medical and forensic animation for trial attorneys by Cal Shipley, M.D., A.B.F.P.

Obstetrical Shoulder Dystocia

During the process of human birth, the term Shoulder Dystocia refers to the entrapment of the fetus within the birth canal. This entrapment results from the impaction of either the Anterior shoulder (most common) against the maternal pubic bone, or the Posterior Shoulder (least common) against the bony protuberance of the sacral bone (sacral promontory – see fig. 1). Occasionally, both shoulders may become impacted. Prolonged or severe shoulder dystocia may lead to serious injury of the plexus of nerves supplying sensation and function to the fetal upper limb, and can also result in permanent brain damage as a result of interruption of fetal cerebral blood flow. Fetal Shoulder Dystocia may occur in up to 3% of all vaginal deliveries, and it is critical that delivery physicians and staff be well versed in both the recognition and treatment of this problem. 

 

fig. 1

Most authorities have defined significant dystocia to include any delivery requiring one or more maneuvers (discussed below) in addition to gentle downward traction on the fetal head to effect delivery.

Relevant Maternal and Fetal Anatomy

The key maternal anatomical elements in shoulder dystocia are the pubic bone, which forms the anterior (frontal) border of the pelvic inlet, and the sacrum, which forms the posterior (rear) border of the inlet (see fig. 2).

fig.2

The fetal shoulders must pass through the pelvic inlet, and in doing so, successfully squeeze past the pubic bone and sacrum. The dimension of the fetal shoulders represented by a measurement taken from the outer edge of one shoulder to the outer edge of the opposite shoulder (bisacromial diameter) is often larger than the distance measured between the pubic and sacral bones at the pelvic inlet. As a result, it is essential that, as the fetus traverses the pelvic inlet, the shoulders rotate obliquely to permit passage  (see fig. 3 & 4). If the shoulders fail to adequately rotate, dystocia may result.

Dystocia of the Anterior Shoulder

When the fetal shoulders fail to adequately rotate upon reaching the pelvic inlet, the anterior fetal shoulder may become impacted on the maternal pubic bone. This is by far the most common form of  fetal dystocia (fig. 5).  The shoulder may spontaneously dislodge with further uterine contractions, without harm to the fetus.  Many such cases of dystocia likely go unnoticed by the delivery staff. If, however, the shoulder impaction persists,  fetal injury may occur.

Dystocia of the Posterior Shoulder

Dystocia of the posterior shoulder may also result from inadequate rotation of the fetal shoulders as they enter the pelvic inlet. In this case, the posterior shoulder (nearest the mother’s spine) impacts against the promontory of the sacrum (see fig. 6). This is the less common form of dystocia.

Fetal Injuries related to Shoulder Dystocia

Brachial Plexus injury

The most common injury associated with shoulder dystocia is injury to the brachial plexus. The brachial plexus is a group of nerves located in the lower neck, formed by 5 nerve roots emerging from the spinal cord as it runs through the cervical spine (fig. 7 & 8).

fig. 7 - the brachial plexus

fig. 8 - brachial plexus roots (left)

This plexus is responsible for all sensory and muscular function of the corresponding upper limb. Thus, there is a plexus on both the left and right side of the neck. During dystocia (both anterior and posterior), the forward propulsion of the fetus as a result of uterine contractions and maternal bearing down, and the impaction of the shoulder, causes the neck, and the nerve plexus within, to stretch (fig.9) . Repetitive and intensive stretching may damage the nerves of the plexus. The nerves may tear (avulsion), but neurological impairment can also arise as a result of simple stretching of the nerves. In these cases, there is undoubtedly microscopic internal tearing of nerve bundles.

The mechanism of plexus injury resulting from operator traction on the the fetal head and neck in attempts to deliver an infant whose shoulder is impacted is controversial. Many researchers are skeptical of this mechanism, and point to the fact that 40% of all brachial plexus injuries occur in deliveries without known dystocia, where no undue force is exerted on the fetal head.

Most commonly, the nerves of the C5 and C6 nerve roots are injured, resulting in the clinical findings of  Erb-Duchenne palsy: the infant loses the power to abduct the arm from the shoulder, rotate the arm externally, and supinate the forearm. The characteristic position consists of adduction and internal rotation of the arm with pronation of the forearm. Power to extend the forearm is retained, but the biceps reflex is absent; the. The outer aspect of the arm may have some sensory impairment. Power in the forearm and hand grasp are preserved unless the lower part of the plexus is also injured; the presence of hand grasp is a favorable prognostic sign.

Rarer brachial plexus injuries include Klumpke’s Palsy (injury of the C7, C8 and T1 nerve roots. This results in a clinical picture of. a paralyzed hand, and eyelid weakness and constricted pupil (ptosis and miosis - Horner syndrome) if the sympathetic fibers of the 1st thoracic root are also injured. Damage to the entire brachial plexus has occasionally been seen, as well as paralysis of the respiratory diaphragm,, and facial nerve injury.

