Ep 223: What You Need To Know About Shoulder Dystocia

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Some of you may have heard about the tragic incident in Atlanta involving a case of shoulder dystocia during childbirth. In light of this case, I thought I’d take the opportunity to explain exactly what shoulder dystocia is, how likely it is to occur, and what makes it so dangerous.

I delve into this topic in more detail in the episode, but essentially shoulder dystocia occurs when a baby’s shoulder gets stuck behind the pelvic bone during delivery. Nine times out of ten the situation will resolve with no harm to the birthing person or baby. However, there’s no way to predict when it might happen so maternity care providers like myself need to stay prepared to handle it during childbirth.

In this Episode, You’ll Learn About:

  • What shoulder dystocia is
  • How likely is it to occur
  • What some of the common risk factors are
  • Why addressing dystocia needs to happen as quickly as possible
  • What hospitals and medical providers do to stay prepared to handle it
  • What maneuvers are used to deal with shoulder dystocia
  • Which injuries are most common
  • How to reduce complications
  • How care decisions should be made
  • What to do after baby comes out

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Transcript

Dr. Nicole (00:00): In this episode, you are going to learn all about shoulder dystocia. Welcome to the All about pregnancy and birth podcast. I'm Dr. Nicole Callaway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world and I'm here to help you be calm, confident and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

(00:50): Hello there. Welcome to another episode of the podcast. This is episode number 223. Whether you are a new listener or returning listener, I'm grateful that you are spending some of your time with me today. So in today's episode, you're going to learn about shoulder dystopia and I wanted to talk about this after that recent tragic case in Atlanta where a baby died after what happened in a shoulder dystopia birth and there was just a lot of information circulating about shoulder dystocia. So I want to give you the accurate information today. So you are going to learn what exactly is shoulder dystocia. You'll learn how often shoulder dystocia occurs. You will learn risk factors for those who may be at risk for shoulder dystopia. You'll learn how shoulder dystopia is treated, potential complications, and are there any ways to prevent it. Now, before we get into the episode, I have a favor to ask of you.

(01:50): Can you share this podcast with someone that share it with two or three people? Pop it into a Facebook group. If you're in a Facebook group, share it on Facebook, share it on an Instagram story. Tag me. I love to see what you say and I'll reshare it and repost it. Share this podcast with your communities. I on a mission to reach and serve as many pregnant people as I can. I want to reach and serve millions. I just love, love, love helping folks have a better birth In our patriarchal system in the US that too often tries to take away power from people over what happens in their own bodies and can be racist and I would just love your help in doing so. So share this podcast with your communities. Tag me on Instagram at Dr. Nicole Rankins. I would so, so, so appreciate it.

(02:36): Okay, let's talk about shoulder dystocia. So first up, what exactly is shoulder dystocia? So shoulder dystocia is a complication that occurs when the baby's head is born and then the shoulders become stuck behind the pubic synthesis behind the pelvic bone. So if you reach down, feel like right at the top of your pelvic area, you feel that bone right there, the shoulder gets stuck behind that bone and it can potentially lead to some serious complications. This is a true, true obstetric emergency. Shoulder dystocia is a true true obstetric emergency and it requires quick thinking. It requires skill to prevent harm to both the mother and the baby. So this is really a true, true emergency and one of the things that we as obstetricians just never want to hear, never want to hear, or it can always strike fear in us, I should say that because it's truly, truly, truly an emergency.

(03:52): Now as far as how often it happens, it really varies, but on the high end it happens as much as 3% of vaginal birth. So it's not very common that shoulder dystocia happens. It is higher in certain populations, but in general, thankfully shoulder dystocia is not very common up to about 3% of births. So how do we diagnose a shoulder dystocia? Well, it really is a subjective clinical diagnosis, so it's not something that you can measure or there are like if this happens for this number of seconds that the head is not, the body's not coming after the head, then it's a shoulder dystocia. It's not like that. We suspect it sometimes when we see something called turling where the head looks like it starts to come out and then comes back in, starts to come out and comes back in. But even that is not reliable.

