Shoulder Dystocia - Lippincott Williams & Wilkins

J Perinat Neonat Nurs
Vol. 22, No. 1, pp. 14–20
Copyright c○ 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Shoulder Dystocia
Nursing Prevention and Posttrauma Care
Cecilia M. Jevitt, CNM, PhD; Shannon Morse, ADN, RNC, LCCE, CLC;
Yong Sue O’Donnell, MSN, ARNP
Shoulder dystocia is a birth emergency that occurs in approximately 1% of all births.
Shoulder dystocia can be followed by broken clavicle or humerus, brachial plexus
injury, fetal hypoxia, or death. Although risk factors for shoulder dystocia include
previous birth complicated by shoulder dystocia, maternal obesity, excessive prenatal
weight gain, fetal macrosomia, gestational diabetes, and instrumental delivery, shoulder
dystocia is not predictable. Perinatal nurses can reduce the risk for shoulder dystocia
by teaching mothers about optimal weight gain in pregnancy and assisting mothers
with diabetes to prevent hyperglycemia through diet management and medication use.
During childbirth preparation or early labor, nurses can educate mothers about
position changes and maneuvers used for shoulder dystocia. Nurses play a vital role in
obtaining assistance during a shoulder dystocia, keeping time, assisting with maneuvers
such as suprapubic pressure, and documenting the dystocia management. Nurses can
assist mothers and families to review the shoulder dystocia and any newborn injuries in
the postpartum period, thereby reducing confusion and anxiety. Regular drills and case
reviews help build nursing shoulder dystocia management skills. Key words: brachial
plexus injury, gestational diabetes, macrosomia, obesity, shoulder dystocia
Shoulder dystocia is a birth emergency that occurs
when the fetal shoulders cannot be delivered under
the symphysis pubis or out of the posterior pelvis. The
birth attendant is often accused of not recognizing the
risk for a traumatic birth or using incorrect hand maneuvers
to disimpact the fetal shoulders. Shoulder dystocia
actually involves a complex interplay of maternal
and fetal factors that can be affected by many healthcare
providers before and during the birth. Nurses have
an important role in reducing the potential for shoulder
Author Affiliations: University of South Florida College of
Nursing, Tampa (Dr Jevitt); The Baby Place, Florida Hospital,
Zephyrhills (Ms Morse); and Tampa General Hospital, Tampa,
Florida (Ms O’Donnell).
Corresponding Author: Cecilia M. Jevitt, CNM, PhD, University
of South Florida College of Nursing, MDC Box 22, 12901 Bruce B
Downs Blvd, Tampa, FL 33612 (cjevitt@health.usf.edu).
Submitted for publication: July 14, 2007
Accepted for publication: October 10, 2007
14
dystocia and improving the management of a dystocia
emergency.
LITERATURE REVIEW
Incidence
Shoulder dystocia occurs in 0.6% to 1.4% of all vaginal
vertex births. 1 Spong and colleagues 2 defined shoulder
dystocia as “a prolonged head to body delivery time
[eg., more than 60 seconds], and/or the necessitated
use of ancillary obstetric maneuvers.” (p433) Cohen 3 further
classified shoulder dystocia as mild or severe: mild
shoulder dystocia requires only McRobert’s maneuver
and/or suprapubic pressure to effect birth of the shoulders,
whereas severe shoulder dystocia requires the use
of Wood’s screw maneuver or extraction of the posterior
arm.
Newborn injury following shoulder dystocia might
include bruising, fractured clavicle, transient or permanent
brachial plexus injury, hypoxic brain damage, or

Shoulder Dystocia 15
death. Maternal morbidity following shoulder dystocia
can include postpartum hemorrhage, perineal lacerations
and bruising, and pelvic hematoma.
SHOULDER DYSTOCIA CAUSES
When weight exceeds 4000 g, the fetal body assumes
more adult proportions with the width of the fetal
shoulders exceeding the biparietal diameter of the
head. The fetal head is born but the anterior shoulder
becomes trapped behind the symphysis pubis or
the posterior shoulder catches on the sacral promontory.
Stretching of the brachial plexus can happen during
maternal pushing, during vacuum extractor or forceps
use, or during birth hand maneuvers. Stretching
of the brachial plexus nerves can cause a temporary
nerve conduction deficit called neuropraxia. 4,5 Severe
stretching may avulse brachial plexus nerve roots from
the spinal cord causing permanent loss of arm function.
