Shoulder dystocia is a birth complication. During the course of birth, the baby’s shoulder becomes stuck in the mother’s pelvis.
What is shoulder dystocia?
Shoulder dystocia is a rare but feared complication during the birth process. It presents in about one percent of all births. Shoulder dystocia is when the baby’s anterior shoulder gets stuck against the pubic symphysis or the mother’s pelvis after her head protrudes. This prevents the baby’s trunk from leaving the mother’s body. A distinction is made between high and low shoulder straightness. High shoulder straightness is when the infant’s shoulders are not positioned transversely but longitudinally. This causes the anterior shoulder to hang on the mother’s symphysis. The pubic symphysis then obstructs the lowering of the shoulder. The transverse standing of the shoulder on the maternal pelvis is called deep shoulder straightness. This form results from the absence of shoulder rotation. Ultimately, shoulder dystocia results in a delay of the further birth process.
Causes
In most cases, shoulder dystocia is caused by an oversized baby. Doctors speak of this when the baby weighs more than 4000 grams. This is especially the case in mothers who suffer from diabetes mellitus. Often their children have macrosomia, in which the width of the shoulders is greater than the circumference of the head. However, recent evidence sees more of an above-average growth of tissues that are insulin-intensive. These include the shoulders and trunk. Occasionally, massive use of the Kristeller maneuver, too-early pushing along, or vaginal surgical delivery involving forceps or a vacuum cup can also result in shoulder dystocia. In addition, there are some risk factors that make shoulder dystocia more likely. First and foremost, these include severe maternal obesity. In such cases, there are often extensive fat deposits within the pelvis. These hinder the baby from inserting its shoulders into the mother’s pelvis in the correct position. Also among the risk factors are pelvic abnormalities of the mother and a rapid expiration of the expulsion period.
Symptoms, complaints, and signs
A typical feature of shoulder dystocia forms obstetric arrest after the baby’s head has already emerged. In the case of high shoulder straightness, the fetal head is enveloped by the maternal vulva like a ruff. The birth arrest results in more time passing, which in turn increases the risk of hypoxia. It is not uncommon for shoulder dystocia to result in fractures of the clavicle or humerus. Likewise, the nerve plexuses in the child’s arm can be affected. Even paralysis is within the realm of possibility. In severe cases, traumatic damage to the brain or lack of oxygen can even put the baby’s life at risk.
Diagnosis and course of the disease
For the obstetrician, the occurrence of shoulder dystocia is usually very surprising. Thus, this rare complication does not announce itself before birth. However, some factors may provide clues to possible shoulder dystocia before the birth process. For example, the expulsion phase takes longer in some cases. Similarly, difficult passage of the head may indicate dystocia. It can be recognized by the retraction of the child’s head after its protrusion. Physicians also refer to this process as the turtle phenomenon. Shoulder dystocia carries the risk of late effects such as brain damage. These are caused by a lack of oxygen because the child’s head becomes entangled in the umbilical cord, for example. The mortality rate from shoulder dystocia ranges from 2 to 16 percent.
Complications
Usually, shoulder dystocia is already a complication during birth. In this case, there is a complete arrest during birth, which can be life-threatening for both the child and the mother. In the worst case, the child or the mother may die. However, this case occurs very rarely and especially if the complication is not treated.Furthermore, a fracture of the patient’s collarbone can also occur, so that surgical intervention is necessary immediately after birth. Various paralyses or sensory disturbances can also occur as a result of the injuries and make the child’s further life more difficult. No prediction can be made about the further course of these paralyses. Damage to the brain is also possible. If there is a lack of oxygen, the child’s internal organs may also be irreversibly damaged. Usually, shoulder dystocia can be treated well with the help of medications. Surgical intervention may also be necessary. However, particular complications do not occur and a positive course of the disease is seen.
When should you see a doctor?