One third of brachial plexus palsies are associated with a fetal bone fracture on the affected side, most commonly the clavicle (94%). Rarely, a fracture of the fetal radius (forearm) may result from either the dystocia or the various maneuvers employed to relieve dystocia.

Brain damage and Death

Maternal Injuries related to Shoulder Dystocia

Factors increasing the risk of shoulder dystocia

Studies have established a significant relationship between increasing birth weight and the risk of shoulder dystocia. In births not complicated by maternal diabetes, only 5% of infants weighing between 4000 and 4250 grams at birth typically experience dystocia, while for infants weighing 4750-5200 grams, almost 21% are so affected.   Despite these findings, attempts to predict dystocia based on previous history of over weight births (macrosomia),  pre-existing or pregnancy induced non-insulin dependent diabetes, excessive maternal weight gain, and delivery after expected dates, have proven  to be unreliable at best. Likewise, fetal birth weight estimates based on ultrasounds performed in the latter stages of pregnancy have not correlated well with the incidence of shoulder dystocia. The most recent recommendation of the American College of Obstetricians is that there is no contra-indication to attempted vaginal delivery for any infant estimated to be up to 5000g (where maternal insulin-dependent diabetes is not present).

Mothers with insulin-dependent diabetes whose babies are of high birth weight show a significantly higher risk for encountering fetal shoulder dystocia during labor. It is thought that this relates to changes in fetal body proportions, including larger chest and trunk circumferences, larger bisacromial diameters and chest to head ratios, all of which may contribute to inadequate shoulder rotation at the pelvic inlet.

Mothers who have had a prior history of fetal shoulder dystocia during labor should also be considered in a special risk category for recurrence with subsequent pregnancies.

Measures to relieve Shoulder Dystocia

Shoulder dystocia is most often recognized after delivery of the fetal head, when gentle downward traction on the head fails to accomplish delivery. The so-called “turtle sign” is often noted – after the delivery of the head, the head is pulled back against the external vagina (perineum). Once dystocia is recognized, the mother should be stopped from pushing until the shoulders have been freed. If the umbilical cord is wrapped around the neck (nuchal cord), an attempt should be made to pull it over the head. If this fails, the cord should not be cut, but rather left intact until complete delivery has been accomplished.  Fetal shoulder dystocia is considered an obstetrical emergency, and steps should be rapidly instituted to relieve the problem. A delay of more than several minutes between head and shoulder delivery increases the chance of brain damage due to hypoxia.

McRoberts maneuver

The McRoberts maneuver is generally the first step taken once dystocia is recognized. The maneuver consists of flexion of both maternal thighs into the abdomen (fig. 10 & 11). This action causes a flattening of the lower spine and a subsequent increase in the front-to-back dimension of the pelvis. This change is often enough to permit the shoulders to slip through the pelvic inlet. Care must be taken not to be too aggressive in the maneuver as this may result  in maternal injury as described previously.

Suprapupic pressure

Suprapubic pressure is often performed in conjunction with the McRoberts maneuver, or shortly thereafter if the McRoberts is unsuccessful. It consists of downward pressure applied with the heel of the hand directly above maternal pubic bone (fig 12 & 13). The intended effect is to push the impacted shoulder below the pubic bone, thus freeing it to move forward through the inlet. Proper positioning of the hands at a point directly above the pubic bone is critical, as pressure applied at a higher level will compress the uterus and may aggravate brachial plexus stretch or umbilical cord compression and fetal hypoxia.

Woods screw

If McRoberts and suprapubic pressure fail, a variety of additional techniques may be attempted, including the Woods Screw and Rubin maneuvers. The Woods Screw consists of application of the operator hands to the anterior and posterior shoulders (fig 14). Pressure is then applied to rotate the shoulders, moving them into an oblique position, thus relieving the impaction. The Rubin maneuver (reverse Woods) involves application of pressure to the back (posterior) of whichever shoulder is most accessible, again with the goal rotation into the oblique position.

Posterior Arm Delivery 

Delivery of the posterior arm (fig 15) has the effect of pulling the posterior shoulder into the pelvic inlet.  When successful, this has the effect of dropping the anterior shoulder beneath the pubic bone. The operator reaches in along the maternal spine, flexes the posterior arm at the elbow, and then delivers the arm with a sweeping motion along the fetal chest.

Zavanelli, Symphisiotomy, Hysterotomy  

When the above measures have failed to relieve dystocia, more aggressive, so-called “heroic” measures may be required. The Zavanelli maneuver consists of an attempt to replace the fetal head back into the labor canal, thus disimpacting the shoulders, and relieving stress on the brachial plexus and umbilical cord.  Once accomplished, the decision can be made whether to re-attempt vaginal delivery or proceed to an emergency caesarian section.

Symphisiotomy involves the obstetrician performing an external incision of the symphysis pubis, the ligament that joins the right and left pubic bones. This results in a separation of the pubic bones with subsequent release of the impacted shoulder.

Hysterotomy involves performing a transverse incision along the lower end of the uterus. The posterior arm is delivered through the incision, and the operator then rotates the shoulders to the oblique position to effect delivery.