Cervical nerves 5 through 8 and T1 may be involved.
Future function of the fingers, hand, and arm will depend
on which nerves are damaged.
The clavicle or humerus may fracture during attempts
to relieve the shoulder dystocia. These are temporary
injuries and heal with splinting of the arm. An
arm is splinted by positioning it across the chest with
the hand resting under the opposite shoulder, held in
place with a Velcro strap or a length of fabric wrapped
around the trunk and pinned in place.
Brachial plexus injury is the morbidity most often
associated with shoulder dystocia and is a common
source of liability claims. 6 The incidence of brachial
plexus injury ranges from 0.4 to 1.5 per 1000 births. 7,8
Fifty percent of brachial plexus injuries occur without
shoulder dystocia. 1 Brachial plexus injuries have occurred
after cesarean delivery. 1 Brachial plexus injuries
to the posterior shoulder have also been documented. 1
Postcesarean and posterior arm injuries raise the question
of the relationship of maternal pushing efforts to
the stretching of the brachial plexus.
Most newborns recover spontaneously from brachial
plexus injury with physical therapy. 7 Only 5% to 22% of
infants have permanent injury. 7,8 Spontaneous elbow
flexion at 3 months is a favorable sign for recovery without
corrective surgery. 8 Infants who need surgical repair
rarely have full return of neurologic function. 9
Shoulder dystocia with permanent arm or brain injury
or newborn death is a frequent source of malpractice
claims. 6,10 Nurses working together with other professionals
during prenatal and intrapartum care can reduce
the incidence and improve the outcomes of shoulder
dystocia (Table 1).
ANTENATAL EDUCATION TO DECREASE
SHOULDER DYSTOCIA RISKS
Nurses are an important source of health information
for expectant mothers. The office nursing staff may
provide the most care continuity for women as obstetricians
and midwives rotate between the prenatal
office and labor and delivery. Three risk factors for
shoulder dystocia—obesity, excessive prenatal weight
gain, and diabetes—are all related to another risk factor,
macrosomia. 1,10
Weight management
With 30% of American childbearing-age women obese
before pregnancy, 14 weight management education
may be the most important tool a nurse can provide
to reduce the threat of shoulder dystocia. Assess overweight
and obesity at the first prenatal visit. An accurate
height and weight measurement is an essential
part of the prenatal record. Measuring height, preferably
with a stadiometer (a wall mounted height measure),
is more accurate than maternal height recall.
Body mass index (BMI) graphs, calculation wheels, or
computer calculator programs should be readily available.
Many adult women have never had their BMI calculated.
This presents the nurse with an opportunity
to teach how excess weight can influence pregnancy,
the birth, and the future health of both mother and
infant.
Body mass index determination offers a more precise
measure of weight related to height and is most
useful in advising an adequate but not excessive prenatal
weight gain. 15,16 The Institute of Medicine issued
recommended prenatal weight gains in 1990 that are
based on pregravid BMI (Table 2). 11 Women of normal
weight, for example, are advised to gain 25 to 35
lb for a healthy pregnancy and obese women at least
15 lb. Using these tailored recommendations helps
women avoid unnecessary weight gain, which predisposes
them to a macrosomic infant and maternal obesity
in later life.
The recommended weight gain should be documented
on the prenatal record so that all prenatal care
providers use the same reference point. A maternal
BMI of 30 or more should be documented on the prenatal
record problem list as obesity is a risk factor
for many perinatal problems, including gestational diabetes,
preeclampsia, stillbirth, macrosomia, prolonged
labor, shoulder dystocia, and cesarean section. 1,10 Documenting
BMI indicates more about the risks of obesity
than the labels obese or morbidly obese.
Weight gain should be measured at each prenatal visit
and assessed for adequacy. Graphs are available that

16 Journal of Perinatal & Neonatal Nursing/January–March 2008
Table 1. Perinatal nursing interventions in shoulder dystocia
Prenatal
Measure height and weight at first prenatal visit. Calculate Body mass index (BMI) and document in prenatal record
Teach weight gain recommendations based on Institute of Medicine guidelines 11
Provide facts about the risks of excess weight gain, uncontrolled diabetes, and shoulder dystocia 1;10
Advise nutritious foods using national guidelines 11;12
Ensure routine screening for diabetes in pregnancy. Screen obese women in the first and third trimesters 13
Document fetal growth and/or estimated fetal weight at each prenatal visit. Communicate fetal weights that may exceed 4000 g
to the prenatal care provider
Educate women about shoulder dystocia positions and maneuvers during childbirth preparation
Perform regular team shoulder dystocia drills
Intrapartum
Ensure that height, pregravid weight, current weight, BMI, and assessment of pelvic adequacy are documented in the health
record
Assess maternal history for shoulder dystocia risk factors
Palpate and document fetal position. Document estimated fetal weight and/or fundal height.
