Shoulder dystocia.Protocols for High Risk Pregnancies

Royal College of Obstetricians and Gynaecologists. Shoulder dystocia.Protocols for High Risk Pregnancies. London. 2012;(2):18.

Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed. An objective diagnosis of a prolongation of head-to-body delivery time of more than 60 seconds has also been proposed, but these data are not routinely collected. Shoulder dystocia occurs when either the anterior, or less commonly the posterior, fetal shoulder impacts on the maternal symphysis, or sacral promontory, respectively.

There can be significant perinatal morbidity and mortality associated with the condition, even when it is managed appropriately. Maternal morbidity is increased, particularly the incidence of postpartum haemorrhage (11%) as well as third and fourth-degree perineal tears (3.8%). Their incidences remain unchanged by the number or type of manoeuvres required to effect delivery. Brachial plexus injury (BPI) is one of the most important fetal complications of shoulder dystocia, complicating 2.3% to 16% of such deliveries.

The purpose of this guideline is to review the current evidence regarding the possible prediction, prevention and management of shoulder dystocia; it does not cover primary prevention of fetal macrosomia associated with gestational diabetes mellitus. The guideline provides guidance for skills training for the management of shoulder dystocia, but the practical manoeuvres are not described in detail – these can be found in standard textbooks and course manuals.

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