How To Deliver A Baby With Shoulder Dystocia

Shoulder dystocia is one of those birth complications that can escalate quickly, requiring immediate action from the delivery team. When a baby’s head delivers but the shoulders get stuck behind the mother’s pelvic bone, every second counts. Understanding how medical teams respond to this emergency can help families recognize what proper care looks like and what to expect if complications arise.

What Is Shoulder Dystocia and Why Does It Happen?

Shoulder dystocia occurs during a head-first vaginal delivery when the baby’s shoulders fail to deliver after the head has already emerged. The anterior shoulder (the one facing the mother’s front) typically gets caught behind the pubic bone, preventing the baby from being born with normal gentle traction.

This isn’t just a matter of pulling harder. The obstruction is bony, meaning the baby is physically stuck, and additional specialized maneuvers are required to safely complete the delivery. The condition represents a true obstetric emergency because the baby’s chest remains compressed in the birth canal, potentially compromising blood flow through the umbilical cord.

The medical team typically recognizes shoulder dystocia when the baby’s head retracts tightly against the perineum after delivery (sometimes called the “turtle sign”) and the shoulders don’t follow with gentle downward traction during the next contraction.

How Common Is Shoulder Dystocia in Vaginal Births?

Shoulder dystocia happens in approximately 0.2% to 3% of all vaginal deliveries, though the rate varies significantly based on risk factors. The numbers shift dramatically with baby size. For infants weighing less than 4,000 grams (about 8 pounds, 13 ounces), the incidence is around 1%. When babies weigh between 4,000 and 4,500 grams (8 lbs 13 oz to 9 lbs 15 oz), that rate jumps to 5-9%. For babies over 4,500 grams (nearly 10 pounds), the risk climbs to 14-23%.

While these statistics might sound alarming, it’s important to remember that the majority of shoulder dystocia cases are resolved successfully with proper management. However, the potential for injury makes recognition and correct response absolutely critical.

What Makes Some Babies More Likely To Experience Shoulder Dystocia?

Several factors increase the likelihood of shoulder dystocia, though it’s worth noting that the condition can occur even without any identifiable risk factors present. The most significant predictors include:

• Fetal macrosomia: Babies estimated to weigh over 4,000 grams (approximately 8 lbs 13 oz) carry higher risk, with risk increasing substantially above 4,500 grams
• Maternal diabetes: Both gestational and pre-existing diabetes are associated with increased risk because they can affect how the baby’s weight is distributed, with more fat deposited around the shoulders and chest
• Previous shoulder dystocia: If a mother experienced shoulder dystocia in a prior delivery, there’s an increased chance of recurrence in subsequent pregnancies
• Prolonged second stage of labor: When the pushing stage extends longer than typical, particularly beyond two hours for first-time mothers or one hour for those who’ve given birth before
• Operative vaginal delivery: The use of forceps or vacuum extraction to assist delivery is associated with higher rates

Even when these risk factors are present, shoulder dystocia cannot be predicted with certainty. Many cases occur in deliveries without any identified risk factors, which is why all delivery teams must be prepared to respond.

What Should Happen the Moment Shoulder Dystocia Is Recognized?

The immediate response to shoulder dystocia follows a critical protocol. First, someone on the team must clearly announce “shoulder dystocia” to alert everyone present. This isn’t about causing panic but about ensuring the entire team shifts into emergency protocol mode.

Additional help should be called immediately, including extra obstetric staff, anesthesia personnel, and pediatric or neonatal team members who can care for the baby once delivered. Someone should start a timer to track how long the emergency lasts, which is essential for accurate documentation and helps the team track their progress through maneuvers.

Critically, the mother should stop pushing during the maneuvers. While pushing helps during normal delivery, it can actually worsen the impaction when shoulder dystocia is present. The delivery team needs to reposition and manipulate the baby’s position, and maternal pushing works against those efforts.

What Is the McRoberts Maneuver and Why Is It Tried First?

The McRoberts maneuver is typically the first intervention attempted because it’s quick, non-invasive, and remarkably effective. The technique involves hyperflexing the mother’s legs, bringing her thighs tightly against her abdomen. This positioning rotates the pelvis, tipping the symphysis pubis (the front of the pelvic bone) upward and slightly flattening the curve of the lower spine.

These positional changes accomplish several things simultaneously. The pelvic outlet widens, the angle of the pelvis shifts to better align with the baby’s shoulder position, and the movement can sometimes be enough to dislodge the stuck shoulder without any internal manipulation.

The success rate for McRoberts alone is approximately 42%, meaning that in nearly half of shoulder dystocia cases, simply repositioning the mother’s legs resolves the emergency. Even when additional maneuvers are needed, McRoberts is maintained throughout because it optimizes the pelvic space for the other techniques.