(04:44): We really diagnose it when at the time when the head comes out, we generally, typically for vaginal birth we do a gentle downward traction of the head to help release that shoulder from under the pubic bone and the amount of time that people feel comfortable waiting for that to happen varies. Some people get really antsy and want the baby just her to be born kind of thing. They get concerned. Midwives I think take that period of time a little bit longer for after the head comes for that gentle traction wait for another contraction for a baby to be born. So it's really a subjective thing that happens or is diagnosed. It's not like a specific amount of time and also looking back and deciding how severe it was, it's also something that's fairly subjective. We look back and say whether this was a minor shoulder, shoulder dystocia because it was relieved in say 30 seconds or a minute and pretty easily, or maybe it was a severe shoulder dystocia because it took some time for the baby and a lot of time in a shoulder dystocia is two or three minutes.

(05:56): That's a lot of time in the shoulder dystocia. So really those things are not hard and fast cut and dry. It can also be categorized based on whether or not the severity of it based on if the mom was injured or if the baby was injured as well. Okay, so how long it took if the mom was injured, if the baby was injured, those things. Now, one of the things that's really, really important to understand about shoulder dystopia is that despite all of the studies people trying, people doing what they can, we have no accurate way of predicting who will have a shoulder dystocia, okay? We have no accurate way of predicting. There are some risk factors. Risk factors can increase the chances, but they don't predict it, okay? There's no accurate way to predict it and therefore no way to completely avoid those complications from a shoulder dys short of a C-section, which I'll talk about.

(06:59): So because we cannot accurately predict it, then we as obstetricians or midwives need to be prepared for the possibility of a shoulder dystocia at every single vaginal birth and we have a stepwise plan. We all do in our heads for the maneuvers and things that we are going to try to relieve that shoulder dystocia when it happens. Okay? So we have to be prepared for it at every single birth. So let's talk about some of the risk factors for shoulder dystopia. There are a lot of risk factors that can increase the chances for shoulder dystopia, but remember, just because these factors can contribute to an increased likelihood, it still occurs unexpectedly. I think in that particular case there was a lot of talking about shouldn't we have known that this was going to happen? We have known, no, we can't know. There is no way to predict a shoulder dystocia.

(08:01): Okay, so let's talk about some of the factors though that may increase the risks because we do need to be on the lookout for things. One, the biggest one, I shouldn't say the biggest one, this is probably the second biggest one is if the baby is large, a baby with a larger than average size, anticipated size, especially more than 4,000 grams, which is about 8.8 ounces, that is going to be a risk factor for shoulder dystocia, okay? The risk increases as the baby's weight increases, and there's another important risk factor that's related to that and that is diabetes. So whether or not someone has diabetes and the birth weight together can increase the chances of shoulder dystocia because sometimes having diabetes can the things go together is what I'm trying to say. It's hard to separate out some of the other risk factors. So high birth weight, diabetes being an older age at first birth, carrying extra weight or being considered obese, those are all things that can increase the chances of having a shoulders dystocia, but they're all kind of related, okay?

(09:10): They're all kind of related. So when we look at the numbers of shoulder dystocia and non-diabetic versus diabetic pregnancies, so if the baby weighs less than 4,000 grams, that's 8.8 pounds. The risk of shoulder dystocia and a non-diabetic pregnancy is as high as 1.1% in a diabetic pregnancy is 3.7%. If the baby weighs 4,000 to 4,499 grams and 4,499 grams is nine pounds, nine ounces, then the risk of shoulder dys distortion in non-diabetic pregnancy is 10%, whereas in a diabetic pregnancy is as high as 23% and then 4,500 grams or more. So more than that 9.9 pounds in a non-diabetic pregnancy it's as high as 22%. In a diabetic pregnancy it can be as high as 50% and the reason it's different in diabetes versus non-diabetes is because the baby's distribution of fat is different when mom has diabetes. But even with all of that being said, the majority of babies that are high birth weight still don't have a shoulder dystocia.

