An Objective Definition of Shoulder Dystocia:
Prolonged Head-to-Body Delivery Intervals
and/or the Use of Ancillary Obstetric
Maneuvers
C. Y. SPONG, MD, M. BEALL, MD, D. RODRIGUES, MD, AND M. G. ROSS, MD
Objective: To generate an objective definition of shoulder
dystocia by timing the events of the second and third stages
of labor, and to define the true incidence of shoulder
dystocia.
Methods: In 34 arbitrarily selected 24-hour time periods, a
nonparticipating observer prospectively timed intervals of
the second stage of labor in all vaginal deliveries and
recorded the use of obstetric maneuvers (McRoberts, episiot-
omy after delivery of the fetal head, intentional extension of
initial episiotomy after delivery of the fetal head, suprapu-
bic pressure, posterior arm rotation to an oblique angle,
rotation of the infant by 180 , delivery of the posterior arm,
and general anesthesia) and whether the obstetric attendant
identified a delivery with shoulder dystocia. All data are
reported as mean --- standard error of the mean.
Results: Two hundred fifty deliveries were timed and
recorded prospectively. Mean intervals (in seconds) in non-
maneuver patients were as follows: head to anterior shoul-
der 14.8 1.0, anterior to posterior shoulder 3.9 + 0.6,
posterior shoulder to body 5.4 0.8, and total head-to-body
time 24.2 1.3. Three groups of patients were defined after
delivery. The maneuver group consisted of 27 patients
requiting any of the aforementioned obstetric maneuvers,
although the obstetric attendant identified only 16 of these
as shoulder dystocia. The prolonged delivery group in-
cluded 29 patients with the head-to-body delivery interval
exceeding the mean plus two standard deviations (60 sec-
onds) of nonmaneuver patients. Sixteen of the 27 maneuver
patients were identified as prolonged. The 210 not identified
as maneuver or prolonged were considered to be normal.
Normal patients had a significantly lower newborn birth
weight (3269 + 38 g), and a lower proportion of 1-minute
Apgar scores of 7 or less (11%) than did the maneuver (4247
86 g, 41%) and prolonged groups (3952 118 g, 34%).
From the Department of Obstetrics alut Gynecology, Harbor-UCLA
Medical Center, Torrance, California.
We would like to ackuowledi~e the technical support of the Perinatal
Clinical Research Nurses ~unded in part by GCRC grant MO1-
RR00425, National Centers tor Research Resources, National Institutes
of Health.
VOL. 86, NO. 3, SEPTEMBER 1995
Defining shoulder dystocia as a prolonged head-to-body
delivery time and/or the use of obstetric maneuvers identi-
fied 40 patients who had birth weights and 1-minute Apgar
scores significantly different from the normal patients.
Conclusion: The incidence of shoulder dystocia, as defined
by the use of ancillary obstetric maneuvers, is higher than
that reported previously, and the reporting of shoulder
dystocia appears to be unreliable. The interval from head-
to-body delivery is delayed significantly in patients with
shoulder dystocia, despite the lack of recognition of shoul-
der dystocia. We propose defining shoulder dystocia as a
prolonged head-to-body delivery time (eg, more than 60
seconds) or the need for ancillary obstetric maneuvers.
(Obstet Gynecol 1995;86:433-6)
S h o u l d e r dystocia is r e c o g n i z e d as a major c o m p l i c a t i o n
in obstetrics and has a r e p o r t e d infant m o r t a l i t y rate
r a n g i n g f r o m 21-290 per 1000.1 A l t h o u g h the stated
incidence is 0.2% of cases, 2 clinical o b s e r v a t i o n suggests
that m a n y m o r e patients are m a n a g e d as s h o u l d e r
dystocia.
