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Shoulder dystocia

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of shoulder dystocia are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2020,2017) and the Royal College of Obstetricians and Gynaecologists (RCOG 2012).
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Screening and diagnosis

Diagnosis: as per RCOG 2012 guidelines, consider performing routine traction in an axial direction to diagnose SD. Avoid performing any other traction.
C
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Classification and risk stratification

Prediction of SD
As per RCOG 2012 guidelines:
Be aware of existing risk factors in laboring females and be alert to the possibility of SD.
B
Recognize that risk assessments for the prediction of SD are insufficiently predictive to allow prevention of the large majority of cases.
B
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Medical management

General principles
As per RCOG 2012 guidelines:
Manage SD systematically.
E
Call for additional help immediately after recognition of SD. State the problem clearly as 'this is SD' to the arriving team.
E
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Inpatient care

Intrapartum monitoring: as per RCOG 2012 guidelines, ensure that all birth attendants are:
aware of the methods for diagnosing SD and the techniques required to facilitate delivery
looking for the signs of SD routinely
alert to the possibility of postpartum hemorrhage and severe perineal tears.
E
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Therapeutic procedures

McRoberts maneuver: as per RCOG 2012 guidelines, perform the McRoberts maneuver as the first intervention for SD.
B
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  • Suprapubic pressure

  • Fundal pressure

  • Internal maneuvers

  • All fours position

  • Last-resort procedures

Surgical interventions

Episiotomy: as per RCOG 2012 guidelines, do not perform episiotomy routinely.
D
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Patient education

General counseling: as per RCOG 2012 guidelines, provide an explanation of the delivery to the parents.
E
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Preventative measures

Induction of labor
As per RCOG 2012 guidelines:
Consider offering induction of labor at term to reduce the incidence of SD in patients with gestational diabetes.
C
Do not offer induction of labor for the prevention of SD in non-diabetic females with a suspected macrosomic fetus.
D
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  • Cesarean delivery

Follow-up and surveillance

Immediate care of the newborn: as per RCOG 2012 guidelines, examine the newborn for injury by a neonatal clinician.
E
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  • Birth after previous SD

Quality improvement

Health professional training: as per RCOG 2012 guidelines, ensure that all maternity staff participates in SD training at least annually.
B
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  • Documentation