(10:16): Okay? Also 50% of shoulder dystocias happen in babies with a birth weight less than 4,000 grams. So I just want to reiterate that it's really, really difficult to predict. It's impossible to predict who will and who will not have a shoulder dystocia, but that is probably one of the biggest risk factors is suspected increased weight and then as I said, the maternal diabetes, whether you have gestational diabetes or preexisting diabetes, obesity. And then the biggest risk for social dystopia is a previous history of shoulder dystopia. If you have experienced one in the past, then the risk of it can be as high as I should say, at least 10%. It's at least 10%. Some studies have reported it as high as 25% and this actually may not be an accurate estimate. It may underestimate it because if there's a vaginal birth that is complicated by long shoulder dystocia, then we very often for the next pregnancy, we'll talk about the recommendation for a planned cesarean birth in order to avoid another bad shoulder dystocia, especially if there was an injury to the baby.

(11:32): So this may underestimate it, but this is going to be the highest risk if you had a previous shoulder dystocia before and recurrent shoulder dystocia is more likely if the birth weight in the next pregnancy is more, it is more likely if your pre-pregnancy weight is greater than in the previously affected pregnancy, it's more likely if you gain more weight during the next pregnancy than you did during the first pregnancy, it's more likely if the birth weight is above 4,000 grams. Of course, if you have a previous shoulder dystocia and a suspected high birth weight, that's particularly bad, that can be as high as 50% recurrence of a shoulder dystocia. Some other things that may be surprising that increase the risk of shoulder dystocia are long labor. A prolonged or difficult labor can increase the chances of a shoulder dystocia. It's thought that maybe it leads to exhaustion in both the mother and the baby and that can affect the baby's ability to descend into the vagina in a way that's going to not help a shoulder dystocia happen.

(12:39): A post-term pregnancy. So babies in that 41st 42nd week, they're going to have a higher chance of soldiers dystocia most likely related to having a higher birth weight just from cooking a bit longer induced labor actually with Pitocin can slightly increase the chances of shoulder dystocia, not by much because we use Pitocin quite a bit and don't see a huge number of shoulder dystocias, but there is some evidence that induced labor can increase the chances of shoulder dystocia and instrumental delivery with a forceps or vacuum birth can increase the risk of shoulder dystocia by altering the baby's position as the baby is being born and then the shape of your anatomy can increase the risk of shoulder dystocia, but there's not any x-rays or anything or things that we can do to tell that ahead of time. Some other things are maternal age. Women who are older may have a slightly increased risk of shoulder dystopia, but some of that may be related to a slightly increased risk of diabetes. Again, some of these things go together. Having an epidural may slightly increase the risk because of your lack of sensation depending on how dense the epidural is and the way you push may affect the way that the baby's worn and slightly increase the risk of shoulder dystocia and then excessive weight gain during pregnancy can make the baby bigger and then increase the chances of shoulder dystopia.

(14:05): And of course we do our best to address these things as they come up. Not everything can be addressed all the time right away, but those are some things that we are on the lookout for. Shoulder dystopia, really the biggest one is going to be birth weight or suspected birth weight and the previous history of a shoulder dystocia. Okay, previous history. Alright, so how do we manage a shoulder dystocia when it happens? Again, I want to reiterate it is a true, true obstetric emergency, true obstetric emergency. It's one of the things that obviously we're all trained for, but those minutes, those moments that you're trying to get that baby out feel like a long time, they can feel like a long time. The goal of course in the management of a shoulder dystocia is to safely deliver the baby before there's any lack of oxygen or brain injury from the cord being compressed and also not have any nerve injury in the process of delivering the baby.

(15:12): There are some maneuvers that can be done that can cause some nerve injuries and I'm going to talk about those in a minute. And we also don't want to see any maternal trauma or fetal trauma. We're just trying to get the baby delivered as quickly as possible, as safely as possible. Okay? Now in general, and this is why we have such a, it's not nervousness, but when we recognize the shoulder distortion want to get delivered quickly in general it's about five minutes before there is a risk of brain damage or injury. That doesn't mean that there will be if there's longer, if it's longer than that, I have certainly seen and know of a lot of stories where it's taken longer to get a baby delivered than that and the baby ended up being just fine. Plenty of stories like that, but in general we have at least five minutes before there's any sort of injury.