S h o u l d e r dystocia is defined as those deliveries re-
q u i r i n g m a n e u v e r s in a d d i t i o n to gentle d o w n w a r d
traction on the fetal head for d e l i v e r y of the shoulders. 3
Research has focused on elucidating risk factors, includ-
ing m a c r o s o m i a , obesity, diabetes, m i d p e l v i c o p e r a t i v e
delivery, and p r o l o n g e d second stage of labor. 4's O t h e r
reports h a v e identified specific obstetric m a n e u v e r s that
are helpful in delivery, i n c l u d i n g McRoberts m a n e u -
ver, 5 s u p r a p u b i c pressure, 6 rotation of the s h o u l d e r
girdle, 7 d e l i v e r y of the posterior arm, 6 Zavanelli ma-
n e u v e r , s and deliberate fracture of the clavicle. 6
In deliveries in w h i c h s h o u l d e r dystocia is antici-
pated, one or m o r e of these m a n e u v e r s m a y be u s e d
prophylactically, and often no diagnosis of s h o u l d e r
dystocia is recorded. In other cases, one or t w o m a n e u -
vers are used w i t h rapid r e s o l u t i o n of s h o u l d e r dystocia
0029-7844/95/$9.50 433
SSDI 0029-7844(95)00188-W
a n d excellent outcome, and the d i a g n o s i s is not identi- Table 1. Comparison of Patients Who Did and Did Not
fied. The r e p o r t e d incidence of s h o u l d e r d y s t o c i a m a y Require Ancillary Obstetric Maneuvers for
Delivery
therefore be s k e w e d t o w a r d patients w i t h p o o r out-
comes, artificially e l e v a t i n g the associated m o r b i d i t y . Maneuvers No maneuvers
Thus, a m o r e objective definition of s h o u l d e r dystocia is 0l - 27) 0l ~ 223) P
necessary. Gestational age (wk) 39.6 0.3 39.2 - 0.2 NS
A l t h o u g h p r o l o n g e d length of the second stage of Maternal age (y) 28.6 ~ 1.1 24.7 +_0.4 <.005
Graviditv 4.l +- 0.5 2.7 + 0.1 <.001
l a b o r has been associated w i t h an increased incidence of
Parity 2.4 0.4 1.4 0.1 <.001
s h o u l d e r d y s t o c i a (as defined earlier), we p o s t u l a t e d Crowning to head (sec) 207.1 + 41.0 133.7 + 12.4 NS
that s e c o n d - s t a g e events b e g i n n i n g with d e l i v e r y of the Anterior shoulder (sec) 61.6 + 18.3 14.8 + 1.0 <.01
fetal h e a d m a y be a better indication of s h o u l d e r Posterior shoulder (sec) 9.0 + 2.8 3.9 -+ 0.6 NS
dystocia. To o u r k n o w l e d g e , no p r e v i o u s s t u d y has Body (sec) 11.9 2.5 5.4 = 0.8 <.05
Total time (sec) (delivery 82.6 + 21.5 24.2 + 1.3 <.05
e v a l u a t e d the time intervals for s e c o n d - s t a g e events and
of head to bodv)
related these to infant outcomes. This research was Placenta (sec) 490.9 - 67.(/ 575.8 47.3 NS
u n d e r t a k e n to collect d a t a on the t i m i n g of the events of Birth weight (g) 4247 + 86 3284 + 37 <.001
n o r m a l delivery, a n d to d e v e l o p an objective definition l-rain Apgar --<7 11 (41~) 25 (I1%) <.05
of s h o u l d e r dystocia. 5-rain Apgar -<7 1 (49;) 5 (2%) NS
NS not significant.
Data are presented as mean standard error of the rnean or n (%).
Materials and Methods
The s t u d y w a s p e r f o r m e d at H a r b o r - U C L A Medical
Center in Torrance, California. In 34 arbitrarily selected weight, sex, A p g a r scores, a d m i s s i o n to the special care
24-hour intervals, a n o n p a r t i c i p a t i n g o b s e r v e r prospec- nursery, and length of hospital stay. All d a t a are re-
tively timed intervals of the second stage in all vaginal p o r t e d as m e a n + s t a n d a r d error of the mean. Statistical
deliveries a n d r e c o r d e d the use of obstetric m a n e u v e r s . tests i n c l u d e S t u d e n t t test, ~ , a n d Fisher exact test
The following p r e n a t a l data w e r e collected: g r a v i d i t y , w h e n a p p r o p r i a t e . The Bonferroni correction of P val-
p a r i t y , p r e v i o u s n u m b e r of v a g i n a l deliveries, largest ues was u s e d for m u l t i p l e c o m p a r i s o n s of time inter-
p r e v i o u s infant d e l i v e r e d vaginally, n u m b e r of cesarean vals. A corrected P v a l u e of -<.05 w a s a c c e p t e d as
deliveries, a n d indications for cesarean. Labor d a t a statistically significant.
