Shoulder dystocia: Clarifying the care of an old problem
Should maternal pushing stop once dystocia is diagnosed? Here’s light on the standard of care.
Confusion doesn’t end there
In its section on shoulder dystocia, ACOG’s publication Precis (1998) states:
Management of shoulder dystocia involves both anticipation of and preparation for problems. The key to preventing fetal injury is avoidance of excess traction on the fetal head. When shoulder dystocia is diagnosed, a deliberate and planned sequence of events should be initiated. Pushing should be halted and obstructive causes should be considered. Aggressive fundal pressure or continued pushing will only further impact the anterior shoulder.
We are left with the paradox that the current edition of Williams Obstetrics, in its discussion of shoulder dystocia, carries a statement recommending maternal pushing based on a 1994 ACOG document—a statement that subsequent ACOG documents no longer contain. In fact, one of those documents—Precis—tells us that pushing should be halted, an instruction supported by the mathematical modeling of Gonik and colleagues.2 And a popular online text (UpToDate.com) advises: “The mother should be told not to push during attempts to reposition the fetus.”8 Once the fetus is successfully repositioned, maternal pushing or traction, or both, can be reinstated.
Putting it all into clinical perspective
The current ACOG practice bulletin on shoulder dystocia (no. 40 from November 2002) observes that “retraction of the delivered fetal head against the maternal perineum (turtle sign) may be present and may assist in the diagnosis of shoulder dystocia.” When present, the turtle sign strongly suggests that the anterior shoulder is already impacted against the symphysis pubis. Maternal expulsive forces may have already put enough pressure on the nerve roots of the brachial plexus to cause damage. Any degree of traction or continued maternal pushing is likely to compound an already potentially serious problem.
In such cases, it is prudent to resort to known maneuvers, avoid encouraging continued maternal pushing, and simply support and guide the head without supplying any real traction.
When the turtle sign is absent, shoulder dystocia can be diagnosed only after the head is delivered, when the usual methods (ie, downward traction and continued maternal pushing) fail to advance delivery. Diagnosis in these cases requires recognition on the part of the delivering physician that shoulder dystocia is present. At that point, continued expulsive force and any real degree of traction no longer are appropriate.
