Management of shoulder dystocia

Abstract

Shoulder dystocia is a predominantly unpredictable and non-preventable event.• The progressive incidence of obesity and diabetes has determined the contemporary increase in shoulder dystocia incidence. • The main risk factors for shoulder dystocia are fetal macrosomia, diabetes mellitus, dystocia in the functional periods of labor and operative vaginal delivery. • Clinical imaging and pelvimetry are not helpful in identifying women at higher risk for shoulder dystocia.• Diagnosis and severity of shoulder dystocia are subjective. Failure of the head-shoulder maneuver and the turtle sign are the main diagnostic criteria. The need for multiple delivery maneuvers and the occurrence of maternal and/or neonatal injuries better evidence the severity of cases. • Professionals involved in childbirth care must be prepared to recognize shoulder dystocia and immediately perform a sequence of maneuvers for its correction in a timely manner. • Control of body weight and blood glucose levels is the main strategy likely to reduce the risk of shoulder dystocia. • The most common serious maternal complications of shoulder dystocia are postpartum hemorrhage and complicated perineal lacerations. • The most frequent neonatal complication of shoulder dystocia is transient brachial plexus palsy.• Skills training and simulation improve the care and documentation of shoulder dystocia, promoting evidence-based management and reducing transient brachial plexus injuries. Recommendations• In pregnancies with diabetes and estimated fetal weight above 4,500 grams (g) and in those without diabetes and estimated fetal weight above 5,000 g, cesarean section appears to prevent shoulder dystocia. • In the prolongation of the second stage of labor in diabetic parturient women with an estimated fetal weight between 4,000 and 4,500 g, and in non-diabetic women with an estimated fetal weight between 4,500 and 5,000 g, cesarean section for the prevention of shoulder dystocia is also applicable. • In the prolonged pelvic period of fetuses with estimated weight of more than 4,500 g, intrapartum cesarean section for prevention of shoulder dystocia is preferable to low operative vaginal delivery or forceps delivery.Similarly, operative vaginal delivery with the fetal head in the mid-pelvis should be avoided in fetuses estimated to weigh more than 4,000 g, and intrapartum cesarean section is indicated. In these situations, birth instrumentation should only be considered in the presence of experienced operators, through an individualized assessment of fetal position and size, history of previous deliveries and maternal habits. • Induction of labor to prevent shoulder dystocia is indicated in pregnant women with gestational diabetes at 39 weeks and estimated fetal weight between 4,000 and 4,500 g. In pregnant women without diabetes, induction can also be offered at 39 weeks when the estimated fetal weight is between 4,000 and 5,000 g, but expectant management is also a reasonable alternative. • A sequence of maneuvers that may vary according to the parturient ...