Difficult labor [dystocia] due to shoulder presentation. Shoulder dystocia: clinical guidelines

List of Abbreviations

Terms and Definitions

Symphysiotomy – a surgical intervention involving the division of the pubic symphysis; in SD, its purpose is to increase the capacity of the maternal pelvis.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Shoulder dystocia (SD) is the arrest of labor after the delivery of the fetal head due to the failure of spontaneous descent of the shoulder girdle and the inefficacy of gentle auxiliary downward traction during pushing efforts for more than 60 s. Additional maneuvers are required to deliver the fetal shoulder girdle to resolve this complication.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

In an uncomplicated second stage of labor, at the moment of extension and delivery of the fetal head, the shoulders descend into the pelvic inlet plane in an oblique or transverse pelvic diameter. Then, as the shoulders pass through the pelvic cavity, internal rotation occurs. As a result of this rotatory-translatory movement, the shoulders align in the direct (anteroposterior) diameter of the pelvic outlet plane on the pelvic floor. Internal rotation of the shoulders is accompanied by external rotation of the head. Once the shoulders are positioned in the direct diameter of the pelvic outlet, the midwife gently directs the fetus downward and backward, helping the anterior shoulder roll out from under the pubic bone up to its upper third. Then the direction is cautiously reversed and the posterior shoulder is delivered from the perineum, after which the entire shoulder girdle is completely born. In approximately 20% of cases, during extension and delivery of the fetal head, the shoulders remain in the direct or slightly oblique diameter of the pelvic inlet and do not descend into the pelvic cavity until the next contraction and pushing effort. If the shoulders fail to rotate during the subsequent push, the mechanism of labor is disrupted. The fetal shoulders become fixed in this position, further fetal descent stops, and SD develops. In this process, the anterior shoulder most frequently impacts against the pubic symphysis, less commonly the posterior shoulder against the sacrum, and very rarely both shoulders encounter obstruction. Disruption of the mechanism of labor occurs when forcing the descent of the shoulders via downward traction on the head or in cases of operative delivery.

Additionally, SD may be caused by fetopelvic disproportion (macrosomia, contracted pelvis) and other risk factors listed below.

1.3 Epidemiology of the Disease or Condition

The incidence of shoulder dystocia (SD) ranges from 0.2 to 3%. The prevalence of SD varies depending on fetal weight: from 0.6% to 1.4% at a fetal weight of 2500 to 4000 g, and increases to 5-9% at a fetal weight of 4000 to 4500 g [1].

1.4 Features of Coding the Disease or Condition

O66.0. Obstructed labor [dystocia] due to shoulder dystocia.

1.5 Classification of the disease or condition

Classification is absent

1.6 Clinical presentation of the disease or condition

• after the delivery of the fetal head, the delivery of the shoulders is delayed for more than 60 seconds;

• gentle deflection of the born head (no more than 30-40° downwards from the axis) during the next push is not accompanied by the delivery of the shoulder;

• "turtle sign" – the fetal head has been delivered, but the neck remains tightly grasped by the vulva, and the chin is retracted back into the perineum.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition.

The diagnosis is established based on the clinical picture (section 1.6).

2.1 Complaints and Anamnesis

When collecting complaints, medical history, and assessing the course of labor to ensure heightened vigilance due to the high probability of SD development, the physician is recommended to take into account the following risk factors [61]:

Comments: According to the literature, the risk of recurrent SD ranges from 1 to 25%, and in the presence of maternal DM, the risk of developing SD is 2-4 times higher compared to fetuses of the same weight whose mothers do not have DM. During vacuum extraction of the fetus, the incidence of SD reaches 2.7%, and with the application of obstetric forceps, 3.4% [13,14,15]. Risk factors such as oxytocin-induced labor**, pronounced fetal head molding with the formation of a large caput succedaneum, and premature acceleration of pushing (when the head is above the pelvic inlet plane) may be associated with a prolonged second stage of labor [16]. Even a correctly performed assessment of risk factors has insufficient prognostic potential to prevent the development of SD. Traditional risk factors predict only 16% of SD cases [17]. In 48% of cases, SD is observed with a fetal weight of less than 4000 g [15]. Thus, SD is difficult to predict and prevent in advance in a specific situation [14,15,18,19,20].

2.2 Physical Examination

2.3 Laboratory Diagnostics

Not applicable.

2.4 Instrumental Diagnostics

Not applicable.

