Shoulder dystocia

The head is out. It sits hard against the perineum, the chin will not clear, and the cheeks are fat and purple. You pull the way you always pull and nothing moves. That gap between the head and the body is the whole emergency, and it is measured in minutes.^[5][6]

Everything you need is already in the room. What separates the good outcome from the litigated one is whether you can run a rehearsed sequence, out loud, while somebody writes down the time.^[3][4]

Overview and definition

Two definitions are in use, and the examiner wants both. ^[1][16]

• Operational: a birth that needs additional obstetric manoeuvres after gentle downward traction on the head has failed to deliver the shoulders. This is the definition RCOG Green-top 42 and ACOG Practice Bulletin 178 both work from.^[1][16]
• Objective: a head-to-body delivery interval of more than 60 seconds. It removes operator judgement, which is why researchers like it and why clinical audits use it.^[5]

The operational definition depends on who is standing at the bed, so reported incidence swings with how confident the accoucheur is. That is not a footnote — it is why unit rates range from around 0.2% to over 2% for the same population.^[3][18]

References20ShowHide

1. [1]American College of Obstetricians and Gynecologists Practice Bulletin No 178: Shoulder Dystocia Obstet Gynecol, 2017.PMID 28426618
2. [2]Hoffman MK, Bailit JL, Branch DW, et al. A comparison of obstetric maneuvers for the acute management of shoulder dystocia Obstet Gynecol, 2011.PMID 21555962
3. [3]Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training Obstet Gynecol, 2008.PMID 18591302
4. [4]Crofts JF, Lenguerrand E, Bentham GL, et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study BJOG, 2016.PMID 25688719
5. [5]Leung TY, Stuart O, Sahota DS, et al. Head-to-body delivery interval and risk of fetal acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a retrospective review BJOG, 2011.PMID 21199293
6. [6]Lerner H, Durlacher K, Smith S, et al. Relationship between head-to-body delivery interval in shoulder dystocia and neonatal depression Obstet Gynecol, 2011.PMID 21775848
7. [7]Lok ZL, Cheng YK, Leung TY, et al. Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study BMC Pregnancy Childbirth, 2016.PMID 27793109
8. [8]Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor J Reprod Med, 1998.PMID 9610468
9. [9]Cluver CA, Hofmeyr GJ Posterior axilla sling traction: a technique for intractable shoulder dystocia Obstet Gynecol, 2009.PMID 19155929
10. [10]Cluver CA, Hofmeyr GJ Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling Am J Obstet Gynecol, 2015.PMID 25731695
11. [11]Dharmasena D, Berg L, Hay A, et al. The Zavanelli manoeuvre revisited: A review of the literature and a guide to performing cephalic replacement for severe shoulder dystocia Eur J Obstet Gynecol Reprod Biol, 2021.PMID 34592651
12. [12]Boulvain M, Senat MV, Perrotin F, et al. Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial Lancet, 2015.PMID 25863654
13. [13]Gardosi J, Ewington LJ, Booth K, et al. Induction of labour versus standard care to prevent shoulder dystocia in fetuses suspected to be large for gestational age in the UK (the Big Baby trial): a multicentre, open-label, randomised controlled trial Lancet, 2025.PMID 40319899
14. [14]Jeppegaard M, Larsen MH, Thams AB, et al. Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study Acta Obstet Gynecol Scand, 2024.PMID 38409800
15. [15]Poggi SH, Allen RH, Patel CR, et al. Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery Am J Obstet Gynecol, 2004.PMID 15467557
16. [16]Giouleka S, Tsakiridis I, Ralli E, et al. Diagnosis and Management of Macrosomia and Shoulder Dystocia: A Comprehensive Review of Major Guidelines Obstet Gynecol Surv, 2024.PMID 38640129
17. [17]Athukorala C, Crowther CA, Willson K, et al. Women with gestational diabetes mellitus in the ACHOIS trial: risk factors for shoulder dystocia Aust N Z J Obstet Gynaecol, 2007.PMID 17261098
18. [18]Mollberg M, Ladfors LV, Strömbeck C, et al. Increased incidence of shoulder dystocia but a declining incidence of obstetric brachial plexus palsy in vaginally delivered infants Acta Obstet Gynecol Scand, 2023.PMID 36345990
19. [19]Matsuo K, Shiki Y, Yamasaki M, et al. Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration Arch Gynecol Obstet, 2009.PMID 19263062
20. [20]Wilson A, Truchanowicz EG, Elmoghazy D, et al. Symphysiotomy for obstructed labour: a systematic review and meta-analysis BJOG, 2016.PMID 27126671