(16:14): Now obviously we can't do a C-section in five minutes, so you want to try and get those maneuvers and I'm going to get to how of the order of maneuvers and things like that, but it's after just about five minutes that we start to get worried that there could potentially be some brain damage. Doesn't have to be, but the potential definitely goes up after five minutes. Okay? Now, shoulder dystocia maneuvers and drills are things that we are trained on during residency. We often have drills in the hospital for shoulder dystopia. How often those happen really depends on the hospital. I actually have, as part of my job as a hospitalist, have to do an extensive every couple years. It's like a three hour training on shoulder dystopia. As a matter of fact, I'm going to start do for my training right now about learning about the maneuvers and what happens and trying to resolve them so that you keep that fresh of mind because again, it doesn't happen that often.

(17:16): It only happens in about 3% of births. So we really have to be comfortable with springing into action very quickly when these things happen. Now, we all have sort of a order of how we do things, but it's not based on science or evidence. There's no studies that show which maneuvers work in the best order because that's not something you can study like, oh, this is a shoulder dystocia, let's try this maneuver first and test it against this maneuver. That doesn't happen. But we try for things in sort of an order that makes sense and kind of from easiest and we know that resolves things to what's called maneuvers of last resort and I'll talk about that. So in general, when there is a shoulder dystocia, hear how things are managed, the first most important thing is to recognize that there is a shoulder dystocia.

(18:10): It should be after just a little bit of gentle traction. If the baby's head isn't coming, then it could potentially be a shoulder dystocia. If you tell mom to push, baby's not coming and then it's a shoulder dystocia. As soon as they shoulder dystocia is recognized, we need to immediately and clearly say this is a shoulder dystocia and everybody's going to be a little bit different. I personally say when there's a shoulder dystocia, I say we have a shoulder dystocia so that the nursing staff can hear me and they can mobilize the things that we need. Call for extra help. You may need to call for extra nurses for an extra nurse in the room. We'll call for the NICU team so that the pediatric folks can be there. If you're in a hospital that doesn't have a nicu, then the pediatric team will be there and be ready to help in case the baby needs some help being resuscitated after birth because again, that head is out, that body is there and that cord is being squeezed and we don't have long before there can potentially be some concerns.

(19:11): Okay, so you call for help very clearly say the situation and you start timing. Someone hits a clock, someone should be like, when did we recognize it and how long did it take for the delivery? That's really important in the documentation for things that happen afterwards. Okay? Now the first maneuver that we always try with shoulder dystocia that we always go to is something called Mc Roberts maneuver. And what that is is that the legs are flexed back towards the mom's belly, okay? It's like if you wrap your hand around the back of your knees and pulled your knees back towards you and then open your legs out wide, that's kind of Mc Roberts, but the nurses do it for you. We do not push on the uterus, we don't push on the actual uterus or the belly, okay? We just pull back the legs in Mc Robert's maneuver.

(20:03): It's the first maneuver, okay? First maneuver, and that is going to relieve a good number of shoulder dystocias just doing that maneuver alone. And that is in combination with super pubic pressure. I got a little bit of ahead of myself when I said we don't push on the belly, this is when people get confused and think we're pushing on the uterus, but we're not sra. Pubic pressure is pressure applied to just above the pubic bone where the nurse is literally using her fist to help push that shoulder and dislodge it from underneath the pubic bone, okay? That's super pubic pressure. We don't do pressure on top of the uterus to help push the baby out. That has not been shown to be effective. Now the good news is that with Mc Roberts and super pubic pressure, over 90% of shoulder dystocias will be relieved by those two things alone with no consequences in less than a minute.

(21:01): So most of them are resolved with just those two maneuvers and are resolved fairly quickly. So that's great. Okay, that's great. Then the next maneuvers that we try, and these are the ones where the order is going to differ depending on the provider. We'll all try Mc Roberts and super pretty big pressure pretty quickly with screws. Maneuver is rotating the baby's shoulder to try to turn the baby to create a little space and get it underneath that pubic bone. Ruben's maneuver is basically pushing across the baby's back. So it's like one maneuver is pushing the baby one way, one is pushing the baby the other way, essentially try to get the baby out. We can also deliver the posterior arm. The posterior arm is the arm that is the one that's closest to the floor. Alright? So if the baby's heads out, the baby's going to be looking one way or the other, the anterior shoulders above that pubic bone.