Notify birth attendant of inadequate progression of dilatation and descent in labor.
Check and have ready emergency resuscitation equipment.
During shoulder dystocia
Know whom to summon when the birth attendant asks for help
Know the correct use of McRobert’s maneuver and suprapubic pressure
Avoid the use of fundal pressure
Record times of head delivery, head-to-body delivery interval, times when help was requested, and arrival times of other
personnel
Postpartum
Record any physical abnormalities on the newborn such as bruising or lack of arm muscle tone. Notify nursery nurses and
pediatricians
Acknowledge mother’s and family’s emotions
Provide factual information
Ensure that documentation of the shoulder dystocia by all birth personnel is correct and consistent
Notify organizational risk manager of shoulder dystocia. Participate in case review
Teach mother and family care of the newborn. Assist with referrals for physical therapy or neurologists
plot actual weight gain against a healthy gain. These
can be useful in helping women visualize their weight
changes. Many nurses hesitate to discuss weight with
women for fear of insulting them. A focus on risk prevention
and the best future health for mothers and newborns
shifts the discussion from clothing size to risk
reduction that is under individual control. Nurses can
provide obese women with resources such the Centers
for Disease Control and Prevention’s 5 a Day Program 12
that encourages 5 servings of fruits and vegetables a
day. Fruits and vegetables provide minerals, vitamins,
and filling fiber, while being less calorie dense than processed
foods.
Women who gain weight in excess of the Institute
of Medicine recommended levels should receive
counseling about food intake and activity. 15,16 Excess
weight gain provides calories for excessive fetal
growth. Women with large weight gains should be seen
Table 2. 1990 Institute of Medicine recommended prenatal weight gains a
Recommended weight gain
Height for weight category BMI b range kg lb
Underweight women 29.9 At least 6.0 At least 15
a Used with permission from the Institute of Medicine. 11
b Body mass index, calculated as (weight in pounds)/(height in inches) 2 × 703.

Shoulder Dystocia 17
more often during pregnancy, every 2 weeks instead of
monthly, to provide more frequent nutrition coaching.
They many benefit from a referral to a nutritionist. Nutrition
counseling for some women may be obtained
through the Women, Infants and Children’s Supplemental
Nutrition Program (WIC). Obese women may
qualify for WIC, for example, by being anemic. Women
who are overweight or obese demonstrate periods of
excess caloric intake, not necessarily adequate nutrient
ingestion.
Diabetes in pregnancy
Obesity and excessive weight gain are risk factors
for gestational diabetes. 13 Pregestational and gestational
diabetes complicated by obesity, poor glycemic
control, or excessive weight gain increase risk for
shoulder dystocia. 1,17,13 All pregnant women should
be screened for diabetes during pregnancy by using
national standards. 13 The 2005 American College of
Obstetricians and Gynecologists standards for obesity
management during pregnancy advise consideration of
gestational diabetes screening at the first-trimester firstprenatal
visit with repeated screening later in pregnancy
if the first screen is within a reference range. 13
The prenatal nurse can ensure that these guidelines
are integrated into practice and that abnormal screens
are followed by 3-hour glucose testing and treatment
as needed. Testing, treatment plans, and blood glucose
records should be copied into the prenatal record so
that all providers can assess progress with glucose control.
If diabetes management is provided by a perinatologist
or diabetologist outside of the prenatal practice,
the nurse can enhance communication between
practices by seeing that both practices have copies of
laboratory values, visit records, and consultation summaries.
These complete records should also be available
in the prenatal records that are used for the labor
and delivery record.
Macrosomia
Regular fundal height assessment during prenatal visits
documents fetal growth and can be a screen for
macrosomia. 17 Estimated fetal weight based on clinical
palpation including Leopold’s maneuvers is as accurate
as ultrasound estimation of fetal weight 17 ; therefore,
nurses should practice their palpation skills and
have confidence in their ability to estimate fetal size.