i n c l u d e d labor analgesia a n d anesthesia (none, sys-
temic, or regional) a n d time the cervix took to b e c a m e
c o m p l e t e l y dilated. D u r i n g labor, no fetus was esti-
Results
m a t e d to w e i g h m o r e than 4500 g and no fetus of a T w o h u n d r e d fifty deliveries w e r e t i m e d a n d r e c o r d e d .
diabetic m o t h e r was e s t i m a t e d to w e i g h m o r e than A l t h o u g h a n c i l l a r y obstetric m a n e u v e r s ( m a n e u v e r
4000 g b e c a u s e these patients were offered elective g r o u p ) w e r e u s e d in 27 (10.8%) deliveries, s h o u l d e r
cesarean delivery. d y s t o c i a was r e c o g n i z e d and r e c o r d e d b y the obstetric
Second-stage t i m i n g intervals w e r e from c r o w n i n g of a t t e n d a n t in o n l y 16 of these cases. G e s t a t i o n a l age w a s
the h e a d (the a p p e a r a n c e of the fetal scalp at the not different b e t w e e n the m a n e u v e r a n d n o n m a n e u v e r
introitus b e t w e e n pushes) to d e l i v e r y of head, suction- patients, a l t h o u g h m a t e r n a l age, g r a v i d i t y , a n d p a r i t y
ing of nose or m o u t h , d e l i v e r y of anterior s h o u l d e r , increased significantly in the m a n e u v e r g r o u p (Table 1).
d e l i v e r y of p o s t e r i o r s h o u l d e r , c o m p l e t i o n of d e l i v e r y Five of these 27 deliveries (19%) h a d no p r e v i o u s
of b o d y , a n d d e l i v e r y of placenta. Recorded obstetric vaginal deliveries (four n u l l i p a r o u s , one p r i o r cesare-
m a n e u v e r s include McRoberts (maternal flexion of the an). Eighty-four of the 223 n o n m a n e u v e r deliveries
hips), either intentional extension of e p i s i o t o m y inci- (38%) had no prior v a g i n a l deliveries (76 w e r e n u l l i p a -
sion after d e l i v e r y of fetal head or initial e p i s i o t o m y rous, eight h a d p r i o r cesareans). Indications for p r i o r
after d e l i v e r y of the fetal head, s u p r a p u b i c pressure, cesareans i n c l u d e d failure to progress, a b n o r m a l fetal
rotation of the p o s t e r i o r arm to an oblique angle, lie, n o n r e a s s u r i n g fetal h e a r t rate tracings, m a c r o s o m i a ,
rotation of the infant 180 ( W o o d s screw" m a n e u v e r ) , a n d placenta previa. N o n e of the m a n e u v e r patients
d e l i v e r y of the p o s t e r i o r arm, and the use of general had p r i o r cesarean deliveries for m a c r o s o m i a . Patients
anesthesia. The presence of anesthesia or p e d i a t r i c r e q u i r i n g m a n e u v e r s had significantly l o n g e r d u r a t i o n s
practitioners at the d e l i v e r y was recorded. Deliveries of s e c o n d - s t a g e events, h e a v i e r birth weights, a n d
c o n s i d e r e d by the p a r t i c i p a t i n g p h y s i c i a n s to be com- lower 1-minute A p g a r scores c o m p a r e d w i t h those not
plicated b y s h o u l d e r dystocia w e r e also noted. r e q u i r i n g m a n e u v e r s (Table 11.
