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Patient handout

Shoulder Dystocia

PRODUCTION

1. Your condition

This handout is for shoulder dystocia. Your care team identified this based on: turtle sign at vaginal delivery — fetal head retracts against perineum after crowning; defining feature of shoulder dystocia (acog pb 178 2017).

Other reasons your team may use this plan: failure of normal axial-traction delivery of the anterior shoulder after the head has emerged — defining feature of shoulder dystocia (acog pb 178 2017); estimated fetal weight ≥ 4500 g (diabetic) or ≥ 5000 g (non-diabetic) at delivery — anticipatory cesarean indication per acog pb 178 2017; prior shoulder dystocia in prior pregnancy + current vaginal delivery underway — recurrence ~ 12%; cesarean recommended if prior severe / bpi / macrosomia recurrence (acog pb 178 2017).

3. When to call your provider

Contact your care team if any of the following happen:

  • Postpartum bleeding / persistent uterine tenderness / foul lochia → endometritis or retained products workup (ED visit)
  • New mental health crisis (PHQ-9 ≥ 15 or PCL-5 elevated with suicidal ideation) → urgent mental health referral
  • BPI no recovery at 3-6 mo → surgical exploration consideration; ped neuro / ortho urgent visit
  • HIE developmental concerns → urgent peds neurology evaluation
  • Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns, asymmetric arm persistence) → urgent peds visit

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

  • Shoulder dystocia at recognition — turtle sign + failed axial-traction delivery of anterior shoulder — life-threatening obstetric emergency; immediate call for help + start clock + HELPERR sequence (Help / Episiotomy-for-room / Legs-McRoberts / Pressure-suprapubic / Enter-rotational / Remove-posterior-arm / Roll-Gaskin); each maneuver ~ 30 s without progress → escalate; do NOT perseverate on failed maneuvers; clock-time documentation mandatory for medicolegal(life-threatening)
  • Head-to-body interval > 5 min — life-threatening; HIE risk rises sharply as cord pH falls ~ 0.04 per min after head delivery; all HELPERR + posterior arm + Gaskin failed → expedite delivery via Zavanelli (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only); emergent peds team for neonatal resuscitation; therapeutic hypothermia evaluation if HIE criteria met(life-threatening)
  • Neonatal brachial plexus injury (BPI) — Erb's palsy C5-C6 (most common; arm internally rotated + adducted + elbow extended + wrist flexed) vs Klumpke C8-T1 (intrinsic hand weakness + claw hand) vs complete plexus injury (flail arm) — severe; immediate post-delivery neurologic exam mandatory (arm symmetry + Moro + grasp + spontaneous movement); pediatric neurology + orthopedic consult; PT engagement starting at 2-3 wks; ~ 90% resolve by 1 year; ~ 10% persistent → surgical exploration / repair consideration at 3-6 mo if no recovery; subsequent pregnancy cesarean recommended
  • Prior shoulder dystocia in prior pregnancy — severe future-pregnancy risk; recurrence ~ 12% (range 6-25%); ACOG PB 178 2017 + RCOG GTG 42 2012 recommend cesarean for prior severe dystocia / BPI in prior delivery / suspected macrosomic recurrence (EFW ≥ 5000 g non-diabetic OR EFW ≥ 4500 g diabetic); preconception MFM counseling + serial growth US + glycemic optimisation if diabetic
  • Zavanelli maneuver (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only) — life-threatening last resort; all HELPERR + posterior arm + Gaskin maneuvers have failed + head-to-body interval approaching or exceeding 5 min; very high complication rate; case-series data only; symphysiotomy used only in LMIC where cesarean unavailable (significant maternal morbidity); cleidotomy (intentional fetal clavicle fracture) reserved for fetal demise(life-threatening)
  • Neonatal hypoxic-ischemic encephalopathy (HIE) post-shoulder dystocia — life-threatening; criteria ≥ 36 wk GA + (cord pH ≤ 7.0 OR base excess ≤ -16 OR 10-min Apgar ≤ 5 OR sentinel hypoxic event including prolonged dystocia > 5 min head-to-body) + moderate-severe encephalopathy on Sarnat staging → therapeutic hypothermia within 6 h (whole-body cooling to 33.5°C × 72 h then controlled rewarming); reduces death + major neurodevelopmental disability NNT ~ 9; NICU + neuroprotection sub-engine; continuous EEG + neuroimaging at completion; developmental tracking through 18-22 mo(life-threatening)
  • Postpartum hemorrhage after shoulder dystocia — severe; dystocia is a known atony + laceration PPH antecedent (~ 11-19% incidence); uterotonic ladder (oxytocin → carboprost if no asthma → methylergonovine if no HTN → misoprostol) + TXA within 3 h + laceration repair; if EBL > 1500 mL OR DIC features → MTP 1:1:1 PRBC:FFP:platelets + cryoprecipitate (Pacheco SMFM 47 2019); B-Lynch / uterine artery ligation / hysterectomy if uncontrolled; routes to ob.postpartum-hemorrhage.core.v1 with dystocia carryover

5. Follow-up

6-wk postpartum visit + dystocia-specific anticipatory guidance: recurrence ~ 12% (cesarean for prior severe / BPI / macrosomia recurrence — EFW ≥ 5000 g non-diabetic OR ≥ 4500 g diabetic); mental health screen (EPDS for PPD; PCL-5 for peripartum PTSD — dystocia is a known PTSD trigger); contraception counseling; immunization review. If BPI: PT continued; ortho/neuro followup at 1 + 3 + 6 mo; surgical exploration / repair consideration at 3-6 mo if no recovery; ~ 90% resolve by 1 year. If clavicle/humerus fx: pediatric ortho; usually heals without intervention. If HIE: pediatric neurology + developmental tracking; therapeutic hypothermia outcomes assessment at 18-22 mo per Shankaran NEJM 2005. Preconception MFM consultation for next pregnancy (timing + delivery mode planning). Simulation team feedback loop closed.

6. Sources

Guideline: ACOG Practice Bulletin 178 (2017, reaffirmed 2024) — Shoulder Dystocia + RCOG Green-top Guideline 42 (2012, in-force reaffirmed) — Shoulder Dystocia + Gherman 1997 McRoberts methodology (PMID 9077624) + Bruner 1998 Gaskin all-fours maneuver (J Reprod Med 1998; 43(5): 439-443; PMID 9610468) + Gurewitsch AJOG 2006 Posterior arm delivery (PMID 17077244 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) + Shankaran NEJM 2005 Therapeutic hypothermia for HIE (PMID 16221780) + Pacheco LD et al SMFM Consult Series 47 (2019) Massive transfusion in pregnancy (PMID 30447216 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) — carryover for PPH-after-dystocia overlap + WOMAN trial Shakur 2017 (PMID 28456509) — TXA in PPH carryover + ACOG PB 183 2017 — PPH uterotonic ladder + ACOG PB 190 2018 — GDM anticipatory planning + WHO 2017 Managing complications in pregnancy and childbirth — symphysiotomy LMIC framework + Higgins 2016 (PMID 26855098) — chorio overlap carryover

  1. pubmed.ncbi.nlm.nih.gov/9077624
  2. pubmed.ncbi.nlm.nih.gov/9610468
  3. pubmed.ncbi.nlm.nih.gov/17077244