(21:56): The posterior shoulder is the one that's towards the floor. If we can grab that arm and deliver that arm and by deliver it, it means bring it out of the vagina, then it's going to reduce the diameter of the shoulders, create some space and that anterior shoulder can fall down and be delivered. So that's often a great maneuver is deliver of the posterior arm. Now a maneuver that I don't think we use enough in obstetrics as obstetricians, it's something that midwives use a lot more. Something we don't use a lot is gaskin maneuver. It's named after anime gaskin actually. And that's when we put mom on hands and knees. Alright? Hands and knees can help. I know it kind of doesn't make sense because you're flipping the baby over and then the bone is still like gravity, the pubic bone is closer to the floor, but it creates that space.

(22:46): It can create space for that baby to come out. So we do all of those things. Gaskin to maneuver can help and sometimes we go through those a couple times if we need to. So we try Mc Roberts super pubic the maneuvers, try to get the posterior arm gasket maneuver and then we may go back and try them again. Alright? Knock on wood, I haven't had to do that, but that is part of what is considered a normal sequence. A episiotomy interestingly doesn't help. You would think a episiotomy would help because it cuts and it makes space, but no evidence has been shown that a episiotomy helps with the shoulder dystocia, it does help if there's not enough room to get a hand inside the vagina, but it does not help with making space for the baby. It only helps with getting a hand inside of the vagina.

(23:39): Now, maneuvers of last resort, and I believe in the case in Atlanta, this is what it got to because the ended up having a C-section after the shoulder. Dystocia maneuvers of last resort are just that last resort. These are last ditch efforts. These are rare, these are extreme. Most often when these happens, it's a high chance that the baby is going to die, okay? And that is called the zanelli maneuver where we push the baby back into the vagina and then do a C-section. That is not as easy as you think. Knock on wood, I have never seen that or had to do that in 20 years and I pray that I never have to, but you push the baby's head back in the vagina and then go for a C-section. Now remember I said we have some concern for lack of oxygen after five minutes, if we still got to go back to a C-section and do a C-section and pull a baby all the way from the bottom of vagina up through an incision in the belly, that's going to take some time.

(24:42): There's going to be a high risk of damage, a high risk of death, alright? High risk of death. And then another option, and I have never seen this on quite frankly I don't know how to do it, is breaking the pubic synthesis. So like cutting the pubic synthesis bone in order to make space for the baby. I've never seen that done. That is a last resort, exceedingly painful, terrible to recover from, but that would be a last resort because you do have to deliver the baby at some point in order to save the mom's life if necessary. So because a baby just can't stay there, that's going to be dangerous for the mother. So eventually you do have to get the baby out by whatever means necessary. So that is a truly, truly last resort. I forgot to mention a couple of other maneuvers that are like right underneath the last resort, before the Z elli, but after all of the gaskin maneuvers and everything, and that is intentionally breaking a bone where you can break the collarbone and that will help reduce the diameter of the shoulders or you can break the long bone of the arm and that will also help to bring the arm out.

(25:57): Thankfully I have never had to do those, but they do because it's actually harder to do than you think is to break that bone. Thankfully they heal up very easily. But that is an option in order to break those bones and make that space.

(26:13): And then once the baby is out, then we have to assess the baby's condition. We have to see if there are any injuries like brachial plexus injuries. I'll talk about what that is in a minute. Any fractures or anything we have to attend to mom because it's an increased risk of postpartum hemorrhage, all of those things. And one of the most important things that we have to do is communicate, is communicate. We have to debrief, talk about what happened. We have to tell the parents that there was a shoulder dystopia because they need to tell their next healthcare provider whether or not if it happens, because again, one of the biggest risk factors for a shoulder dystocia is having had one in the past. I actually had a patient, she was sweet as can be. We had a shoulder dystocia and it took a little bit longer.