The estimated weight of fetuses with fundal heights
greater than 40 cm should be measured carefully. Fetal
chest circumferences equaling or exceeding fetal head
circumferences measured by ultrasound may indicate
shoulder dystocia risk. 3 When estimated fetal weight
exceeds 5000 g in women without diabetes and 4500 g
in women with diabetes, the prenatal care provider
needs to determine whether an induction of labor or
elective cesarean birth is indicated and whether a plan
has been made with the mother for the timing and manner
of birth. 1,18
PRIOR SHOULDER DYSTOCIA
A previous shoulder dystocia with or without brachial
plexus injury should be recorded on the prenatal problem
list. 10 A prior shoulder dystocia increases the risk
for a subsequent shoulder dystocia (9.8%–16.7%), although
most subsequent births do not involve shoulder
dystocia. 19 Women who have had a prior shoulder dystocia
need careful informed consent on prenatal weight
gain, the risk of recurrence, and birth options. 1,10 The
prenatal care provider should form a plan for time and
place of birth with the mother that is documented in
the prenatal record. The nurse can help prepare the
mother for scheduled births by teaching about induction
of labor or presurgical routines.
CHILDBIRTH PREPARATION
Nurses who teach childbirth preparation can prepare
mothers and their families for the common maneuvers
used in shoulder dystocia management without scaring
the family with worst-case complications. 10 The childbirth
preparation nurse can say,
Some large newborns are tight fits through the vagina. The
labor and delivery nurses may help you pull your legs back
to your chest to help move the pubic bone over the baby’s
shoulder. A nurse might also push down just above your pubic
bone to nudge the baby’s shoulder under the bone. Sometimes
the midwife or doctor might put a hand behind the
baby’s back to push it sideways into a large part of the pelvis
so the shoulders move down.
Mothers can practice McRobert’s maneuver in class by
pulling their legs to their chests while sitting on the
floor resting against their seated coaches. The childbirth
preparation teacher can demonstrate suprapubic
pressure on a recumbent mother without using any
pressure.
INTRAPARTUM NURSING PREVENTION
OF SHOULDER DYSTOCIA
Risk assessment
Although shoulder dystocia is unpredictable, the labor
admission history and physical examination give the
labor nurse the opportunity to recognize risk factors

18 Journal of Perinatal & Neonatal Nursing/January–March 2008
for shoulder dystocia. Pregravid height, weight, and
BMI should be included in the health record. 10 Estimated
fetal weight or fundal height should be assessed
and recorded at labor admission along with clinical
pelvimetry and a determination of clinical adequacy
for labor. 10 Although these elements of the physical
examination are most often done by the midwife or
physician, the labor nurse can remind the birth attendant
if items are missing from the admission record.
The labor nurse might also advocate for the use of a
standard labor admission form or electronic template
that contains blank fields for estimated fetal weight,
fundal height, and assessment of pelvic adequacy.
Blank fields remind clinicians to document these elements
of assessment.
Fetal position should be palpated and documented
as part of the nursing labor admission. Palpation may
be difficult if the mother is obese. Location of the fetal
heart tones may assist in determining fetal position.
Knowing the location of the fetal back will assist the
nurse in giving the most effective suprapubic pressure
if needed during the birth.
Family and environmental preparation
Early labor gives the nurse another chance to prepare
the family for shoulder dystocia management. The art of
prevention nursing is in recognizing the risk factors for
shoulder dystocia, being physically and mentally prepared
for the emergency, but conveying only optimism
and confidence to the parents. The nurse can have the
mother and family practice McRobert’s maneuver. The
nurse can also assist the mother in moving to her left
side or onto all fours if the birth attendant uses these
positions during shoulder dystocia maneuvers. 10 The
nurse can also use early labor to review shoulder dystocia
assistance preferences with the birth attendant.
The nurse anticipates if the birth attendant will want
suprapubic pressure, changes in the birth bed configuration,
or the mother assisted into a left lateral position
if a shoulder dystocia occurs.
Since even small infants can have a shoulder dystocia,
a well-prepared labor nurse will have each birth
room ready for this emergency. Resuscitation equipment
should be in place and working. A stool for nurses
to stand on during suprapubic pressure should be near
the bed.