2.5 Other Procedures

Not applicable.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. List of initial actions aimed at resolving SD

Comment: From the moment the diagnosis is made, it is necessary to: remain calm; take timely action; give clear commands; calmly explain to the woman and her partner what is happening and what you will be doing; note the time of head delivery (there is a 5-minute window during which the possibility of severe hypoxic damage or fetal death is low) [21]. If possible, a specialist should be assigned to record all moments and the sequence of care provision (it is advisable to use a timer or CTG markings for time control). Anesthesia can be applied (without wasting time waiting), as a number of therapeutic maneuvers involving the introduction of the entire hand into the vagina may require anesthesia for easier and faster execution. If the delivery is taking place under regional anesthesia, this is sufficient. In other cases, perineal infiltration anesthesia or general anesthesia can be used [22].

Comment: Excessive traction increases the rate of neonatal morbidity, including the incidence of brachial plexus injury (Erb's palsy, Klumpke's palsy, Horner's syndrome) [63].

3.2. Maneuvers for resolving SD

Comment: Each maneuver should not last longer than 30 s, which corresponds to approximately two attempts to perform the maneuver; if unsuccessful, a change in tactics is necessary, as continued execution increases neonatal morbidity [16].

External and internal first-line maneuvers

• It is recommended to use the McRoberts maneuver first, which is simple and relatively safe [14,15,20].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: Technique: in the supine position, flex the woman's knees and bring her thighs maximally toward her chest (Fig. 1). This maneuver tilts the pubic symphysis anteriorly, straightening the lumbosacral angle (which leads to the flattening of lordosis). This allows the posterior shoulder to descend below the sacral promontory. In addition, the pelvic inclination angle decreases, and the pelvic inlet plane becomes perpendicular to the expulsive forces, facilitating the advancement of the shoulder girdle. The woman can do this herself by holding her legs with her hands, or medical staff or a partner can help her. The McRoberts maneuver is the simplest and relatively safe maneuver, effective in 40-90% of SD cases, and is therefore recommended to be performed first [20]. However, cases of complications have been described with forced or excessively prolonged use of the maneuver: neonatal brachial plexus palsy, symphysis pubis diastasis, sacroiliac joint displacement, lateral femoral cutaneous neuropathy [30,31,32].

Fig. 1 McRoberts maneuver

Comment: When performing suprapubic pressure (Fig. 2), movements should be sharp, short, and sufficiently strong. The assistant performing the maneuver should stand on the side of the mother toward which the fetal back is turned. Pressure should be applied above the pubic bone, onto the shoulder on the side of the fetal back, directed toward the woman's spine and laterally [8] to shift the shoulder girdle into one of the oblique diameters of the pelvic inlet plane. The effectiveness of the maneuver is higher with an empty bladder. Simultaneous performance of the two previous maneuvers, as well as combination with the internal rotational Rubin maneuver, is possible.

Fig. 2 Suprapubic pressure.

Commentary: As a result of the successful application of this maneuver, the fetal torso is delivered not by its biacromial (>12 cm) diameter, but by its acromio-axillary (9.5 cm) diameter (Fig. 3). When performed correctly, the maneuver is highly effective. To deliver the posterior arm, the operator's corresponding hand is introduced along the fetal back, scapula, and arm down to the elbow. The thumb is placed into the antecubital fossa, while the other four fingers wrap around the elbow, thereby flexing the arm at the elbow joint. Next, the obstetrician's hand moves along the forearm to the wrist; the fetal wrist is grasped between the first and second or second and third fingers, and the arm is delivered outward with a "swearing-in" (sweeping) motion along the chest toward the face. If performed correctly, the hand and forearm of the posterior arm emerge from the vagina first, followed by the humerus and shoulder. If delivery of the anterior shoulder does not occur under these conditions, an internal fetal rotation must be performed to shift the anterior shoulder into the posterior position. A potential complication of the maneuver is fracture of the humerus [8]. 

Fig. 3. Delivery of the posterior arm (Jacquemier maneuver).

First-line internal rotational maneuvers

Commentary: To perform this maneuver, introduce a hand into the vagina beneath the posterior fetal shoulder (left hand for the first fetal position, right hand for the second), placing the thumb on its anterior surface and the other four fingers on its posterior surface (Fig. 4). Grasp the posterior shoulder with the thumb and index finger forming a ring ("ok" sign) through the axilla. Apply slight downward and outward traction to the posterior shoulder ("shrugging" motion). Support the fetal head and the extended shoulder together (as a single "head-neck" unit) and rotate it 180 degrees toward the fetal chest. The anterior shoulder will move into the posterior position, resolving the dystocia. Delivery will be completed with gentle tractions. The maneuver is effective and particularly useful when the hand or elbow crease of the posterior arm is out of reach.

