Shoulder Dystocia. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/098, 10/2024)

Abstract

Purpose This is an official guideline of the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG), the Austrian Society for Gynecology and Obstetrics (Österreichische Gesellschaft für Gynäkologie und Geburtshilfe, ÖGGG) and the Swiss Society for Gynecology and Obstetrics (Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe, SGGG). Shoulder dystocia is a rare but feared obstetric complication with potentially far-reaching medical consequences for mother and child. The purpose of this guideline is to standardize the processes which provide individual obstetric solutions for shoulder dystocia in accordance with current scientific knowledge and current clinical practice. The aim is also to emphasize that no matter how good the medical care, shoulder dystocia and its associated complications cannot be entirely prevented and are not fully controllable.

Methods Representative members from different medical specialties were commissioned by the guidelines programm of the DGGG, OEGGG and SGGG to develop this S2k-guideline using a structured consensus process.

Recommendations The guideline provides recommendations about the definition, diagnosis, epidemiology, risk factors and prevention, logistics, and measures to treat shoulder dystocia including an algorithm for action, and the associated complications, documentation requirements, debriefing, forensic aspects, education, training and simulation as well as follow-up discussions on the shoulder dystocia event.

Keywords

guideline - shoulder dystocia - prevention - McRoberts maneuver - Gaskin maneuver - arm extraction - internal rotation - first-line maneuver - second-line maneuver - last resort maneuver - algorithm - obstetric emergency - brachial plexus injury - fracture

I  Guideline Information

Guidelines program of the DGGG, OEGGG and SGGG

More information on the program is available at the end of the guideline.

Citation format

Shoulder Dystocia. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/098, 10/2024). Geburtsh Frauenheilk 2025; 85: 169–189

Guideline documents

The complete German-language long version of this guideline together with a list of the conflicts of interest of all the authors is available on the homepage of the AWMF: https://register.awmf.org/de/leitlinien/detail/015-098

Guideline authors

See [Tables 1] and [2].

Author	AWMF professional society
Abele Harald, Prof. Dr. med.	DGGG
Jakubowski Peter, Dr. med.	DGGG

Abele Harald, Prof. Dr. med.	DGGG (AGG)
Bamberg Christian, Prof. Dr. med.	DEGUM
Bogner Gerhard, PD Dr. med.	OEGGG
Fazelnia Claudius, Dr. med.	OEGGG
Hamza Amr Sherif, PD Dr. med.	DEGUM
Heihoff-Klose Anne, Dr. med.	DGPGM
Jakubowski Peter, Dr. med.	DGGG
Janning Luise, B. Sc.	DGHWI
Jückstock Julia, PD Dr. med.	DGGG (AGG)
Kimmich Nina, PD Dr. med.	SGGG
Köbke Andrea	DHV
Kyvernitakis Ioannis, Prof. Dr. med.	DGPM
Lütje Wolf, Dr. med.	DGPFG
Reister Frank, Prof. Dr. med.	DGPM
Reitter Anke, PD Dr. med.	DGGG (AGG)
Seeger Sven, Dr. med.	DGPGM
Seehafer Peggy, M. A.	DGHWI
Springer Laila, Prof. Dr. med.	GNPI
Valet Axel, Dr. med.	BVF
Wallwiener Stephanie, Prof. Dr. med.	DGPFG

The following professional societies/working groups/organizations/associations wanted to contribute to the guideline text and nominated representatives to attend the consensus conference.

Abbreviations

AC: abdominal circumference

ACOG: American College of Obstetricians and Gynecologists

aOR: adjusted odds ratio

aRR: absolute risk reduction

AWMF: The Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V.)