Although there are conflicting reports of the relationship
of prolonged labors and shoulder dystocia, 1
protracted labors are risk factors for a number of maternal
and fetal morbidities and should be managed attentively.
Extra caution is warranted when preparing
for a forceps or vacuum-assisted birth especially when
multiple risk factors for shoulder dystocia and brachial
plexus injury coexist. 19 Instrumental births are associated
with shoulder dystocia. 1,19
NURSES’ ACTIONS DURING A SHOULDER
DYSTOCIA
Although the midwife or physician will perform the
maneuvers to dislodge an impacted shoulder, the labor
nurses provide essential support measures. To act efficiently
when seconds matter, nurses must thoroughly
understand the safety measures employed during a
shoulder dystocia. Shoulder dystocia drills done with
the regularity of fire or code blue drills provide nursing
with the practice necessary to act automatically during
a dystocia. 20
The midwife or physician will request that the nurse
summon additional help. Other personnel might include
additional nursing staff, a resuscitation team from
the nursery or respiratory therapy, or another midwife
or physician. If the mother is semisitting for the
birth, nurses will be expected to assist the mother into
McRobert’s position by flexing the maternal thighs toward
the maternal chest. McRobert’s maneuver slides
the pubic bone over the anterior shoulder. 20 It is not
useful as shoulder dystocia prophylaxis and should be
employed only once a dystocia is evident. 21
If McRobert’s maneuver does not dislodge the dystocia,
the birth attendant will request suprapubic pressure.
Optimal suprapubic pressure is accomplished by
placing a clenched fist or the heel of the hand behind
the anterior shoulder and pushing the shoulder
toward the fetal chest and down. 20 This pushes the
shoulder into the larger oblique diameter of the pelvis
and presses it under the suprapubic bone. Adequate
force must accompany suprapubic pressure. For the
most effective strength, the nurse may place the second
hand on top of the clenched fist and with both
elbows straightened lean into the maternal abdomen.
Short nurses may need to stand on a stool to have sufficient
height and reach for the maneuver.
If McRobert’s maneuver and suprapubic pressure do
not release the shoulder, the birth attendant may use
Rubin’s maneuver, Wood’s screw maneuver, or several
other techniques. 1,10,20,22 There is no correct order or
superior order for maneuver use; however, fundal pressure
should be avoided. 1,20 Fundal pressure is steady
pressure exerted by one hand pushing on the uterine
fundus, assisting movement of the fetus down the
birth canal. It may cause or further aggravate a shoulder
dystocia. 1,20 The perinatal nurse has the right to
refuse an order to do fundal pressure during a shoulder

Shoulder Dystocia 19
dystocia. 1,20 Shoulder dystocia results from shoulder
bones impacted against the pubic bone or the sacral
promontory, not against soft tissue; therefore, an episiotomy
does not improve outcomes and is not a necessary
component of shoulder dystocia management. 10,23
One nurse should become the scribe and timekeeper
during a shoulder dystocia. Documentation of
the time the shoulder dystocia started, head-to-body
delivery time, and the time other providers, such
as a nursery resuscitation team, arrived should be
noted by the nurse. 10 The Association of Women’s
Health, Obstetric, and Neonatal Nurses (AWHONN)
recommends a narrative summary that shows a “logical
step-by-step approach to relieving the affected
shoulder.” 20(p8) AWHONN cautions that recorded times
must be accurate. 20
A resuscitation area should be ready for the newborn.
Any resuscitation needed and Apgar scores should be
recorded by nursing. An arm that is limp, unmoving,
and extended with absent reflexes indicates brachial
plexus injury. 20 Any bruising of the newborn and limitations
in arm movement should be recorded in the
nurses’ immediate newborn assessment. The nurse
must communicate these findings to the midwife or
physician and the nursing staff receiving the newborn
for postpartum care.