Fig. 4 Rotational maneuver of grasping the posterior fetal shoulder

Commentary: To perform the maneuver, insert two fingers from the side of the fetal back toward the anterior shoulder and apply pressure to shift the shoulder girdle by 45º into the corresponding oblique diameter (Fig. 5). If the anterior shoulder is inaccessible, move the fingers to the area of the posterior shoulder and, applying pressure, shift the shoulder girdle by 45 degrees into the oblique diameter (similar to applying pressure on the fetal shoulder in the reverse Woods' screw maneuver – see Fig. 8 below).

Fig. 5 Rubin maneuver.

Commentary: The Woods' screw maneuver consists of converting the posterior shoulder into the anterior one by applying pressure with the fingers of the physician's hand introduced into the pelvic cavity from the side facing the fetal chest (Fig. 6). In the case of position I (back to the left), insert the palm of the left hand into the right part of the pelvic cavity toward the posterior shoulder from the fetal chest side and attempt to rotate the posterior shoulder into the anterior position (by 180º). In this position, combination with the Rubin maneuver is possible (Fig. 7). In the case of position II (back to the right), insert the palm of the right hand into the left part of the pelvic cavity toward the posterior shoulder from the fetal chest side and attempt to rotate the posterior shoulder into the anterior position (by 180º). The maneuver is effective, however, it carries a risk of humeral fracture [22]. If the maneuver is ineffective, it is advisable to proceed without delay to the next maneuver – the reverse Woods' screw.

Commentary: The reverse Woods' screw maneuver involves converting the posterior shoulder into the anterior one by applying pressure with the fingers of the physician's hand introduced into the pelvic cavity from the side facing the fetal back (Fig. 8). For position I, the physician uses the right hand, and for position II, the left hand. The physician's hand approaches the posterior fetal shoulder from the back side and attempts to push the shoulder in the direction opposite to that of the standard Woods' screw maneuver.

Fig. 8 Reverse Woods' screw maneuver.

Commentary: A loop is formed from a soft plastic tube (e.g., a CH/FR 14-16 duodenal catheter, less commonly a Foley catheter). With one hand, the loop is guided beneath the axilla of the posterior shoulder. Using the index finger of the other hand from the opposite side, the loop is caught and pulled out. A sling is formed around the posterior shoulder by applying a clamp to the free ends of the plastic tube. Direct tractions are then applied to deliver the posterior shoulder (Fig. 9). Assistance from the second hand to deliver the posterior arm is possible.

Fig. 9 Posterior axillary sling traction

If the aforementioned method is unsuccessful, rotational movements using a sling may be used. For this purpose, sling tractions are applied with one hand to the side, while the other hand is guided to the anterior shoulder and pressure is applied in the opposite direction (Fig. 10) [37]. Instead of a sling, posterior axillary traction performed with the middle fingers of both obstetrician's hands is possible [35].

Fig. 10 Rotation using a sling

Commentary: The woman should get on all fours, supporting herself on her hands and knees (Fig. 11). With gentle traction, the posterior shoulder is delivered first. Often, the fetal shoulder is released even during the rotation of the parturient from the supine to the knee-chest position. This maternal position is compatible with the performance of the aforementioned fetal rotation maneuvers, except for McRoberts' maneuver and suprapubic pressure. This procedure is usually used if previous ones have proven ineffective. In a number of cases during upright deliveries (e.g., on all fours or sitting on a stool), it is advisable to begin assistance with this maneuver.

Fig. 11 Gaskin maneuver

Comment: Second-line maneuvers are typically used when the aforementioned methods are ineffective and the 5-minute time limit—during which the probability of irreversible and severe fetal injury is still relatively low—has already been exhausted. These maneuvers are more traumatic for both mother and fetus. Due to the poor perinatal prognosis and high травматичность [note: traumatic nature], the use of these methods in modern obstetrics is a subject of debate [8,14,15].