The following d e l i v e r y data were collected: fetal McRoberts m a n e u v e r w a s u s e d in 22 (81%) of the

434 Spong et al Dystocia Obstetrics & Gynecology

Table 2. Head to Body Delivery Intervals 7 in those with s h o u l d e r dystocia were also significantly
>60 seconds <60 seconds different from n o r m a l patients (Table 3). A m o n g the
(n 29) fi~ 221) P s h o u l d e r dystocia g r o u p , there w e r e s i g n i f i c a n t l y
Gestational age (wk) 39.8 * 0.3 39.1 -+ 0.2 NS longer intervals for delivery of the anterior shoulder,
Maternal age (y) 26.5 + 1.0 24.8 * 0.4 NS posterior shoulder, body, a n d total time from delivery
Gravidity 3.1 * 0.4 2.8 + 0.1 NS of the head to b o d y (Table 3). The frequency of use of
Parity 1.8 + 0.3 1.5 -+ 0.1 NS forceps a n d v a c u u m extractor were not significantly
Birth weight (g) 3952 - 118 3319 + 39 <.001 different. Five patients in the s h o u l d e r dystocia g r o u p
1-min Apgar <-7 I0 (34~,~) 25 (11~) <.05
5-min Apgar <7 1 (3(A) 5 (2q4) NS (12.5%) a n d 20 n o r m a l patients (10%) had operative
vaginal deliveries. A d m i s s i o n to the special care n u r s -
NS not significant.
Data are presented as mean - standard error of the mean or ~l (9;). ery was not significantly different b e t w e e n the two (10
versus 12%, respectively). N e o n a t a l m o r b i d i t y was not
significantly different b e t w e e n the groups, a l t h o u g h
m a n e u v e r deliveries. Extension of the episiotomy inci- there was one fractured clavicle in the s h o u l d e r dysto-
sion occurred in nine (33q7,) w o m e n in the m a n e u v e r cia group.
group, s u p r a p u b i c pressure in 14 (52~7~,),rotation of the In c o m p a r i n g 169 patients with a n d 81 patients with-
posterior s h o u l d e r in five (19%), rotation of 180 in four out previous vaginal delivery, the time from c r o w n i n g
(15%), delivery of the posterior arm in three (11~4), and (the fetal scalp b e i n g visible at the introitus w i t h o u t
the use of general anesthesia in one (4~). The average p a r t i n g the labia) to delivery of the head was signifi-
n u m b e r of m a n e u v e r s per delivery was two (range one cantly longer in those w i t h o u t a previous vaginal deliv-
to seven). Twelve (44~) of the deliveries required one ery (190.0 22.1 versus 111.9 13.3 seconds, P < .05).
m a n e u v e r , seven (26%) used two, and eight (30~Y~) No significant differences in h e a d - t o - b o d y delivery in-
required three or more m a n e u v e r s for delivery. terval or all other t i m i n g intervals were noted.
In patients w h o did not require m a n e u v e r s for deliv-
ery, the time from delivery of the head to delivery of the
Discussion
b o d y averaged 24.2 seconds (Table 11. A p r o l o n g e d
h e a d - t o - b o d y delivery interval was defined as the m e a n Shoulder dystocia is reported to have significant mor-
plus two s t a n d a r d deviations (SD) in these patients (60 bidity a n d mortality. 9 Complications, i n c l u d i n g bra-
seconds). There were 29 patients defined as prolonged chial plexus n e r v e d a m a g e a n d paralysis, are k n o w n to
(more than 60 seconds). C o m p a r e d with patients with occur with s h o u l d e r dystocia a n d are considered a
head to b o d y delivery times u n d e r 60 seconds, the c o m m o n outcome. With an objective definition, the
prolonged patients d e m o n s t r a t e d significantly greater occurrence of s h o u l d e r dystocia is more frequent t h a n
birth weights (3952 _+ 118 g) a n d low 1-minute A p g a r reported. We hypothesize that the delivery of a n o n -
scores (34~), although they were d e m o g r a p h i c a l l y sim- d a m a g e d infant with the aid of m a n e u v e r s is a good
ilar (Table 2). Sixteen of the 29 p r o l o n g e d patients o u t c o m e and frequently m a y not be recorded as a
required obstetric m a n e u v e r s .