BE: base excess

CI: confidence interval

COA: cephalic occiput-anterior position (of fetus)

CTG: cardiotocography

EA: epidural anesthesia

GDM: gestational diabetes

GW: weeks of gestation

HC: head circumference

HPD: head-perineum distance

IQTIG: Institute for Quality Assurance and Transparency in the Healthcare Sector

MLU: midwifery-led unit

OP: occiput position

OPP: occiput-posterior position (of fetus)

OR: odds ratio

PNB: pudendal nerve block

PPH: postpartum hemorrhage

PTSD: post-traumatic stress disorder

RANZCOG: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

RCOG: The Royal College of Obstetricians and Gynaecologists

RR: relative risk

SOGC: The Society of Obstetricians and Gynaecologists of Canada

s/p: status post

WHO: World Health Organization
 

II  Guideline Application

Purpose and objective

Around 1% of all births are complicated by shoulder dystocia. In many cases it is an unforeseeable emergency.

The purpose of the guideline was to develop evidence-based guidelines for the management of such emergencies to avert potential injuries and long-term consequences for the mother and child.

Targeted areas of care

• In-patient care sector

• Ambulatory care sector (births in a home environment or a midwifery-led unit [MLU])

• Short-term in-patient care sector

Target user groups/target audience

The recommendations in this guideline are aimed at gynecologists in private practice, hospital-based gynecologists, neonatologists, and midwives and are intended to provide information to pediatricians, anesthetists, nursing staff and other health professionals providing obstetric care.

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organizations, and associations as well as the boards of the DGGG, SGGG, OEGGG and the DGGG/OEGGG/SGGG Guidelines Commission in October 2024 and was thereby approved in its entirety. This guideline is valid from 1 October 2024 through to 30 September 2029. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated earlier if urgently necessary. Similarly, if the guideline still reflects the current state of knowledge, its period of validity can be extended.

III  Method

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classifed as: S2k

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations of the guideline is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols (see [Table 3]).

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the level of consensus is determined, based on the number of participants (see [Table 4]).

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
−	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

1  Definition/diagnosis

Shoulder dystocia is a rare, unforeseeable obstetric emergency which cannot be completely averted during vaginal delivery. It is an acute failure to progress in labor after delivery of the infant head. Subsequent delivery of the body of the child is delayed.

Obstetrically, there are two variants of shoulder dystocia:

• Anterior shoulder impaction: The shoulders do not enter the oval anterior pelvic arch of the mother. The head is delivered very close to the perineum and retracts again immediately. It remains tightly applied to the vulva. This type of presentation is referred to as the turtle sign. Sometimes, the head may show a slight external rotation to adjust to the impacted anterior shoulder. Compared to impaction of the anterior shoulder on the symphysis pubis, impaction of the posterior shoulder on the sacral promontory is less common. It is not possible to palpate the shoulders in the vagina alongside the head.

• Posterior shoulder impaction: Inadequate rotation of the shoulders when they enter the pelvic inlet which means that the position of the shoulders has not adjusted to the longitudinal oval pelvic outlet, preventing delivery of the infant. External rotation of the head does not occur with posterior shoulder impaction, although in contrast to anterior shoulder impaction, the head does not retract. The shoulders are stuck at the level of the ischial spine. The shoulders may be palpated lateral to the head in the vagina.

Consensus-based recommendation 1.E1
Expert consensus	Level of consensus +++
After the fetal head has been delivered, physiological rotation of the shoulder should not be attempted before the next contraction so as not to induce shoulder dystocia through forced delivery of the child.

Consensus-based statement 1.S1
Expert consensus	Level of consensus +++
A diagnosis of shoulder dystocia is not entirely based on objective criteria but also always includes a subjective component.

Consensus-based statement 1.S2
Expert consensus	Level of consensus +++
In retrospect, the strongest confirmation of a diagnosis of shoulder dystocia is based on the maneuvers required to deliver the child.

The following clinical symptoms may be predictors for shoulder dystocia:

• Difficulties when delivering the face and chin

• The fetal head remains strongly applied to the vulva or even retracts when the uterus retracts (so-called “turtle” sign).

• No external rotation of the head

• No shoulder rotation

2  Epidemiology

There is no uniform definition of shoulder dystocia in the literature. This means that the reported incidence ranges from between 0.2% and 3% of all vaginal births. A study carried out in three Level 1 perinatal centers in Germany found an incidence of 0.9% for the period from 2014 to 2017.