(26:59): It was a little over a minute to relieve the shoulder dystocia. And when I was explaining to her that this was a shoulder dystocia, the baby's shoulder got stuck and those kinds of things really important for you to let your doctors know. She was like, oh yeah, I think I had that with my first one, but it didn't last very long. You definitely want to mention that you have a shoulder dystocia before so that we can be really, really ready for any possibility of it happening in the future. Now speaking of complications of shoulder dystocia, I want to say that about 95% of shoulder dystocia, most of them are resolved without any issues to the baby at all. Okay? No injury to baby at all. Now, among those babies that are injured then it could be trauma, it could be where something's broken or damaged.

(27:49): It could be injury from a lack of oxygen or it could be both. Okay? It could be both. Now as far as injury, the most common one is going to be a brachial plexus injury. The brachial plexus is a network of nerves that controls it's like in the neck and it controls sensation in the arms and the hands. And during a shoulder dystocia, the baby's neck can, shoulders can be stretched and that can stretch the brachial plexus nerve group and that can cause some injury. It can result in herbs, palsy or clunky palsy. These are different types of injuries that there's weakness where there's loss of sensation or there's straight up paralysis in that arm where it cannot be used. Now most often brachial plexus injuries if they happen are transient. They're not very common. Transient. Brachial plexus injuries happen anywhere from three to 16% and in most cases they resolve over time.

(28:49): So over a year or so, those nerves will reiterate, get back together and resolve. But a small percentage will have a permanent brachial plexus injury from as high as 1.6%. So not very common, not very common, but a small percentage of people will have a brachial plexus injury. Now another thing that can happen in terms of injury is fracture, like I talked about, that clavicle fracture or fracturing the humerus, which is the long bone of the arm, the top bone clavicular fractures happen anywhere from 1.7 to 9.5%. I honestly have not ever seen a clavicular fracture. So that number sounds a bit high to me, but that's what the data shows. Humerus factor, which I also haven't seen, 0.1 to 4.2%. And again, those heal very well. They heal without any incident at all. Bones are just particularly resilient and most people don't have any issues with that.

(29:54): Now, when we look at things like injury from a lack of oxygen's called, which is called hypoxic, that's low oxygen, ischemic lack of blood flow encephalopathy, that's like an inflammation of the brain that only happens about 0.3% of the time, 0.3. And that comes from the umbilical cord being compressed, cutting off oxygen to the baby. And the longer it is, the higher that risk is of it happening, but it doesn't happen very often, thankfully, okay, it's not a very common complication at all. And then death is very, very rare from shoulder dystocia. The studies I saw, it was only as high as 0.35%. So not very common at all. I personally have never seen it and again, hope and pray never to see it. Now, there are also complications that the mother can experience. Mom can have an increased risk of peroneal tears just from trying to maneuvering the tissue, getting the baby out. They can go as high as 16%. In some studies there's an increased risk of postpartum hemorrhage from managing a shoulder dystocia. So we have to be careful about that. And then one thing that we don't talk about is the emotional impact.

(31:13): If you're in a shoulder to social situation and it's not relieved by those first two maneuvers, and then we could be telling you, okay, you really got to push or we got to turn you, we got to do these things. It can be a really charged environment and it can be scary. It can be scary. So it can be traumatic. It can be traumatic for sure. So there definitely can be some potentially emotional impact and especially so if the baby has some sort of injury or needs to go to the NICU for some observation or those kinds of things. Alright, now just to wrap up, as far as reducing the complications from shoulder dystocia, jco, the joint commission that credits hospitals recommends that we do regular drills in order to help prepare for shoulder dystocia, and those are done at varying frequencies. They're not required, but they are recommended and they help just to know what to do so you can snap into action if something happens. So that is one important way of reducing complications, kind of regular training.

(32:17): And then there are some things that can be done in terms of planning bursts that are at a higher risk, although it's not as straightforward as we think. So there used to be in the past trying to look at pelvic bones and x-rays and things like that. That's not useful at all. It's also not very useful to check for the baby's weight towards the end of pregnancy, even though we know that weight increases the risk because ultrasound can be quite off in the third trimester. So we haven't found that that helps to be routine. We may do it in diabetic patients because they're going to be at a higher risk of having a baby with a higher rate, with a higher weight, excuse me. So we may do it then, but it's just not something that's necessarily done routinely and hasn't been shown to improve outcomes.

