Shoulder dystocia is a delivery emergency that occurs when a baby’s shoulder becomes stuck behind the mother’s pubic bone after the head delivers. How medical providers respond in the next few minutes determines whether the baby escapes unharmed or suffers permanent nerve damage, brain injury, or death. Proper training and adherence to established protocols can prevent most shoulder dystocia injuries.
What Is Shoulder Dystocia?
During normal vaginal delivery, the baby’s head delivers first, followed by rotation of the shoulders through the pelvis. In shoulder dystocia, the anterior (front) shoulder impacts the mother’s pubic symphysis and cannot pass through the birth canal without intervention.
Shoulder dystocia is diagnosed when normal downward traction on the fetal head fails to deliver the shoulders, and additional maneuvers are required. The incidence ranges from 0.2% to 3% of vaginal deliveries, depending on risk factors present.
This is a true obstetric emergency. Once the head delivers, the umbilical cord is often compressed between the baby’s body and the birth canal. Every minute of delay increases the risk of oxygen deprivation and brain damage.
Risk Factors for Shoulder Dystocia
While shoulder dystocia can occur unexpectedly, several risk factors increase likelihood:
Fetal Factors
- Macrosomia (large birth weight) – Babies over 4,000-4,500 grams face significantly increased risk
- Post-term pregnancy – Larger babies from extended gestation
- Male fetus – Slightly higher risk than female
Maternal Factors
- Gestational diabetes – Causes disproportionate fetal growth with larger shoulders
- Pre-existing diabetes – Similar effect on fetal growth
- Maternal obesity – Associated with larger babies and difficult deliveries
- Previous shoulder dystocia – Recurrence risk of 10-25%
- Multiparity – Having had previous children
- Short stature or abnormal pelvic structure – Affects passage through birth canal
Labor Factors
- Prolonged labor – Especially prolonged second stage
- Operative vaginal delivery – Use of forceps or vacuum extraction
- Precipitous delivery – Very rapid labor with insufficient time for fetal rotation
The Standard of Care: McRoberts Maneuver and Beyond
When shoulder dystocia occurs, medical providers must follow established protocols to safely deliver the baby without causing injury. The American College of Obstetricians and Gynecologists (ACOG) and other professional organizations have developed clear guidelines.
First-Line Response: McRoberts Maneuver
The McRoberts maneuver is the first intervention that should be attempted. The mother’s thighs are sharply flexed toward her abdomen, which flattens the lumbar spine and rotates the pubic symphysis upward. This simple positioning change resolves 40-50% of shoulder dystocia cases and should be performed immediately upon diagnosis.
Suprapubic Pressure
Applied simultaneously with McRoberts, an assistant places downward and lateral pressure just above the pubic bone to push the anterior shoulder under the symphysis. This should NOT be confused with fundal pressure (pushing on top of the uterus), which is contraindicated and can worsen impaction.
Internal Rotation Maneuvers
If McRoberts and suprapubic pressure fail, the provider may attempt internal rotation—reaching into the vagina to rotate the baby’s shoulders to a more favorable diameter. The Rubin maneuver and Woods screw maneuver are established techniques for this purpose.
Delivery of Posterior Arm
The provider reaches into the vagina to grasp the posterior arm and sweep it across the baby’s chest, reducing the shoulder diameter and allowing delivery.
Last Resort Maneuvers
In rare cases when all else fails:
- Gaskin maneuver (all-fours positioning) – Mother repositions on hands and knees
- Zavanelli maneuver – The head is pushed back into the vagina for emergency cesarean
- Symphysiotomy – Surgical cutting of the pubic symphysis (extremely rare)
What Providers Should NOT Do
Certain actions during shoulder dystocia are considered below the standard of care and increase injury risk:
- Excessive downward traction on the fetal head – Pulling hard on the baby’s head stretches and tears brachial plexus nerves
- Fundal pressure – Pushing on top of the uterus can worsen shoulder impaction and increase injury risk
- Continued forceful pulling – When initial traction fails, maneuvers should be attempted rather than increased force
- Twisting the head excessively – Rotational forces can damage neck structures
- Panic and disorganization – Shoulder dystocia requires calm, systematic response following established protocols
Injuries from Shoulder Dystocia
Improper management of shoulder dystocia can cause devastating injuries:
Brachial Plexus Injury
The most common injury, occurring when excessive force stretches or tears the nerves controlling the arm. Erb’s palsy (upper brachial plexus injury) causes weakness in the shoulder and upper arm. Klumpke’s palsy affects the hand and forearm. Total brachial plexus palsy paralyzes the entire arm.
Hypoxic-Ischemic Encephalopathy
Prolonged shoulder dystocia can cause cord compression and oxygen deprivation. If delivery is delayed more than 4-5 minutes, permanent brain damage becomes increasingly likely. HIE can result in cerebral palsy, intellectual disability, and seizure disorders.
Fractures
Clavicle (collarbone) and humerus (upper arm) fractures can occur during delivery. While these typically heal well, they indicate significant force was applied during delivery.
Death
In the worst cases, prolonged oxygen deprivation from unresolved shoulder dystocia can be fatal. Mortality rates increase dramatically when delivery takes longer than 7 minutes after head delivery.
Prevention Through Proper Planning
Many shoulder dystocia injuries are preventable through proper antenatal assessment and delivery planning:
Ultrasound estimation of fetal weight – When estimated weight exceeds 4,500 grams in diabetic mothers or 5,000 grams in non-diabetic mothers, ACOG recommends discussing cesarean delivery.
History assessment – Previous shoulder dystocia significantly increases recurrence risk. Providers should review prior delivery records and discuss cesarean delivery.
Labor management – Prolonged second stage of labor with a large baby increases risk. Providers should consider cesarean delivery rather than prolonged pushing or instrumental delivery.
Team preparation – When risk factors are present, additional personnel should be available and the team should be briefed on shoulder dystocia protocols.
Documentation Requirements
Proper documentation of shoulder dystocia management is essential and required by professional standards. Records should include:
- Time the head delivered and time the body delivered
- Specific maneuvers attempted in order
- Personnel present and their roles
- Any traction applied and by whom
- Neonatal condition at delivery (Apgar scores, need for resuscitation)
Incomplete documentation often indicates inadequate management and becomes significant evidence in malpractice litigation.
Medical Negligence in Shoulder Dystocia Cases
Common forms of negligence in shoulder dystocia cases include:
- Failure to recognize and respond to risk factors before delivery
- Not recommending cesarean delivery when risk factors indicate it
- Applying excessive traction before attempting proper maneuvers
- Using fundal pressure during shoulder dystocia
- Failure to call for help and additional personnel
- Not following established shoulder dystocia protocols
- Inadequate training and preparation for the emergency
Proving Your Case
Shoulder dystocia malpractice cases require detailed review of:
- Prenatal records showing risk factors
- Ultrasound reports estimating fetal weight
- Labor and delivery records documenting the emergency
- Nursing notes with timeline details
- Neonatal records showing injury extent
- Fetal monitoring strips
Expert witnesses in obstetrics establish whether the standard of care was met and whether different management would have prevented the injury.
Contact an Illinois Shoulder Dystocia Attorney
If your child suffered nerve damage, brain injury, or other harm from shoulder dystocia, you need attorneys who understand obstetric emergencies and delivery protocols. At Phillips Law Offices, we investigate birth injuries thoroughly, working with medical experts to determine whether negligence caused your child’s injuries.
Contact Phillips Law Offices at (312) 598-0917 for a free consultation. We handle birth injury cases on contingency—you pay nothing unless we recover compensation for your family.