3  Risk factors and prevention

3.1  Risk factors

Despite well-known risk factors, it is not possible to reliably predict shoulder dystocia. As half of the cases with shoulder dystocia occur without known risk factors being present, it must always be reckoned with. [Table 5] lists known factors associated with a higher risk of shoulder dystocia. There is often a connection between risk factors, which may even be causative (e.g., diabetes, obesity, and fetal macrosomia). Shoulder dystocia in a previous birth and fetal macrosomia in the current pregnancy are considered the most important independent risk factors for the occurrence of shoulder dystocia.

Prepartum risks	Intrapartum risks
Status post shoulder dystocia	Protracted dilation
Macrosomia > 4500 g	Failure to progress during labor
Diabetes mellitus	Protracted expulsion
Maternal obesity (BMI ≥ 30 kg/m2)	Use of oxytocin to support labor
Induction of labor	Vaginal-operative delivery
Post-term delivery > 42 + 0 GW	Epidural anesthesia
Multiparity
Fetal head circumference < fetal abdominal circumference and the difference is > 2.5 cm
Maternal height < 160 cm

Consensus-based statement 3.S3
Expert consensus	Level of consensus +++
As shoulder dystocia can occur irrespective of known risk factors, it is important to be aware that this complication can always arise during any vaginal birth.

Consensus-based recommendation 3.E2
Expert consensus	Level of consensus +++
Pregnant women who are status post shoulder dystocia or who are at significant risk of shoulder dystocia and who wish to have a vaginal birth must be advised to give birth in an obstetric center with an affiiated pediatric hospital because of the risk of shoulder dystocia.

Consensus-based recommendation 3.E3
Expert consensus	Level of consensus +++
Pregnant women with a sonographic estimated fetal weight of more than 4250 g should be educated about the increased risk of shoulder dystocia while being aware of measurement uncertainty, especially if the mother is also diabetic. However, any recommendations about the best mode of deliver must be based on the overall obstetric situation.
The SGGG registered a special vote regarding this recommendation.

Consensus-based statement 3.S4
Expert consensus	Level of consensus +++
A diagnosis of infant macrosomia may only be made postpartum. Prepartum, it is only possible to suggest that macrosomia is suspected.

3.2  Prevention

3.2.1  Diabetes/gestational diabetes (GDM)

Consensus-based statement 3.S5
Expert consensus	Level of consensus +++
Adequate therapy of diabetes during pregnancy significantly reduces the risk of shoulder dystocia.

3.2.2  Induction of labor

Consensus-based recommendation 3.E4
Expert consensus	Level of consensus +++
Induction of labor from 37 + 0 GW to prevent shoulder dystocia in pregnant non-diabetic women where there has been a professional assessment of macrosomic fetal growth at the time of measurement is always an individual decision. The decision must be taken based on participatory decision-making which includes all obstetric factors. Inducing labor before 39 + 0 GW must be specially justified.

Consensus-based recommendation 3.E5
Expert consensus	Level of consensus +++
If maternal diabetes is present and the sonographic estimated fetal weight is > 95th percentile, the possible benefits of inducing labor from 37 + 0 GW should be carefully weighed up against the impact of an earlier gestational age at delivery.

The SGGG has registered a special vote on chapter “3.2.2 Induction of labor”.

3.2.3  Primary cesarean section

Consensus-based recommendation 3.E6
Expert consensus	Level of consensus +++
The decision about the hoped-for mode of delivery for a woman at risk for shoulder dystocia is always an individual decision, and it must be arrived at through participatory decision-making. The medical history and current relevant obstetric factors must be considered when deliberating on the decision.

Consensus-based recommendation 3.E7
Expert consensus	Level of consensus +++
Non-diabetic pregnant women must be offered the option to deliver by cesarean section if the estimated fetal weight is 5000 g or above, and diabetic pregnant women must be offered this option when the estimated fetal weight is 4500 g or above.

Consensus-based recommendation 3.E8
Expert consensus	Level of consensus ++
In addition to the estimated fetal weight, a discrepancy between head circumference and abdominal circumference of 2.5 cm and above may increase the risk of shoulder dystocia and should be included in the deliberations about the mode of delivery.

