Shoulder Dystocia, Medical Emergency and a Tragedy

In Light of the Tragedy that has come out of Georgia in the News recently (august 2023), I wanted to write about shoulder dystocia. My Heart goes out to ALL Those Involved.

Shoulder dystocia is a complication that can occur during childbirth when a baby's head passes through the birth canal, but one or both baby’s shoulders become stuck behind the mother's pelvic bone. This situation can lead to an obstruction of the baby's progress through the birth canal, potentially causing significant challenges during delivery. Shoulder dystocia is an Obstetrician’s or Midwifes’ worse nightmare and what keeps me up at night.  

Shoulder dystocia occurs in roughly 3% of vaginal deliveries and is typically encountered when women are full term or past their due date.

Shoulder dystocia is considered an obstetrical emergency because it can lead to complications for both the baby and the mother. During a severe or catastrophic shoulder dystocia, conventional maneuvers and techniques used to resolve a typical shoulder dystocia may not be successful. The baby's ability to oxygenate is compromised due to the prolonged obstruction, which can lead to prolonged oxygen deprivation, brain damage and death.

What happens in a shoulder dystocia? The baby's head is usually delivered, but the shoulders may require additional maneuvers or techniques to safely navigate through the birth canal. The provider and staff must act swiftly and skillfully to address the situation and facilitate the safe delivery of the baby. Some maneuvers that are utilized in order to save the baby’s life, may involve breaking the baby's clavicle to facilitate delivery. The entire process of resolving a shoulder dystocia is wrought with high anxiety and stress. All involved, parents, nursing staff and providers suffer from trauma as a result.

Risk factors for shoulder dystocia include a larger baby size, gestational diabetes, maternal obesity, maternal short stature, a history of previous shoulder dystocia, and a prolonged second stage of labor. However, most of shoulder dystocia’s occur in individuals without any risk factors. Other risk factors are when babies are weighing over 4500gm (8lbs 13oz) or a mothers pelvis is not a gynecoid shaped pelvis or has been changed in shape due to pelvic fractures. This is something that can not be fully predicted, therefore it results in a medical emergency.

Medical interventions and techniques, such as changing the mother's position, applying gentle pressure to the mother's super pubic area, and performing specific maneuvers, like the McRoberts maneuver or the Woods' screw maneuver, are usually employed to resolve the shoulder dystocia and assist with the delivery. Medical professionals must respond urgently and with precision to manage a catastrophic shoulder dystocia.

Other advanced maneuvers and techniques may be required, such as the Zavanelli maneuver (reversing the cardinal movements of labor and returning the baby's head into the birth canal and performing a cesarean section). These interventions are considered extreme measures and are taken only in critical situations. Zavanelli maneuver is difficult and rarely successful. It is associated with poor fetal outcome.

Advanced or rescue procedures may be necessary such as intentionally dividing the pubic symphysis bones to create space. However, this procedure poses significant risks to the mother, leading to excruciating pain, impaired mobility, and an elevated likelihood of severe bladder damage. When a practitioner reaches the point where the decisions for rescue procedures are employed, the neonate is often deceased.

Severe or catastrophic shoulder dystocia underscores the importance of skilled and experienced medical personnel, as well as careful prenatal monitoring to identify any risk factors that might increase the likelihood of this complication. While exceedingly rare, this scenario highlights the critical nature of emergency preparedness and the need for swift, well-coordinated actions to address complex birthing complications.