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Insights into Shoulder Dystocia

Baby Photo 2.jpgShoulder dystocia occurs during vaginal delivery when, after delivery of the fetal head, the fetal shoulders become impacted against the maternal pelvis. This causes the baby to become stuck in the birth canal, requiring additional obstetrical maneuvers beyond gentle traction to enable delivery.

Shoulder dystocia is an obstetrical emergency - the obstetrician must recognize it immediately and proceed through a sequence of steps to deliver the baby quickly. Failing to do so can result in fetal asphyxia or death. Avoiding physical injury (such as bone fractures or maternal trauma) is also a goal, but may be required to prevent severe permanent injury in the baby.

Can Shoulder Dystocia be Prevented?

Shoulder dystocia occurs in 0.5 to 3 per cent of births. It arises due to a discrepancy in the relative size or position between the fetus and the dimensions of the mother's pelvis. It is difficult to predict when shoulder dystocia will occur. Women with diabetes or women who are overweight are more likely to have big babies, but often shoulder dystocia occurs for unknown reasons. Shoulder dystocia should be suspected if the fetal head retracts after expulsion (i.e. turtle sign) due to the shoulders being impacted at the pelvic inlet. The diagnosis is made when gentle, downward traction of the fetal head does not result in the delivery of the anterior shoulder.

What Injuries Can Result from Shoulder Dystocia?

Many complications can occur as a result of shoulder dystocia. Brachial plexus injury to the newborn is the most common, and is caused by deviation or rotation of the fetal head from the shoulder. The majority of brachial plexus injuries resolve with therapy, but some children experience permanent functional impairment. Rarely, very serious complications of catastrophic shoulder dystocia can occur. These include neonatal hypoxic-ischemic encephalopathy (HIE) and death, usually due to oxygen deprivations from compression of the umbilical cord.

How is Shoulder Dystocia Managed?

Several techniques can be used to manage shoulder dystocia, and can be broadly divided into two categories: fetal maneuvers (where the manipulation is directly upon the baby) and maternal maneuvers (where the primary manipulation is on the mother). The goal is to safely deliver the baby before asphyxia and brain injury occur due to cord compression, and without causing peripheral nerve injury or other trauma to the mother or baby. As most cases of shoulder dystocia occur in the absence of risk factors, doctors need to be prepared for the possibility in every labour, and must be aware of the various procedures that have been shown to be effective in safely delivering the baby in these situations.

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