Second-line maneuvers

Commentary: To perform the maneuver, it is recommended to palpate the middle third of the anterior (upper) fetal clavicle with a finger and apply pressure from bottom to top; this will fracture the clavicle and reduce the distance between the fetal shoulders. Complications of the maneuver include injury to the underlying neurovascular bundle and lung tissue. At the same time, it should be noted that in the event of shoulder dystocia, fracturing the clavicle is not always easy to perform, especially with large fetuses [14,40].

Commentary: When performing the Zavanelli maneuver, the head is rotated to the occiput anterior position (sagittal suture in the direct diameter), followed by flexion of the head and its careful replacement back into the birth canal. That is, the movements performed precisely repeat the mechanism of fetal head delivery in reverse order. After replacing the head, the physician's hand remains in the birth canal and continues to apply constant upward pressure, holding the head inside until the surgical team performs a Cesarean section. Sometimes the execution of the maneuver may require acute tocolysis and anesthesia. One of the most severe potential complications of the maneuver is uterine rupture [41].

Comment: In some cases of severe SD, lower segment Cesarean section is performed. The surgeon then pulls up the anterior shoulder and performs an internal rotation of the fetus, positioning the shoulders in the oblique diameter of the pelvis. This facilitates the delivery of the posterior shoulder followed by the anterior shoulder, and the birth of the fetus through the vagina with the assistance of a second assistant [44].

Comment: In modern obstetrics, symphysiotomy is practiced in developing countries and is used in very rare cases in countries with high-income healthcare systems [47]. If a Cesarean section is not feasible, symphysiotomy may be performed under local anesthesia by a surgeon well-versed in the operative technique. The patient is placed in the lithotomy position with the abducted legs fixed at no more than 80°. The urinary bladder is emptied using a catheter. The index and middle fingers of one hand are inserted into the vagina, the urinary catheter is located and displaced laterally along with the urethra so that the middle finger lies directly beneath the joint space of the pubic symphysis. A small midline skin incision is made at the border of the upper and middle thirds of the symphysis. The incision is carried through deeper layers until the finger feels the tip of the blade. Then, in a single motion, the lower 2/3 of the pubic symphysis is divided. Afterward, the scalpel is removed from the wound, rotated 180°, and the upper third is divided. The separation of the pubic bones should not exceed the width of a thumb or 2.5 cm. Complications (approx. 2%) are possible, including hemorrhage, injuries to the lower urinary tract, osteitis pubis, or instability of the sacroiliac joints and pubic symphysis [22, 28, 40].

Postpartum management:

a) The urinary catheter is left in place for 4-7 days until the urine is clear.

b) Systemic antibacterial drugs are prescribed for 7 days.

c) Thromboprophylaxis is performed according to the risk level.

d) The patient should spend most of the time lying on her side with her knees loosely tied together to prevent leg abduction. She must maintain this position for the first 3 days.

1. Documentation [48] (see Appendix A3. SD Care Chart).

2. Counseling the postpartum patient and relatives.

3. Debriefing of the actions performed and their outcome by the team to analyze potential errors in order to improve future work efficiency [49].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

3.3. Features of neonatal resuscitation

Comment: Even with timely delivery (within 5 minutes), the risk of delivering a newborn requiring resuscitation in shoulder dystocia is quite high. Even in the absence of documented fetal distress prior to the onset of dystocia and timely extraction of the infant (acute hypoxia duration not exceeding 5 min), infants are frequently born with low Apgar scores, require resuscitation and intensive care, and experience adverse neurological outcomes [28]. The severity of the infant's condition in SD is caused not only by hypoxia, but also by hypovolemia, which develops due to the compression of the umbilical cord vessels and, consequently, a reduction in blood flow to the infant [28, 50, 51, 52]. There is evidence regarding the efficacy of delayed cord clamping (as a method for correcting hypovolemia) and initiating resuscitation before cord clamping (if technically feasible) [53].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable

5. Prevention and Dispensary Observation

Comment: To prevent a single case of severe SD complications, such as Erb-Duchenne palsy, 443 Cesarean sections would need to be performed in pregnant women with GDM and a fetal weight >4500 g, whereas in the absence of maternal GDM and with a similar fetal weight, 3695 abdominal deliveries must be performed to prevent one such case [15].

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

Not applicable.

Indications for discharging the patient from the medical organization: in accordance with the course of the postpartum period (see clinical guidelines "Postpartum care and examination"). The puerpera is discharged with recommendations for follow-up care in the postpartum period at the local antenatal clinic.