Once the newborn and mother are settled and
starting postpartum recovery, nurses should complete
documentation and review it for consistency with the
documentation of other providers. If, for example,
the provider’s note says there was no episiotomy
but a second-degree laceration and the nurses’ labor
summary says there was an episiotomy, the documentation
must be reconciled for accuracy. Electronic fetal
monitoring time and comment recordings are another
potential source of discrepancy with the medical
record. 20
POSTPARTUM CARE
In the past, physicians, midwives, and nurses avoided
discussing the shoulder dystocia event or prognosis
for fear of receiving blame for mismanagement and increasing
the risk of a negligence claim. Immediate dialogue
following the shoulder dystocia can maximize
effective communication, which can minimize anger
and frustration for the mother and family. 24,25 Debriefing
offers the opportunity to explain the event to the
mother who may not remember or understand what
occurred. Vandekkieft 26 uses an ABCDE (Advance,
Build, Communicate, Deal, Encourage) approach that
includes Advance preparation (know relevant clinical
information). Build a therapeutic environment by determining
what the patient wants and needs to know
and discuss with supportive family members present.
Communicate effectively by being frank but compassionate
and avoiding medical jargon. The nurse further
deals with patient and family reactions allowing time
for tears, anger, and silence and by encouraging and
validating emotions.
The pediatric staff should discuss medical follow-up
with the family so they can anticipate home physical
therapy and additional physician visits. Mothers who
have had a shoulder dystocia need to be informed that
the risk of shoulder dystocia in subsequent pregnancies
is increased. 19 Nursing staff may link mothers with social
or chaplaincy services for extra support. 27
Following a shoulder dystocia with brachial plexus
injury, the nursing staff should contact the organizational
risk manager. The risk manager will assist the
staff with documentation and communication between
providers, the mother, and family. The risk manager can
lead a review of the dystocia management. The purpose
of the case review is not to assign blame but to determine
what measures were successful and what steps
might be refined or changed. The case review should
be attended by anyone present at the birth. This increases
information about the event and potential improvements
to shoulder dystocia management.
The risk for postpartum hemorrhage increases following
a shoulder dystocia. 1 The fundus should be
palpated to assess uterine contraction at least every
15 minutes during the first postpartum hour. Early
newborn breast-feeding increases endogenous maternal
oxytocin to decrease postpartum bleeding. In the
absence of breast-feeding, vigilant assessment and documentation
of maternal blood loss with exogenous
pitocin use can limit maternal blood loss. Perineal
trauma such as bruising and lacerations is common following
a shoulder dystocia. Ice packs applied to the
perineum immediately postpartum reduce edema and
perineal pain. After 24 hours, pain relief may be more
effective using warm sitz baths.
The newborn with a fractured clavicle or humerus
may wear a cloth sling to splint the injured arm. Recovery
is spontaneous. Approximately 80% of brachial
plexus injuries heal over 3 to 6 months postpartum. 7,8
Newborns who lack spontaneous arm movement or
show no improvement in 4 to 6 weeks postpartum
should be referred to pediatric neurologists for
evaluation. 8 Demonstrating any special arm care and
assessing parental comfort with that care are essential
components of newborn discharge planning. Parents
need to understand any newborn referrals and be able
to schedule the appointments.

20 Journal of Perinatal & Neonatal Nursing/January–March 2008
CONCLUSION
Shoulder dystocia is traditionally viewed as a labor
emergency that is managed by the birth attendant.
However, perinatal nurses can work with mothers
to reduce the risk of shoulder dystocia during both
the prenatal and intrapartum periods. Education and
practice in assisting with the management of a shoulder
dystocia can improve outcomes for the newborn
and mother. Perinatal nurses can ease the transition
between birthplace and home by preparing mothers
and families for the care of the newborn with a brachial
plexus injury. Actions provided by perinatal nurses are
essential in reducing the risk of shoulder dystocia and
improving the outcomes following a shoulder dystocia
throughout pregnancy and birth.
REFERENCES
1. American College of Obstetricians & Gynecologists
(ACOG). Shoulder Dystocia. Washington, DC: ACOG
Practice Bulletin #40;2002:1–5.
2. Spong CY, Beall M, Rodrigues D, Ross MG. An objective
definition of shoulder dystocia: prolonged head-to-body
delivery intervals and/or the use of ancillary obstetric
maneuvers. Obstet Gynecol. 1995;86(3):433–436.
3. Cohen B, Penning S, Ansley D, Porto M, Garite T. The incidence
and severity of shoulder dystocia correlates with a
sonographic measurement of asymmetry in patients with
diabetes. Am J Perinatol. 1999;16(4):197–201.
4. Pollack R, Buchman A, Yaffe H, Divon M. Obstetrical
brachial palsy: pathogenesis, risk factors, and prevention.
Clin Obstet Gynecol. 2000;43(2):236–246.