3.2.4  Status post shoulder dystocia

Consensus-based recommendation 3.E9
Expert consensus	Level of consensus +++
Pregnant women who are status post shoulder dystocia must be told that the risk of recurrence is 10 – 15%.

Consensus-based recommendation 3.E10
Expert consensus	Level of consensus ++
Pregnant women who are status post shoulder dystocia must be given firm advice about the mode of delivery.

Consensus-based recommendation 3.E11
Expert consensus	Level of consensus +++
Pregnant women who are status post shoulder dystocia and have an estimated fetal weight of more than 4000 g should be offered a cesarean section as an alternative mode of delivery because of the risk of recurrence.

3.2.5  Vaginal-operative delivery

Consensus-based recommendation 3.E12
Expert consensus	Level of consensus +++
The presence of additional risk factors for shoulder dystocia is not a contraindication for vaginal-operative delivery. But obstetric specialists should be prepared to deal with this complication and discuss the option of having a cesarean section with the parturient as a real alternative if tvaginal-operative delivery is classed as difficult.

3.2.6  Role of ultrasound

Consensus-based statement 3.S6
Expert consensus	Level of consensus +++
During prepartum counselling, medical history and fetal biometry are important when assessing the risk of shoulder dystocia. They are not the sole reasons for deciding on the mode of delivery as the extent of complications during shoulder dystocia (fetal and maternal morbidity and mortality) cannot be properly estimated.

Consensus-based recommendation 3.E13
Expert consensus	Level of consensus +++
Women who are at risk of shoulder dystocia should have fetal biometry around 14 days prior to the due date to create a basis for making an individual decision about the mode of delivery.

Prenatal factors which can indicate a risk of shoulder dystocia were evaluated using the retrospective data of more than 15 000 singleton births in cephalic presentation ≥ 37th GW. The overall prevalence of shoulder dystocia in this study was about 1%, and three significant risk factors were evaluated:

• Estimated fetal weight 14 days prior to delivery at least 4250 g (OR 4.27; p = 0.002)

• Head to abdomen discrepancy (fetal head circumference < fetal abdominal circumference) of at least 2.5 cm (OR 3.96; p = 0.001)

• Any form of maternal diabetes mellitus (OR 2.18; p = 0.009)

The study data were used to develop a risk score for the prediction of shoulder dystocia based on the above-mentioned risk factors. Maternal diabetes was scored as one point, and an estimated fetal weight of 4250 g or above and a discrepancy between head and abdomen of at least 2.5 cm were each scored as two points. The incidence was calculated using the scores, and the number of cesarean sections to prevent shoulder dystocia was also calcaluted (number needed to treat). The results are summarized in [Table 6].

Score	Observed incidence of shoulder dystocia	Number needed to treat
0	0.5% (60/11 336)	189
1	0.9% (16/1764)	110
2	2.1% (38/1809)	48
3	5.4% (18/336)	19
4	10.4% (10/96)	10
5	25% (5/20)	4

The authors concluded that in clinical decision-making, an elective cesarean section should be considered for a score of 4 or 5, especially as practical application of the model, which included monitoring progression, showed that the risk of shoulder dystocia was underestimated when the score was 4 – 5. It must be emphasized, however, that almost 41% of cases with shoulder dystocia in this cohort did not have risk factors.

Consensus-based statement 3.S7
Expert consensus	Level of consensus +++
Prenatal ultrasound is currently the most suitable method to predict fetal macrosomia. The actual birthweight of macrosomic infants tends to be underestimated.

Consensus-based statement 3.S8
Expert consensus	Level of consensus +++
When using sonography to assess fetal macrosomia, it is important to be aware that results can differ significantly depending on the biometry formula used.

4  Logistics

4.1  Planning, management, and implementation of treatment procedures when shoulder dystocia occurs

Consensus-based recommendation 4.E14
Expert consensus	Level of consensus +++
As shoulder dystocia is an emergency which may occur any time, every obstetric facility should have an emergency plan to treat shoulder dystocia.