How Does Suprapubic Pressure Help Free a Stuck Shoulder?

While the mother is in the McRoberts position, an assistant typically applies suprapubic pressure. This involves placing firm, downward pressure just above the mother’s pubic bone, aiming to push on the baby’s anterior shoulder (the stuck one).

The pressure should be applied from the side, attempting to push the shoulder toward the baby’s chest. This adducts the shoulder, meaning it brings the baby’s arm closer to the body, effectively narrowing the shoulder width. The pressure is continuous and firm but not violent.

It’s crucial to understand what suprapubic pressure is not. It is absolutely not fundal pressure, which involves pushing down on the top of the uterus. Fundal pressure is contraindicated in shoulder dystocia because it can actually worsen the impaction, driving the anterior shoulder harder against the pubic bone. Fundal pressure also carries risks of uterine rupture and should never be used in this situation.

The combination of McRoberts positioning and suprapubic pressure resolves the majority of shoulder dystocia cases. When these first-line maneuvers don’t work within a reasonable timeframe (typically 30-60 seconds), the team moves to secondary interventions.

What Are the Secondary Maneuvers When Initial Attempts Fail?

When McRoberts and suprapubic pressure don’t free the shoulder, clinicians move to internal maneuvers that require reaching into the vagina to directly manipulate the baby’s position.

The Rubin Maneuver involves the clinician inserting a hand into the vagina and applying pressure to the baby’s posterior shoulder (the one facing the mother’s back). The pressure is directed toward the baby’s chest, which adducts that shoulder and can create a rocking motion that helps rotate the baby’s body. This rotation can dislodge the anterior shoulder from behind the pubic bone.

The Woods Screw Maneuver also uses internal manipulation but focuses on rotation. The clinician applies pressure to the posterior aspect of the posterior shoulder, essentially pushing it toward the baby’s back. This creates a corkscrew-like rotation of the baby’s entire body, which can walk the anterior shoulder past the obstruction.

Delivery of the Posterior Arm is another option where the clinician reaches into the vagina, locates the baby’s posterior arm, and sweeps it across the baby’s chest and out of the birth canal. Delivering the posterior arm accomplishes two important things: it reduces the overall shoulder width that needs to pass through the pelvis, and it often causes the body to rotate, which can free the anterior shoulder. This maneuver has a high success rate but carries a small risk of fracturing the humerus (upper arm bone).

What Are the Rescue Maneuvers Used in Severe Cases?

When standard maneuvers fail, medical teams have several additional options, though these are used much less frequently and typically only when other interventions haven’t worked.

The Gaskin Maneuver involves moving the mother onto her hands and knees (the all-fours position). This positional change can alter the pelvic dimensions and use gravity differently, potentially freeing the shoulder. However, this maneuver is generally not recommended when the mother has epidural anesthesia because she may not have the strength or sensation to safely support herself in this position.

Intentional clavicle fracture is a rarely used technique where the clinician deliberately fractures the baby’s clavicle (collarbone) to reduce shoulder width. This sounds dramatic, but clavicle fractures typically heal well in newborns. The technique is technically difficult to perform and is reserved for situations where other maneuvers have failed and the baby’s condition is deteriorating.

The Zavanelli Maneuver represents the most extreme intervention. It involves pushing the baby’s head back into the birth canal (cephalic replacement) and immediately performing an emergency cesarean section. This is extraordinarily rare and represents a last resort when all other options have been exhausted.

Why Documentation and Team Training Matter for Shoulder Dystocia Outcomes

The way medical teams document and prepare for shoulder dystocia directly impacts both immediate outcomes and any subsequent review of the case. Immediate documentation should include the exact time the head delivered, each maneuver attempted and in what order, how long the emergency lasted, the baby’s Apgar scores at one and five minutes, any complications observed, and the names of all personnel present.

This level of detail serves multiple purposes. It provides an accurate medical record for the baby’s ongoing care, helps the team review their response to improve future performance, and creates a clear timeline if questions arise later about whether care met the standard.

Hospitals are expected to conduct regular training drills for obstetric emergencies, including shoulder dystocia simulations. These drills help teams practice the maneuvers, improve communication under pressure, and ensure everyone knows their role when seconds matter. Research consistently shows that teams who train regularly perform better in actual emergencies, with faster resolution times and better outcomes.

What Injuries Can Happen to the Baby During Shoulder Dystocia?

Even with appropriate management, shoulder dystocia carries risks of injury to the baby. The most common injury is damage to the brachial plexus, the network of nerves running from the spine through the shoulder and down the arm. Brachial plexus injuries occur in approximately 2.3% to 16% of shoulder dystocia cases.