A doctor should be consulted in case of shoulder dystocia. There can be no self-healing in this disease, so treatment by a doctor is always necessary. The earlier the symptoms are detected and treated, the better the further course of the disease. In most cases, the shoulder dystocia is detected directly at birth by the doctor or midwife and then treated directly. No further complications or other complaints occur. Only in severe cases can injuries occur in the child. If there are any injuries to the child after birth, a doctor must be consulted in any case to guarantee proper healing of these injuries. In some cases, the shoulder dystocia injuries cause psychological upsets or depression in the parents or in the relatives. In this case, a psychologist should be consulted to prevent further psychological discomfort.
Treatment and therapy
The type of therapy for shoulder dystocia depends on what form it is. If there is high shoulder straightness, the first step is to administer a tocolytic so that the mother’s contractions are inhibited. Then, to get more space, an episiotomy is performed. The next step is to perform what is called the Roberts maneuver. In this procedure, the obstetrician stretches the mother’s legs, resulting in an increase in the size of the conjugata vera by approximately one centimeter. The manual application of pressure immediately above the pubic symphysis also helps the child to rotate in the longitudinal axis. It is even possible to adjust the child’s shoulders to the oblique diameter. If the rotation succeeds, a maximum flexion movement takes place within the hip joint. In this way, the anterior shoulder gets more space. If the Roberts maneuver does not lead to the desired success, intubation anesthesia must be performed in order to be able to release the pelvic floor. If a deep transverse shoulder is present, the turning of the child’s head is performed after an extended perineal incision. Similarly, the shoulders are rotated in longitudinal axis. A useful support is to perform the Kristeller handgrip, which is used to exert pressure on the fundal roof. With a deep transverse shoulder position, there is less risk of complications. Other possible treatment maneuvers include the Gaskin maneuver, the Woods maneuver, the Rubin maneuver, or posterior arm release.
Prevention
To prevent shoulder dystocia, the risk factors that trigger it should be identified early. In the case of diabetes mellitus, a macrosomia-related birth complication can often be counteracted by adjusting the metabolism. If excessive weight of the baby can be detected in advance, a cesarean section usually takes place.
Follow-up care
The pediatrician or physical therapist will provide information on how to manage affected infants and follow-up care for a shoulder dystocia. It is important to provide ongoing physical therapy consistently from the second to third week of life. Therapeutic modification goals include building and maintaining muscle function, preventing restricted movement due to muscle shortening, and stimulating the muscles. Physical therapy is also used to help spontaneous development in plexus palsy, prevent poor posture and build coordination. In addition to the encouraging movement exercises in pediatric physical therapy, parents receive instruction in exercises to do at home.Only continuous implementation ensures that the nerve functions recover and strengthening of the musculature is achieved. During physiotherapeutic treatment, the caregivers also learn to carry and position the child in various positions, adapted to its developmental stages. This is to prevent additional damage to the brachial plexus. Neurophysiological treatment methods such as the Bobath concept and/or Vojta therapy are recommended and prescribed throughout Germany for the follow-up treatment of shoulder dystocia. However, these intensive therapy methods can cause great reluctance in infants and children. Many parents therefore suffer from fears and worries, which they should talk about with the person treating them. Sudden discontinuation of therapy can cause significant problems.
What you can do yourself
Because shoulder dystocia is a complication of childbirth, it is strongly advised to plan the delivery early and have a trained obstetric team around you. Under no circumstances should the birth of the child take place independently and alone in the home. The possibility to go to the nearest hospital with the help of a relative or to alert an ambulance service should be organized in time. Failure to do so may result in serious complications for the birthing mother or the offspring. If a birth arrest occurs, seeking medical help is essential, as the lives of both mother and child are at risk. In the case of an inpatient birth or a delivery in the presence of a midwife, the instructions of the medical staff must be followed. Calmness should be maintained under all circumstances. Additional stress and excitement caused by the expectant mother or relatives will further worsen the situation. Communication with the obstetricians is necessary during the entire birth process. Changes, abnormalities or special features should be discussed with each other immediately and open questions should be clarified. Since developments during childbirth are often surprisingly sudden, it is important not to allow any additional panic or anxiety to arise and to trust the obstetricians.