4.2  Communication – human/technical resources

Consensus-based recommendation 4.E15
Expert consensus	Level of consensus +++
After shoulder dystocia has been diagnosed, the diagnosis must be clearly communicated to all persons involved in the birth.

Consensus-based recommendation 4.E16
Expert consensus	Level of consensus +++
The most experienced obstetric specialist must take over management of the birth after shoulder dystocia has been diagnosed.

Consensus-based recommendation 4.E17
Expert consensus	Level of consensus +++
If possible, other medical specialties (e.g., neonatology, anesthesia, etc.) must be involved in the treatment process, at the latest at the start of a secondary maneuver to deliver the infant.

4.3  Rooms and equipment

There is no ideal equipment or facilities to manage shoulder dystocia. The spatial conditions differ considerably depending on the place of birth. What is required, however, is that the environment is optimized in such a way that the maneuvers required to deliver the infant can be carried out without delay and emergency care can be provided to the infant.

5  Measures to manage shoulder dystocia

5.1  Information provided to the parturient

Consensus-based recommendation 5.E18
Expert consensus	Level of consensus +++
In the event of shoulder dystocia, the parturient must be informed about the emergency that has arisen and the maneuvers that will be required as appropriate to the situation.

5.2  First-line maneuver

A coherent algorithm for the treatment of shoulder dystocia aims to avoid compression injuries which may develop from uncontrolled contractions and intrauterine pressure. The following steps must be an integral part of any treatment algorithm:

1. The emergency is communicated to those present (the parturient is informed, further persons are alerted, etc.).

2. Management of the birth is delegated to the most experienced obstetric specialist present.

3. The parturient is asked to stop pushing and to breathe calmly (to avoid further wedging of the fetal shoulder behind the maternal pelvic inlet before further external or internal maneuvers are carried out).

4. Any ongoing oxytocin infusion must be discontinued.

5. If the parturient is having a water birth, she must leave the birth pool immediately to allow the required maneuvers to be carried out.

6. No form of fundal pressure must be applied.

7. Forced traction of the head or additional external rotation of the infantʼs head must be avoided.

8. The bladder should be emptied (if possible and/or necessary in the situation)

9. The parturient must be positioned according to the planned maneuver and the available aids (birthing bed, mat, etc.)

Consensus-based statement 5.S9
Expert consensus	Level of consensus +++
There is no firm sequence or gradation of first-line maneuvers; they are chosen based on the specific obstetric situation.

It is important to emphasize that shoulder dystocia may arise in very different obstetric situations. There is therefore no classic first-line maneuver. The goal of first-line maneuvers is to use movement to change the relation between the infantʼs shoulder and the motherʼs bony pelvis. During a water birth, for example, as with a Gaskin maneuver, even getting out of the birth pool may lead to a release of the shoulder.

Detailed descriptions and illustrations of first-line maneuvers are available in the long German-language version of the guideline. They include:

• the Gaskin maneuver

• the McRoberts maneuver

• the modified McRoberts maneuver

• suprapubic pressure

• Walcherʼs position

5.2.1  The Gaskin maneuver

Consensus-based statement 5.S10
Expert consensus	Level of consensus +++
The Gaskin maneuver is associated with a high success rate in mobile parturients and only requires one helper.

5.2.2  The classic McRoberts maneuver

Consensus-based recommendation 5.E19
Expert consensus	Level of consensus +++
The classic McRoberts maneuver may be carried out with or without suprapubic pressure.

5.2.3  The modified McRoberts maneuver

Consensus-based statement 5.S11
Expert consensus	Level of consensus +++
Use of a modified McRoberts maneuver is very common in German-speaking countries.

5.2.4  Suprapubic pressure

Consensus-based recommendation 5.E20
Expert consensus	Level of consensus +++
The classic McRoberts maneuver combined with suprapubic pressure has higher success rates than a McRoberts maneuver alone. The addition of suprapubic pressure to the maneuver must be considered, at the latest if the McRoberts maneuver alone has not been successful.