N o r m a l patients (n = 210) were those not identified
as b e l o n g i n g in the m a n e u v e r or p r o l o n g e d groups. The Table 3. Comparison of Shoulder Dystocia and Normal
Deliveries
s p o n t a n e o u s use of hip flexion before delivery of the
fetal head (similar to McRoberts m a n e u v e r ) was not Shoulder Dystocia Normal
(n 40) (n = 2101 P
i n c l u d e d as a m a n e u v e r for the definition of s h o u l d e r
dystocia; it occurred in nine (4%) of the n o r m a l deliv- Gestational age (wk) 39.7 + 0.3 39.1 -+ 0.2 NS
eries. As expected, n o r m a l patients had a significantly Maternal age (y) 26.9 + 0.9 24.7 + 0.4 (.05
Gravidity 3.4 -+ 0.4 2.7 - 0.1 (.05
lower n e w b o r n weight (3270 _+ 38 g) a n d a lower
Parity 2.0 + 0.3 1.4 + 0.1 <.05
p r o p o r t i o n of 1-minute A p g a r scores less than 7 (11'~) Crowning to head (sec) 217.9 + 42.8 127.0 + 11.6 (.05
than did either the m a n e u v e r or p r o l o n g e d groups. Anterk~r shoulder (sec) 55.3 + 11.8 12.9 -+ 0.8 (.01
Defining the s h o u l d e r dystocia g r o u p as those h a v i n g Posterior shoulder (sec) 9.0 -+ 1.8 3.6 0.6 <.05
deliveries with p r o l o n g e d head-to-body delivery inter- Body (sec) 14.6 + 2.4 4.5 0.7 <.01
Total time (sec) (delivery 78.8 -+ 13.7 21.0 1.0 <.01
vals a n d / o r the need for m a n e u v e r s identified 40 pa-
of head to body)
tients. Gestational age was not significantly different Placenta (sec) 484.1 -+ 57.2 579.6 -~ 50.4 NS
b e t w e e n s h o u l d e r dystocia a n d n o r m a l delivery, al- Birth weight (g) 4020 -+ 89 3269 - 38 <.001
t h o u g h m a t e r n a l age, gravidity, and parity were signif- l-rain Apgar <7 12 (30~,~) 24 (11%) <.05
icantly higher in the s h o u l d e r dystocia patients. New- 5-rain Apgar <7 1 (2.5%) 5 (2%) NS
b o r n birth weights and l - m i n u t e A p g a r scores less than NS not significant.

VOL. 86, NO. 3, SEPTEMBER 19o5 Spong et al Dystocia 435

shoulder dystocia. Nearly half of the deliveries requir-
ing obstetric m a n e u v e r s in this study were not recorded
as a shoulder dystocia by the delivery attendants.
In addition to those requiring m a n e u v e r s for deliv-
ery, patients w h o experience a prolonged time from
delivery of the head to b o d y m a y also be at risk for
complications associated with shoulder dystocia. In our
data set, these patients had an increased incidence of
low 1-minute A p g a r scores. Notably, 13 of the 29
patients with prolonged head-to-body intervals did not
have obstetric maneuvers. It is possible that obstetri-
cians m a y hesitate to use these m a n e u v e r s to avoid
d e s i g n a t i n g deliveries as s h o u l d e r dystocia. An alter-
native explanation, that deliveries were slower w h e n
performed by certain classes of practitioners (ie, nurse-
midwives), was not supported by our study (data not
shown). Earlier interventions with the use of m a n e u v e r s
m a y improve n e w b o r n outcome.