(33:09): So really talking about the mode of birth and situations and generally this is going to come up when it's suspected that the baby is big and then we have to talk about the options for birth. It's a shared decision making process all. We can't ever force anyone to do anything. We have to talk about the risk of labor, the risk of vaginal birth, the risk of shoulder dystocia. If we're planning a cesarean birth or wanting to talk about a cesarean birth, then we need to talk about the risk of cesarean birth too, because it's not that a cesarean birth is completely without risk. We have to talk about both sides. So generally what ACOG recommends is if the estimated fetal weight is greater than 5,000 grams in a patient without diabetes and 5,000 grams is 11 pounds. So in a patient without diabetes, if the estimated fetal weight is greater than 5,000 grams, the estimated risk of shoulder dystopia is greater than 20%.

(34:10): And then in that instance, we're going to recommend a cesarean birth. Alright? You don't have to choose it, but we're going to recommend a scheduled cesarean birth. If the estimated fetal weight is greater than 4,500 grams in a diabetic patient and that's going to be 9.9 pounds, then the estimated risk of shoulder dystocia is about 15% and above that number, then we recommend a cesarean birth. And again, it's really hard to estimate birth in the third trimester, so we try to take that into account in coming up with those numbers. So that is where we've kind of fallen based on the best evidence. Now, I will say that if we're close to that or if someone decides that they want to try for a vaginal birth in the setting of a baby being potentially big, then we're not doing Pitocin, we're not doing induction. Although some people will offer induction earlier when the baby's at 39 weeks in order to try and help prevent the baby from getting bigger, even though no evidence has shown that induction actually makes a difference for big babies, we still offer it because intuitively it makes sense, right?

(35:32): You induce early, the baby's not going to get as big. But if you decide that you're going to try and we know that the baby is really big, then we're not going to do anything to push labor either the baby comes out all on its own without us intervening or not. So there's not going to be pushing a whole bunch of Pitocin or being aggressive with anything like that because we don't want to push things that weren't supposed to happen or that are going to increase the chances of shoulder dystopia. That's just not going to happen. I actually recall the case once where I suspected that a baby was big and the labor was going really slow and she really wanted us to do something to try to help speed the lab along. And it was just like, we're not going to do this with this suspected big baby. In this instance, the baby did actually end up being big and was born by cesarean, but that's not always necessarily the case. Again, it really is a shared decisionmaking process.

(36:36): So just to wrap up, shoulder dystocia is when the head is born and then the shoulder gets stuck behind the pubic bone. It is a true obstetric emergency. It happens in as high as 3% of pregnancies or 3% of births rather. So not very common. The biggest risk factors are going to be a bigger baby, a previous history of shoulder dystopia. Also, diabetes can increase the risk. However, it really is unpredictable. We cannot predict when a shoulder dystopia is going to happen, and just because you have those things doesn't mean you're going to have a shoulder dystopia. It's something that we have to be prepared for at every single birth. As far as treating shoulder dystocia, there are certain maneuvers that we do that we go through in order to treat it. The vast majority of them, 90, 95% resolve without any incident or problems resolved quickly with no issues with the baby.

(37:27): And a small percentage of cases, there are very serious complications like a brachial plexus injury, suffering from a lack of oxygen and an extremely rare cases death. Now shoulder dystocia is one of those possible complications that I talk about inside of module three in the birth preparation course, prepare for possibilities. The birth preparation course, of course, is my online childbirth education class. They get you calm, confident, and empowered for birth, and it will talk about some things in addition to shoulders of social like infection, like meconium inside the birth preparation course to help you be prepared for those possible things that might pop up. You can check out all the details of the birth preparation course and come join me drnicolerankins.com/enroll. All right, so there you have it. Share this podcast with a friend, how many you reach and serve more folks, subscribe to the podcast. Let me know what you think. Send me a DM on Instagram. My dms are open @drnicolerankins. So that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.