Episode Summary:

Podcast: The OB/GYN Resident Survival Guide
Host: Dr. KC Miller
Episode #13: How to Identify & Manage a Shoulder Dystocia (and the largest baby I've ever delivered)
Date: May 24, 2025

Main Theme

Dr. KC Miller provides a practical, step-by-step guide for OB/GYN residents and medical students on how to identify and manage shoulder dystocia, including the clinical pearls for recognition, intervention maneuvers, and lessons from personal real-world experience—highlighted by the story of delivering an 11 lb 4 oz baby. The episode aims to demystify this obstetric emergency, offer actionable insights, and prepare listeners for both exams and the realities of clinical practice.

Key Discussion Points & Insights

1. Definition and Epidemiology of Shoulder Dystocia

• Definition:
  “A shoulder dystocia is defined as the failure to deliver the fetal shoulder or shoulders with gentle downward traction on fetal head, requiring additional obstetric maneuvers to affect delivery.” (01:23)
• Incidence:
  • Occurs in 0.2–3% of vertex deliveries
  • Recurrence rate: 1–16%, most commonly ≥10%
• Clinical Note:
  • True recurrence and incidence are underestimated since patients with history or complications may choose cesarean for subsequent pregnancies.

2. Risk Factors

• Primary risk factors:
  • Maternal diabetes
  • Suspected fetal macrosomia
• Clinical Pearl:
  • “The majority of shoulder dystocias occur in non diabetic patients with normal sized babies, so it's generally unpredictable and unpreventable.” (02:12)

3. ACOG Recommendations for Cesarean Delivery

• Offer elective cesarean to:
  1. Diabetic patients with EFW ≥ 4,500g
  2. Non-diabetic patients with EFW ≥ 5,000g
     (02:47)

4. Diagnosis/Recognition of Shoulder Dystocia

• Key moment:
  • Head delivers and restitutes (rotates externally), but shoulder(s) don’t deliver with gentle traction.
• Practical note for interns:
  • “You are not likely going to be the one that calls the dystocia because typically if the senior… sees that you're struggling, they will step in to assess…” (03:49)

5. Management Steps: Practical Pearls

• First Actions:
  1. Announce “shoulder dystocia” to the room.
  2. Ask someone to start a timer.
  3. Instruct the patient to stop pushing.
     (04:15)
• Rationale:
  • Duration tracking is critical for documentation and management.

The Seven Primary Maneuvers

(Techniques are described with progressive invasiveness.)

1. McRoberts Maneuver (04:51)
   • Hyperflex maternal thighs onto abdomen to tilt pelvis.
2. Suprapubic Pressure (Can be done alongside McRoberts)
   • Directed lateral pressure to fetal anterior shoulder.
   • “The direction should be whichever way the head restituted.” (05:17)
3. Posterior Arm Delivery
   • Insert hand, grasp fetal posterior arm, gently flex and sweep it out.
   • Episiotomy can be considered for space.
4. Rubin Maneuver (06:23)
   • Apply pressure to posterior shoulder's back, rotating towards face.
5. Wood Screw Maneuver
   • Pressure on anterior surface of posterior shoulder, rotating away from face.
6. Axillary Sling
   • Loop a soft catheter (size 12 or 14 French) under posterior arm, apply traction.
7. Gaskin (All Fours) Maneuver (07:16)
   • Only feasible without epidural anesthesia; patient on hands and knees for traction attempts.

If All Else Fails: Last Resort Maneuvers

• Repeat primary maneuvers if necessary (07:44)
• Clavicle Fracture:
  • Intentional, decreases bisacromial diameter.
• Zavanelli Maneuver:
  • Cephalic replacement (push head back in), emergent C-section
  • “High morbidity, high mortality” (08:31)
• Abdominal Rescue:
  • Emergent laparotomy, hysterotomy, dislodge shoulder from above.

6. Real-World Application: A Personal Case Study

(Timestamp: 08:53–11:45)

• Dr. Miller recounts assisting/delivering nearly two dozen shoulder dystocias.
• Largest baby delivered vaginally: 11 lb 4 oz (5,140g)
  • “Documented EFW was only 3,900 grams. However, she was also very obese, so I suspect those measurements were very limited due to her habitus, which does happen.” (09:13)
• Preparation Tips:
  • Pre-label high-risk cases in sign-out.
  • Position patient at edge of bed.
  • Step stools ready for immediate maneuvers.
  • Use location landmarks (e.g., “to the window or to the door”) instead of right/left for suprapubic pressure to avoid confusion.

Rapid Maneuver Cycling

• Try maneuvers in 10–15 second intervals due to time sensitivity.
• “From personal experience, I've actually found that delivering the posterior arm is a lot harder than performing Wood screw and Ruben maneuvers.” (11:46)
• Posterior sling rare; communication breakdown in real-world scenario can delay attempts.

Notable Quotes & Memorable Moments

• On recognizing unpredictable cases:
  “The majority of shoulder dystocias will occur in non diabetic patients with normal sized infants.” (12:37)
• On real-world urgency:
  “I'm not spending more than 10 to 15 seconds on one maneuver because getting this baby out as quickly as possible is essential.” (11:31)
• Practical tip for team communication:
  “I find that saying right or left can be confusing sometimes...so landmarks are just a little bit easier to work with.” (10:53)
• On delivering the largest baby:
  “The largest baby that I delivered vaginally that unsurprisingly had a shoulder Dystocia was 11 pounds and 4 ounces.” (08:53)
• On never wanting to use last-resort options:
  “The next two options, I truly hope that I will never have to perform and that you will never have to perform these due to the associated high morbidity and mortality for the fetus.” (08:18)

Important Timestamps

• 01:23 — Definition & Incidence of Shoulder Dystocia
• 02:50 — ACOG Recommendations for Elective Cesarean
• 03:09 — How to Recognize/Call Shoulder Dystocia
• 04:15 — Initial Management Steps (Call it out, timers, and instruct patient)
• 04:51–07:37 — The Seven Maneuvers (Step-by-step)
• 08:53 — Personal Experience: Delivering an 11 lb 4 oz Baby
• 10:53 — Communication Tip: Use Landmarks
• 11:46 — Technical Pearls: Posterior Arm Delivery Challenges
• 12:32 — Recap of the Episode

Episode Recap

• Definition: Failure of fetal shoulders to deliver with gentle downward traction due to impaction
• Risk factors: Diabetes, macrosomia—but most cases are unpredictable
• ACOG surgical threshold: Diabetics ≥4500g, non-diabetics ≥5000g
• Management: Call it, stop pushing, try up to seven maneuvers (McRoberts, Suprapubic Pressure, Posterior Arm, Rubin, Woodscrew, Axillary Sling, Gaskin), repeat if necessary
• Last Resort: Clavicular fracture, Zavanelli maneuver, abdominal rescue
• Clinical Pearls: Preparation is key for high-risk cases; communication and efficiency save lives

References and resources linked in show notes. For more tips, guides, and learning resources, visit drkcmiller.com.