7. Additional Information

Not applicable

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Oleg R. Baev – MD, Professor, Head of the 1st Maternity Department, Head of the Department of Obstetrics and Gynecology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Honored Doctor of the Russian Federation (Moscow). No conflict of interest.

2. Sergey V. Martirosyan – PhD, Associate Professor at the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow), expert at the National Institute of Quality of Roszdravnadzor. No conflict of interest.

3. Margarita D. Andreeva - Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Krasnodar Krai, Professor at the Department of Obstetrics, Gynecology and Perinatology, Faculty of Advanced Training and Professional Retraining of Specialists, Kuban State Medical University of the Russian Ministry of Health, Krasnodar, Russia. No conflict of interest.

4. Sergey V. Apresyan, MD, Deputy Chief Physician for Obstetric and Gynecological Care at the City Clinical Hospital named after A.K. Eramishantsev of the Moscow Healthcare Department, Professor at the Department of Obstetrics and Gynecology with the Course of Perinatology at the Medical Institute of the Peoples' Friendship University of Russia, Professor at the Department of Women's Diseases and Reproductive Health at the National Pirogova Medical Surgical Center (Moscow). No conflict of interest.

5. Artymuk, Natalya V. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology No. 2, Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District (Kemerovo). No conflict of interest.

6. Baranov, Igor I. – D.Sc. (Medicine), Professor, Head of the Department of Scientific and Educational Programs, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

7. Belokrinitskaya, Tatyana E. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Advanced Training and Professional Retraining, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation (Chita). No conflict of interest.

8. Vagushchenko, Ulyana A. – Obstetrician-Gynecologist, Organizational and Methodological Department, Ekaterinburg Clinical Perinatal Center; Assistant, Department of Obstetrics and Gynecology, Faculty of Medicine and Prophylaxis, Ural State Medical University. No conflict of interest.

9. Gagayev, Chelebi G. – D.Sc. (Medicine), Professor, Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute, Peoples' Friendship University of Russia (RUDN University). No conflict of interest.

10. Gracheva, Marina S. – Head of the Pregnancy Pathology Department, Ekaterinburg Clinical Perinatal Center. No conflict of interest.

11. Dolgushina, Nataliya V. – D.Sc. (Medicine), Professor, Deputy Director for Research, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief Freelance Specialist in Women's Reproductive Health of the Russian Ministry of Health (Moscow). No conflict of interest.

12. Zimina, Anna O. – Ph.D. (Medicine), Assistant, Department of Obstetrics and Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health. No conflict of interest.

13. Koltasheva, Irina M. – Obstetrician-Gynecologist, Delivery Suite, Ekaterinburg Clinical Perinatal Center. No conflict of interest.

14. Knyazev, Sergey A. – Ph.D. (Medicine), Associate Professor, Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute, RUDN University; Scientific Expert, StatusPraesens (Moscow). No conflict of interest.

15. Ksenofontova, Olga L. – Ph.D. (Medicine), Deputy Chief Medical Officer, Ekaterinburg Clinical Perinatal Center. No conflict of interest.

16. Logunko, Konstantin P. – Head of the Delivery Suite, Ukhta Inter-Municipal Maternity Hospital, Republic of Komi. No conflict of interest.

17. Lyuskov, Vladimir A. – Highest Qualification Category Physician, Deputy Chief Medical Officer for Medical Work, Komi Republican Perinatal Center, Syktyvkar. No conflict of interest.

18. Oboskalova, Tatyana A. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Medicine and Prophylaxis, Ural State Medical University. No conflict of interest.

19. Olenev, Anton S. – Ph.D. (Medicine), Associate Professor, Chief Freelance Specialist in Obstetrics, Moscow Healthcare Department, Head of the Perinatal Center, City Clinical Hospital No. 24 (Moscow). No conflict of interest.

20. Pankratov, Valeriy V. – D.Sc. (Medicine), Professor, Deputy Chief Medical Officer for Obstetrics and Gynecology, Surgut Clinical Perinatal Center, Khanty-Mansi Autonomous Okrug - Yugra; Medical Institute, Surgut State University. No conflict of interest.

21. Panova, Irina A. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics, Gynecology, Neonatology, Anesthesiology and Intensive Care, Ivanovo Research Institute of Motherhood and Childhood named after V.N. Gorodkov of the Russian Ministry of Health.