5.2.5  Walcherʼs position

Consensus-based statement 5.S12
Expert consensus	Level of consensus +++
The data on the success rate and benefit of Walcherʼs position are not clear.

5.2.6  Episiotomy

Consensus-based recommendation 5.E21
Expert consensus	Level of consensus +++
Placement or expansion of an existing episiotomy may be considered if shoulder dystocia occurs as this can improve vaginal access when carrying out internal maneuvers and the space is insufficient.

5.3  Second-line maneuver

Consensus-based recommendation 5.E22
Expert consensus	Level of consensus +++
If the posterior shoulder is accessible, the first second-line maneuver should consist of attempted delivery of the posterior shoulder and arm. Otherwise, a rotational maneuver should be attempted.

If the primary maneuvers are unsuccessful, treatment should immediately switch to carrying out one of the second-line maneuvers. Delivery of the posterior shoulder and arm should be carried out in preference to rotational maneuvers due to the higher success rate for posterior shoulder and arm delivery. The success rates for delivery of the posterior shoulder and arm are 72 – 97% and the success rates for internal rotation are 43 – 77%.

Detailed descriptions and illustrations of second-line maneuvers are available in the long German-language version of the guideline. They include:

• Jacquemierʼs maneuver

• Menticoglouʼs maneuver to deliver the posterior shoulder or Cluverʼs posterior axilla sling traction

• shoulder shrug maneuver

• Couderʼs maneuver to free the anterior arm

• the inverse shoehorn maneuver

• the Rubin maneuver

• Woodʼs screw maneuver

• a combination of the Rubin maneuver and Woodʼs maneuver

• the Carit maneuver

• Lövsetʼs maneuver

5.4  Last resort maneuvers

A situation in which the obstetric team is forced to deliver the child using a last resort maneuver is rare (casuistical). It is a particular obstetric challenge and places a heavy emotional burden on all persons involved. At this point, the infantʼs outcome and the extent of maternal morbidity are not clear. There is immense time pressure without the certainty that the situation will be resolved with a good outcome for mother and child after using maneuvers for which there is little experience and evidence in practice. Success depends on utilizing all available resources of staff and equipment.

If the child dies before it can be delivered from the birth canal, the focus must be on reducing maternal morbidity when deciding on the next steps.

Consensus-based recommendation 5.E23
Expert consensus	Level of consensus +++
Intubation sedation with effective muscle relaxation must be used during last resort maneuvers.

Consensus-based recommendation 5.E24
Expert consensus	Level of consensus +++
Last resort maneuvers should begin with an attempt at abdominal rescue, followed by a classic or modified Zavanelli maneuver, if necessary with the addition of cleidotomy. Symphysiotomy is less important.

A detailed description with illustrations of last resort maneuvers is available in the long Geman-language version of the guideline. They include:

• abdominal rescue

• classic and modified Zavanelli maneuver

• breaking the babyʼs clavicle

• symphysiotomy

5.5  Analgesia

Consensus-based statement 5.S13
Expert consensus	Level of consensus +++
In cases with shoulder dystocia, ensuring sufficient maternal analgesia is a fundamental part of delivering the baby, especially during second-line and last resort maneuvers.

5.6  Treatment algorithm

Consensus-based recommendation 5.E25
Expert consensus	Level of consensus +++
Management of shoulder dystocia must follow the algorithm agreed upon in the obstetric facility.

The circumstances of shoulder dystocia vary. An algorithm ([Fig. 1]) on how to manage shoulder dystocia can therefore not provide rigid specifications. What is important is to recognize when an emergency has arisen and to refrain from any forced actions (e.g., uncontrolled traction of the fetal head, etc.). Informing the parturient is important to ensure her cooperation during subsequent procedures. It is important that all communications are clear and that the birth (choice and implementation of maneuvers to overcome shoulder dystocia) is managed by the most experienced specialist present. The attending professionals should employ those maneuvers of which they have the most experience and which offer the greatest chance of success based on the presentation of the baby in the birth canal.

Fig. 1 Algorithm on how to manage shoulder dystocia. [rerif]

6  Complications

6.1  Maternal complications

The management of shoulder dystocia can consist of a number of different maneuvers and measures which may lead to complications for mother and baby.

