Shoulder Dystocia: Diagnosis, Evaluation and Management
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Describe the various maneuvers that can be used to reduce shoulder dystocia 2. Discuss the role of simulation for shoulder dystocia preparation
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Shoulder dystocia is an obstetrical emergency. While there are associated risk factors, they are poor at predicting shoulder dystocia. The majority of cases will occur in women without diabetes whose offspring are within normal weight range. Nor is there any evidence that shoulder dystocia can be prevented. Complications include PPH and brachial plexus injuries. ACOG published guidance in 2017 that has been reaffirmed (2019).
Failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery
Prior history of shoulder dystocia
Universal prophylactic cesarean section is not recommended
Due to recurrence risk (1% to 16.7%), evaluate EFW, GA, glucose and severity of previous event
Patient discussion and careful delivery planning is recommended
Diabetes: GDM and pre-gestational diabetes
Macrosomia (see delivery recommendations below)
Large fetal chest relative to biparietal diameter (seen with diabetes)
Bottom line: “…shoulder dystocia cannot be accurately predicted or prevented.”
are no ultrasound findings or labor patterns that are predictive of shoulder
classic “turtle sign” is “…suggestive, but not diagnostic, of the presence of
is based on clinical judgement when there is failure to deliver the fetal
shoulders after initial traction attempts
Management for Suspected Fetal Macrosomia (see Related ObG Topics below):
<39 weeks gestation is not recommended unless there are medical indications
cesarean delivery should be considered for the following
diabetes: estimated fetal weight of 5,000 grams or higher
diabetes: estimated fetal weight of 4,500 grams or higher
suggested for suspected fetal macrosomia as induction has not been shown to
improve maternal or fetal outcomes
fetal macrosomia is not a contraindication to a trial of labor after cesarean
Maneuvers (see videos in ‘Learn More – Primary Sources’ below):
maneuver: Best first step (Level B Evidence)
knees flexed and brought to chest while suprapubic pressure is applied
Posterior Shoulder Delivery to reduce shoulder diameter (Level C Evidence)
option if McRoberts unsuccessful
the diameter of the fetal shoulder girdle
to deliver the posterior shoulder include the following
maneuver: Place hand on the back of the posterior fetal shoulder followed by anterior
rotation towards the fetal face
Screw maneuver: Apply pressure to anterior surface of the posterior shoulder with
fetal rotation until anterior shoulder disengages from behind the maternal
axilla sling traction: Thread a size 12 or 14 French soft catheter around the
posterior shoulder and apply moderate traction to the sling to deliver the
all-fours maneuver (for women without anesthesia): With patient on hands and
knees, apply gentle downward traction on the posterior shoulder or upward
traction on the anterior shoulder
Resort’ maneuvers: Associated with significant maternal and/or fetal morbidity
maneuver: Head placed back in vaginal canal followed by cesarean section
rescue: shoulder dislodged from above via hysterotomy
fetal clavicular fracture
Note: ACOG states that “clinicians should
use the maneuver most likely to result in successful delivery.” (Level C
Evidence) | Maneuvers may be repeated if not successful initially
not apply fundal pressure due to risk for uterine rupture
patient to stop pushing until dystocia is resolved
does not support use of routine episiotomy
for clinical situation where additional room may be needed for above maneuvers
should be contemporaneous and include (Level B Evidence)
is used to train healthcare personnel for particularly severe, high acuity events
that are relatively infrequent
is effective in the setting of shoulder dystocia and improves
| Use of maneuvers | Documentation (Level B Evidence)
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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