The good news is that most brachial plexus injuries resolve on their own. Many babies recover completely within the first few months of life. However, studies indicate that fewer than 10% of affected babies experience permanent impairment. The overall rate of brachial plexus injury in all live births is about 1.4 per 1,000 births, with permanent injury occurring in approximately 0.2 per 1,000 births.

Bone fractures can also occur, most commonly to the clavicle or humerus. While no parent wants their newborn to have a broken bone, these fractures typically heal quickly and completely in infants. In many cases, a clavicle fracture that happens during delivery may be a better outcome than prolonged attempts at delivery that could lead to oxygen deprivation.

The most serious potential complication is neonatal asphyxia and hypoxic brain injury. When the baby’s chest is compressed in the birth canal, blood flow through the umbilical cord can be compromised. The longer the shoulder dystocia persists, the greater the risk that the baby will not receive adequate oxygen. This is why time is so critical and why teams move quickly through the maneuver sequence.

What Risks Does the Mother Face During Shoulder Dystocia?

Mothers also face increased risks when shoulder dystocia occurs. Postpartum hemorrhage (excessive bleeding after delivery) occurs in approximately 11% of shoulder dystocia cases, compared to lower rates in uncomplicated deliveries. The increased risk likely relates to the additional manipulation required, the stress on uterine tissues, and the potential for atony (failure of the uterus to contract properly after delivery).

Third and fourth-degree perineal tears occur in about 3.8% of shoulder dystocia cases. These are the most severe types of tears, extending through the perineal muscles and potentially into the anal sphincter or rectum. These injuries require surgical repair and can have long-term consequences for bowel and sexual function.

Interestingly, research shows that maternal complication rates are not significantly affected by which maneuver is used to resolve the dystocia. This suggests that the complications are related to the emergency itself rather than the specific techniques employed, reinforcing the importance of quick recognition and systematic response.

What Medical Interventions Should Be Avoided During Shoulder Dystocia?

Understanding what not to do during shoulder dystocia is just as important as knowing the correct maneuvers. Fundal pressure, where someone pushes down on the top of the uterus, is absolutely contraindicated. This intervention can worsen the impaction by driving the anterior shoulder harder against the pubic bone. It also significantly increases the risk of uterine rupture, a life-threatening complication for the mother.

Routine wide episiotomy (an incision to enlarge the vaginal opening) is not recommended for shoulder dystocia. While episiotomy increases the soft tissue space, shoulder dystocia is a bony obstruction. The baby is stuck on the mother’s pelvic bone, not blocked by perineal tissue. Cutting an episiotomy doesn’t create more room where it’s needed and may increase the risk of severe tears without providing benefit.

Excessive or forceful traction on the baby’s head should also be avoided. Pulling harder when the shoulder is stuck can cause serious injury to the brachial plexus and doesn’t address the underlying problem. The maneuvers used in shoulder dystocia are about repositioning, rotation, and reducing shoulder width, not about pulling the baby out with force.

Understanding Your Rights and Options After a Shoulder Dystocia Birth

When families experience shoulder dystocia and their baby suffers an injury, they often have questions about whether the care provided met appropriate standards. While shoulder dystocia itself is an unpredictable emergency that can occur even with excellent care, the way medical teams respond to the emergency is something that can and should be evaluated.

Appropriate care includes rapid recognition of the problem, immediate mobilization of additional help, systematic progression through evidence-based maneuvers, avoidance of harmful interventions, and thorough documentation. Delays in recognition, failure to call for help, incorrect technique, or use of contraindicated maneuvers like fundal pressure may indicate substandard care.

Families dealing with birth injuries have the right to obtain complete copies of medical records, including nursing notes, physician documentation, fetal monitoring strips, and operative reports. These records provide the timeline and details necessary to understand exactly what happened during the delivery.

Speaking with medical professionals who can review the care provided is an important step. Birth injury cases are highly specialized, requiring expert analysis to determine whether the standard of care was met. Not every injury indicates improper care, but families deserve to understand whether everything that should have been done was done correctly and in a timely manner.

Moving Forward After Shoulder Dystocia

Shoulder dystocia represents one of the most time-sensitive emergencies in obstetrics. When it occurs, the difference between a good outcome and a devastating one often comes down to how quickly the team recognizes the problem and how systematically they execute the proven maneuvers. Most cases are resolved successfully when medical teams follow established protocols, maintain clear communication, and avoid harmful interventions.

For families affected by shoulder dystocia, particularly those dealing with brachial plexus injuries or other complications, understanding what happened during the delivery can be an important part of processing the experience. The medical information provided here offers a foundation for those conversations, whether with healthcare providers, early intervention specialists, or legal professionals.