All timed fetal delivery intervals were significantly
prolonged in deliveries requiring maneuvers. The inter-
val for placental delivery was not different between
groups, emphasizing that the prolonged intervals are
likely due to the dystocia and not to an intrinsic abnor-
mality of the mother or maternal expulsion efforts. Simi-
larly, patients with previous vaginal deliveries did not
have shorter time intervals after delivery of the fetal
head. A significant increase in fetal weight was noted in
the patients requiring m a n e u v e r s for delivery, with the
average infant birth weight greater than 4 kg. Unfortu-
nately, despite the need for maneuvers, these patients
m a y not be classified as having shoulder dystocia, as
evidenced by the recording of shoulder dystocia in only
67% of these patients. In view of the prolonged duration
of the second-stage events in patients requiring maneu-
vers, it is likely that w o m e n with prolonged second-
stage delivery intervals (from delivery of the head), in
the absence of maneuvers, also represent an at-risk
group. The increased birth weight and incidence of low
1-minute A p g a r scores is consistent with this hypothe-
sis. Maternal age, gravidity, and parity increased sig-
nificantly in the shoulder dystocia group, consistent
with previously demonstrated increased n e w b o r n birth
weight with subsequent pregnancies.
A l t h o u g h each of the defined delivery intervals was
prolonged in the m a n e u v e r group, the greatest differ-
ence was the total head to b o d y delivery time. This
interval is easily timed and the mean plus two-SD value
of 60 seconds conveniently describes the normal range.
We propose defining shoulder dystocia as patients with
a prolonged head-to-body time interval or the use of
ancillary obstetric maneuvers. Further study is needed
to confirm the prolonged value of 60 seconds.
436 Spong et al Dystocia
Despite the significant association in the literature of
neonatal m o r b i d i t y and mortality associated with
shoulder dystocia, our study population sustained only
one significant injury, a fractured clavicle. In addition,
there were no significant differences in the incidence of
5-minute A p g a r scores of 7 or less. In part, the high
morbidity noted previously m a y result from skewed
reporting of poor outcomes.
In conclusion, the incidence of shoulder dystocia is
more c o m m o n , although the incidence of associated
neonatal morbidity m a y be less than that reported
previously. The diagnosis of shoulder dystocia should
be m a d e based on objective criteria to avoid selectively
recording shoulder dystocia in the presence of excessive
m a n e u v e r s or adverse outcomes. We propose that
head-to-body delivery intervals be recorded for all
deliveries and suggest that shoulder dystocia be de-
fined as a prolonged head-to-body delivery time (eg,
more than 60 seconds) a n d / o r the necessitated use of
ancillary obstetric maneuvers.
References
1. Benedetti TJ, Gabbe SG. Shoulder dystocia: A complication of fetal
macrosomia and prolonged second stage of labor with midpelvic
delivery. Obstet Gynecol 1978;52:526-9.
2. Gross SJ, Shime J, Farine D. Shoulder dystocia: Predictors and
outcome. Am J Obstet Gynecol 1987;156:334-6.
3. Resnik R. Management of shoulder girdle dystocia. Clin Obstet
Gynecol 1980;23:559-64.
4. Lee CY. Shoulder dystocia. Clin Obstet GynecoI 1987;30:77-82.
5. Gonik B, Stringer CA, Held B. An alternate maneuver for manage-
ment ot shoulder dystocia. Am J Obstet Gynecol 1983;145:882-4.
6. Harris BA. Shoulder dystocia. Clin Obstet GynecoI 1984;27:106-11.
7. Woods CE. A principle of physics as applicable to shoulder deliv-
ery. Am J Obstet Gynecol 1943;45:796-804.
8. Sandberg EC. The Zavanelli maneuver: A potentially revolutionary
method for the resolution of shoulder dystocia. Am J Obstet
Gynecol 1985;152:479-84.
9. Langer O, Berkus MD, Huff RW, Samueloff A. Shoulder dystocia:
Should the fetus weighing greater than or equal to 4000 grams be
delivered by cesarean section? Am J Obstet Gyneco11991;165:831-7.
Address reprint requests to:
Marie H. Beall, MD
Harbor-UCLA Medical Center
Department of Obstetrics & Gynecology, Box 3
1000 West Carson Street
Torrance, CA 90509-2910
Received December 30, 1994.
Received in revised .form May 5, 1995.
Accepted June 8, 1995.
Copyright 1995 by The American College of Obstetricians and
Gynecologists.
Obstetrics & Gynecology