder dystocia will occur. Your obstetrician may only notice the condition after you deliver your baby’s head. It becomes clear when your baby’s head emerges and then pulls back in against the area between your vagina and rectum (perineum). This is called the “turtle sign.”

What causes shoulder dystocia?

Shoulder dystocia occurs when your baby’s shoulder or shoulders get stuck behind your pubic bones during delivery. The following factors may cause shoulder dystocia:

• Fetal macrosomia: Your baby weighs more than 8 pounds, 13 ounces.
• Your baby is in the wrong position.
• Your pelvic opening is too small.
• You are in a position that limits the room in your pelvis.

How is shoulder dystocia diagnosed?

Your obstetrician will diagnose shoulder dystocia if three factors are met:

• You delivered your baby’s head but you aren’t able to push your baby’s shoulders out.
• At least one minute has passed since your baby’s head has emerged but their body hasn’t.
• Your baby needs medical intervention to be delivered successfully.

How is shoulder dystocia treated?

Your obstetrician may recommend scheduling a C-section if you have diabetes or if your baby is very big.

If you're at risk for shoulder dystocia and having a vaginal delivery, your healthcare provider will have a safety checklist ready. A safety checklist includes steps that should be taken in the event of shoulder dystocia.

Things will happen fast in the delivery room if your obstetrician diagnoses shoulder dystocia. Your obstetrician and nursing team may try several interventions or maneuvers. They may want to move you into a better position to widen your pelvis. Or they may want to move your baby into a better fetal position to move their shoulders.

The HELPERR mnemonic is a tool your healthcare team may use to treat shoulder dystocia. HELPERR stands for:

• H — Help: Your obstetrician will call for help. They'll use the safety checklist and call for additional help from other healthcare providers. These providers may include an anesthesiologist, a neonatologist and extra labor and delivery. Necessary equipment will be brought to your room.
• E — Evaluate for episiotomy: Your obstetrician will decide if you need an episiotomy to assist with the delivery of your baby. An episiotomy is a cut (incision) in your perineum to make the opening to your vagina larger. Your provider will only perform this procedure if they need to make room for rotation maneuvers.
• L — Legs: Your obstetrician may use the McRoberts maneuver. With the McRoberts maneuver, your obstetrician will ask you to press your thighs up against your belly (abdomen). This method helps to flatten and rotate your pelvis.
• P — Pressure: Your obstetrician may use suprapubic pressure. With suprapubic pressure, your obstetrician will press on your lower belly (abdomen) above your pubic bone. This puts pressure on your baby’s shoulder in an attempt to rotate and deliver it.
• E — Enter maneuvers: Your obstetrician may perform enter maneuvers or internal rotation. Your obstetrician will reach up into your vagina to try to turn your baby.
• R — Remove posterior arm: Your obstetrician may use Jacquemier’s maneuver. With Jacquemier’s maneuver, your obstetrician will remove one of your baby’s arms from the birth canal. This may make it easier for their shoulders to pass through.
• R — Roll the patient: Your obstetrician may use the Gaskin maneuver. With the Gaskin maneuver, your obstetrician will have you turn over on your hands and knees to get into a new position.

In severe cases when other techniques aren’t working, your obstetrician may use one of the following methods:

• Clavicle fracture: Your obstetrician will break your baby’s collarbone to release their shoulders.
• Zavanelli maneuver: Your obstetrician will push your baby’s head back into your uterus and perform a C-section.
• Symphysiotomy: Your obstetrician will make a cut (incision) in the cartilage between your pubic bones to enlarge your pelvic opening.

What are the complications of shoulder dystocia?

Complications resulting from shoulder dystocia during labor can affect you and your baby.

Complications that can affect you

• Extreme heavy bleeding after giving birth (postpartum hemorrhage).
• Severe tearing of the area between your vagina and anus (perineum).
• Rectovaginal fistula: A rectovaginal fistula is an abnormal connection between your vagina and rectum.
• Uterine rupture: A uterine rupture means your uterus tears during labor.
• Separation of your pubic bones.

Complications that can affect your baby

The most common complication of shoulder dystocia in your baby is brachial plexus palsy. The brachial plexus nerves run from your baby’s spinal cord in their neck through their arm. These nerves are responsible for providing feeling and movement in your baby’s shoulder, arm and hand. Damage to these nerves can cause weakness and paralysis on the affected side. Other complications to your baby may include:

• Fractures to your baby’s collarbone (clavicle) and/or upper arm bone (humerus).
• Horner’s syndrome: A rare disorder affecting your baby’s eyes and face.
• Compressed umbilical cord: The umbilical cord can get trapped between your baby’s arm and your pelvic bone. When the umbilical cord is flattened, it can cut off oxygen and blood flow to your baby. This is very rare, but it can cause brain injury or death.

What are the risk factors for shoulder dystocia?

Shoulder dystocia can happen to anyone. Most cases of the condition occur in babies with normal birth weights. But certain risk factors increase the likelihood of the condition. These risk factors include:

• Diabetes: Pre-existing diabetes and gestational diabetes can both cause your baby to be large. People with diabetes have a 20% chance of delivering a baby weighing more than 8 pounds, 13 ounces at birth.
• Macrosomia: Macrosomia means your baby weighs more than 8 pounds, 13 ounces at birth. If you have a big baby, your healthcare provider may recommend a C-section.
• Shoulder dystocia in a previous pregnancy.
• Pregnant with twins or other multiples.
• Overweight and/or gaining excess weight during pregnancy.
• Short stature.
• Abnormal pelvic structure.
• Older than 35.
• Giving birth after your due date.

Certain conditions during labor and delivery may also be risk factors for shoulder dystocia. The most common of these risk factors is having an assisted vaginal delivery. This means your obstetrician has to use a vacuum extractor or forceps to help deliver your baby through the birth canal. Other risk factors during labor and delivery may include:

• Taking oxytocin to induce labor.
• Getting an epidural.
• Very long first stage of labor (contraction phase).
• Very short or very long second stage of labor (pushing phase).
• Using inappropriate pressure or maneuvers to deliver your baby.

How can I prevent shoulder dystocia?

Shoulder dystocia can happen to anyone. Most cases happen in babies with normal birth weights and can’t be prevented. But to lower your risk you can:

• Manage your diabetes.
• Maintain a healthy weight throughout your pregnancy.
• Ask your obstetrician about inducing labor.
• If you’re past your due date, call your healthcare provider.
• Discuss the possibility of a C-section with your obstetrician.
• Consider forgoing labor medications such as an epidural.

What is the outlook (prognosis) for shoulder dystocia?

Research has shown that by the age of three months, half of all babies born with shoulder dystocia are functioning completely. By the age of 18 months, 82% of babies are functioning completely.

If your child suffered a brachial plexus injury, the outcome is generally positive. But some interventions may affect your child’s long-term outcome. They may have trouble with fine motor skills and other uses of their affected limb. More than 90% of these injuries improve within six to 12 months. Less than 10% result in permanent injury.

If you’ve had a baby with shoulder dystocia, your chances of the condition occurring again increase by 15%. Be sure to discuss this with your healthcare provider if you plan on having more children. If you had a C-section due to shoulder dystocia, vaginal birth after cesarean (VBAC) isn’t recommended.

A note from Cleveland Clinic

Shoulder dystocia is an injury that can happen during childbirth. It can be overwhelming to think about the things that can go wrong during labor and delivery. But it’s important to remember these conditions are rare and your healthcare team is trained on what to do. In the rare event of any complications, try to stay calm and place your trust in your providers. They’ll do everything they can to deliver your baby safely without any long-term complications.