5. Dunham E. Obstetrical brachial plexus palsy. Orthop
Nurs. 2003;22(2):106–116.
6. Jennett R, Tarby T, Krauss R. Erb’s palsy contrasted with
Klumpke’s and total palsy: different mechanisms are involved.
Am J Obstet Gynecol. 2002;186(6):1216–1220.
7. Donnelly V, Foran A, Murphy J, McFarland P, Keane D,
O’Herlihy C. Neonatal brachial plexus palsy: an unpredictable
injury. Am J Obstet Gynecol. 2002;187(5):1209–
1212.
8. Harele M, Gilbert A. Management of complete obstetric
brachial plexus lesions. J Pediatr Orthop. 2004;
24(2):194–200.
9. Dodds S, Wolfe S. Perinatal brachial plexus palsy. Curr
Opin Pediatr. 2000;12(1):40–47.
10. Jevitt C. Shoulder dystocia: etiology, risk factors, and
management. J Midwifery Womens Health. 2005;50:
485–497.
11. Centers for Disease Control and Prevention. 5 a day program.
http://www.cdc.gov/nccdphp/dnpa/5ADay/. Accessed
July 3, 2007.
12. Institute of Institute of Medicine Subcommittee on Nutritional
Status and Weight Gain during Pregnancy. Nutrition
During Pregnancy. Institute of Medicine. Washington,
DC: National Academy Press; 1990.
13. American College of Obstetricians and Gynecologists
(ACOG). Obesity in Pregnancy. ACOG Technical Bulletin.
Washington, DC: ACOG; 2005.
14. Centers for Disease Control and Prevention. Overweight
and obesity: childhood overweight: overweight prevalence.
http://www.cdc.gov/nccdphp/dnpa/obesity/
trend/index.htm. Accessed July 3, 2007.
15. Cogswell ME, Serdula MK, Hungerford DW, Yip R. Gestational
weight gain among average-weight and overweight
women—what is excessive? Am J Obstet Gynecol.
1995;172(2, pt 1):705–712.
16. Bianco S, Smilen S, Davis Y, Lopez S, Lapinski R, Lockwood
C. Pregnancy outcome and weight gain recommendations
for the morbidly obese woman. Obstet Gynecol.
1998;91(1):97–102.
17. American College of Obstetricians & Gynecologists
(ACOG). Fetal Macrosomia. Washington, DC: ACOG
Practice Bulletin # 22;2000:1–11.
18. Oral E, Cagdas A, Gezer A, Kaleli S, Aydinli K, Ocer F.
Perinatal and maternal outcomes of fetal macrosomia.
Eur J Obstet Gynecol Reprod Biol. 2001;99(2001):161–
171.
19. Gherman G, Chauhan S, Ouzounian J, Lerner H, Gonik
B, Goodwin M. Shoulder dystocia: the unpreventable obstetric
emergency with empiric management guidelines.
Am J Obstet Gynecol. 2006;195:657–672.
20. Association of Women’s Health, Obstetric and Neonatal
Nurses. Perinatal Nursing. Philadelphia, PA: Lippincott,
Williams & Wilkins; 2008.
21. Beall M, Spong C, Ross M. A randomized controlled trial
of prophylactic maneuvers to reduce head-to-body delivery
time in patients at risk for shoulder dystocia. Obstet
Gynecol. 2003;102(1):31–35.
22. Ramsey P, Ramin K, Field C, Rayburn W. Shoulder dystocia:
rotational maneuvers revisited. J Reprod Med.
2000;45(2):85–88.
23. Gurewitsch E, Donithan M, Stallings S, et al. Episiotomy
versus fetal manipulation in managing severe shoulder
dystocia: a comparison of outcomes. Am J Obstet Gynecol.
2004;191:911–916.
24. Woods J, Rozovsky F. What Do I say? Communicating
Intended or Unanticipated Outcomes in Obstetrics. San
Francisco: Jossey-Bass; 2003.
25. Barnett M. Effect of breaking bad news on patients’ perceptions
of doctors. J R Soc Med. 2002;95:343–347.
26. Vandekieft G. Breaking the bad news. Am Fam Physician.
2001;64(12):1975–2001.
27. Kwek K, Yeo G. Shoulder dystocia and injuries: prevention
and management. Curr Opin Obstet Gynecol.
2006;18:123–128.