Shoulder dystocia is defined as a delivery that requires additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. Shoulder dystocia occurs when either the anterior or, less commonly, the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory. There is a wide variation in the reported incidence of shoulder dystocia but unselected population studies in North America and the UK found a 0.6% incidence. There can be a high perinatal mortality and morbidity associated with the condition, even when it is managed appropriately. Maternal morbidity is also increased, particularly postpartum haemorrhage (11%) and fourth-degree perineal tears (3.8%), and their incidence remains unchanged by the manoeuvres required to effect delivery. Brachial plexus injuries are one of the most important fetal complications of shoulder dystocia, complicating 4–16% of such deliveries. This appears to be independent of operator experience. Most cases resolve without permanent disability, with fewer than 10% resulting in permanent brachial plexus dysfunction. In the UK, the incidence of brachial plexus injuries is 1/2300 live births. Neonatal brachial plexus injury is the single most common cause for litigation related to shoulder dystocia. Not all injuries are due to excess traction by the accoucheur and there is now a significant body of evidence that maternal propulsive force may contribute to some of these injuries. Moreover, a substantial minority of brachial plexus injuries are not associated with clinically evident shoulder dystocia. In one series, 4% of injuries occurred after a caesarean section. Specifically, where there is Erb’s palsy, it is important to determine whether the affected shoulder was anterior or posterior at the time of delivery, because damage to the plexus of the posterior shoulder is considered not due to action by the accoucheur. The Confidential Enquiries into Stillbirths and Deaths in Infancy’s (CESDI) 5th annual report recommended ‘a high level of awareness and training for all birth attendants’. Annual skill drills, including shoulder dystocia, are recommended jointly by both the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).
The purpose of this guideline is to review the current evidence regarding the possible prediction, prevention and management of shoulder dystocia. It also provides some guidance for skill drills for the management of shoulder dystocia.
This guideline can be downloaded as a pdf using the link below.