Consensus-based statement 6.S14
Expert consensus	Level of consensus +++
Shoulder dystocia increases the risk of third and fourth-degree lacerations and postpartum hemorrhage.

Consensus-based recommendation 6.E26
Expert consensus	Level of consensus +++
A vaginal examination must be carried out after any birth complicated by shoulder dystocia to investigate potential perineal lacerations with special consideration given to injuries of the anal sphincter.

6.2  Infant complications

The rate of neonatal complications after shoulder dystocia is about 5 – 10%. Typical complications include:

• Erbʼs palsy, also known as brachial plexus injury (60%)

• Klumpkeʼs palsy (4%)

• clavicle fracture (39%)

• humerus fracture (2%)

• hypoxic-ischemic encephalopathy (HIE) (6%)

• neonatal death (0.0025 – 0.004%)

Neonates may suffer several complications.

Consensus-based recommendation 6.E27
Expert consensus	Level of consensus +++
After shoulder dystocia, the neonateʼs physical condition must be assessed by a specialist trained in the postnatal adaptation of newborns (preferably a pediatrician).

Consensus-based recommendation 6.E28
Expert consensus	Level of consensus +++
If the newborn presents with clinically suspicious symptoms after shoulder dystocia, a pediatrican must carry out an assessment and decide on the appropriate therapy where necessary.

6.2.1  Clavicle and humerus fractures

Consensus-based statement 6.S15
Expert consensus	Level of consensus +++
Direct skin contact, breastfeeding, or the administration of paracetamol are effective methods to reduce neonatal pain after shoulder dystocia (e.g., in cases with clavicle and humerus fractures).

6.2.2  Neonatal asphyxia

Consensus-based recommendation 6.E29
Expert consensus	Level of consensus +++
Because of the potential for neonatal complications in the context of shoulder dystocia, a specialist for the treatment of adaptation disorders and unfavorable neonatal outcomes must be present during the initial care provided to the newborn.

Consensus-based recommendation 6.E30
Expert consensus	Level of consensus +++
The baby must be assessed by a pediatrician if neonatal birth trauma (brachial plexus palsies, fractures, hypoxic ischemic encephalopathy) from shoulder dystocia is suspected.

7  Documentation – debriefing – forensic aspects

7.1  Documentation

Consensus-based recommendation 7.E31
Expert consensus	Level of consensus +++
Deliveries which involved shoulder dystocia must be documented in a manner that is accurate to the minute, exactly reproduces the actions taken, and is comprehensible to expert third parties.

7.2  Debriefing

Consensus-based recommendation 7.E32
Expert consensus	Level of consensus ++
After a shoulder dystocia event, the members of the team involved in managing the delivery should be offered an opportunity for debriefing.

7.3  Forensic aspects

Consensus-based statement 7.S16
Expert consensus	Level of consensus +++
Infant and maternal injuries cannot be entirely avoided even if the maneuvers required to resolve the shoulder dystocia were carried out properly.

Consensus-based statement 7.S17
Expert consensus	Level of consensus +++
The term “difficult delivery of the shoulder” is not defined and must therefore not be used in obstetric practice.

8  Education/training/simulation

Consensus-based recommendation 8.E33
Expert consensus	Level of consensus +++
All specialists involved in obstetric care should attend regular training sessions on the management of shoulder dystocia, ideally as part of a multiprofessional team.

9  Follow-up discussion on shoulder dystocia

Consensus-based recommendation 9.E34
Expert consensus	Level of consensus +++
After the shoulder dystocia event, all persons involved (parents and obstetric specialists) should be offered follow-up discussions and psychological support, if necessary.

The literature on which this guideline is based is available in the long German-language version of the guideline under https://register.awmf.org/de/leitlinien/detail/015-098

Conflict of Interest

The conflicts of interest of all the authors are listed in the long German-language version of the guideline.

Publication History

Received: 28 October 2024

Accepted after revision: 25 November 2024

Article published online:
06 February 2025