22. Penzhoyan, Grigoriy A. – D.Sc. (Medicine), Professor, Honored Doctor of the RF, Excellence in Public Health, Board Member of the Russian Society of Obstetricians and Gynecologists, Head of the Department of Obstetrics, Gynecology and Perinatology, Faculty of Advanced Training and Professional Retraining, Kuban State Medical University of the Russian Ministry of Health. No conflict of interest.

23. Pestrikova, Tatyana Yu. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology, Far Eastern State Medical University of the Russian Ministry of Health. No conflict of interest.

24. Perevozkina, Olga V. – Ph.D. (Medicine), Head of the Clinical and Expert Work Department, Perinatal Center of City Clinical Hospital No. 67 named after L.A. Vorohobov; Assistant, Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow). No conflict of interest.

25. Serov, Vladimir N. – D.Sc. (Medicine), Professor, Academician of the Russian Academy of Sciences, President of the Russian Society of Obstetricians and Gynecologists. No conflict of interest.

26. Schwabsky, Oleg R. – Deputy General Director, Center for Monitoring and Clinical and Economic Expertise of Roszdravnadzor. No conflict of interest.

27. Shmakov, Roman G. – D.Sc. (Medicine), Professor, Professor of the RAS, Director, Moscow Regional Research Institute of Obstetrics and Gynecology named after Academician V.I. Krasnopolsky (Moscow). No conflict of interest.

28. Fatkullin, Ildar F. – D.Sc. (Medicine), Professor, Head of the Department of Obstetrics and Gynecology named after Prof. V.S. Gruzdev, Kazan State Medical University; Chief Freelance Obstetrician-Gynecologist of the Russian Ministry of Health in the Volga Federal District. No conflict of interest.

29. Fatkullina, Larisa S. – Ph.D. (Medicine), Associate Professor, Department of Obstetrics and Gynecology named after Prof. V.S. Gruzdev, Kazan State Medical University; Head of the Obstetric and Gynecological Clinic, Republican Clinical Hospital of the Ministry of Health of Tatarstan. No conflict of interest.

30. Filippov, Oleg S. – D.Sc. (Medicine), Professor, Honored Doctor of the RF, Chief Freelance Obstetrician-Gynecologist of the Federal Medical-Biological Agency (FMBA of Russia), Deputy Director, Federal Research and Clinical Center for Children and Adolescents of the FMBA of Russia, Professor of the Department of Obstetrics, Gynecology and Reproductive Medicine, Russian University of Medicine (Moscow). No conflict of interest.

31. Yurova, Mariya V. – Ph.D. (Medicine), Specialist at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Physician at Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Obstetricians-gynecologists

2. Midwives

3. Neonatologists

4. Anesthesiologists-intensivists

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of reliable evidence (LRE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Appendix A3. Reference Materials

Protocol sheet for care in shoulder dystocia

Reporting document - labor management protocol for shoulder dystocia

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

What is shoulder dystocia?

Dystocia is a condition that can occur during vaginal delivery. In shoulder dystocia, the baby gets stuck behind the mother's pubic bone while moving through the birth canal. This results in difficulty delivering the fetal torso after the head has already been born. Shoulder dystocia is an emergency that requires prompt management.

Can it be predicted?

Usually no. However, medical staff know that shoulder dystocia is more likely when the baby is macrosomic. Women with diabetes and overweight women are more likely to have large babies. It also occurs more frequently in women who have had shoulder dystocia in a previous delivery.

However, shoulder dystocia most commonly occurs for unknown reasons. Therefore, there is no effective way to prevent it.

What are the symptoms?

During labor, the doctor or midwife observes that the baby's shoulders fail to deliver as expected after the baby's head is born.

How is it treated? ­

As soon as your doctor or midwife recognizes that shoulder dystocia has occurred, they will immediately advise you to stop pushing for a short time. Then, they will perform various maneuvers to help the baby be born.

Possible assistive maneuvers:

• Flexing the hips and bringing the thighs up toward the abdomen to increase the pelvic inclination angle and thus the space for the baby

• Applying suprapubic pressure against the baby's back to dislodge the impacted shoulder from behind the pubic bone

• Performing vaginal manipulations to assist in delivering the baby

What complications can occur?

The most common complications that can occur in the infant are:

• Fracture of the arm bones or clavicle

• Nerve injury — if the baby's neck is stretched too much, the nerves around the shoulder can be damaged. This can cause weakness in the arm and make it difficult to move. Doctors sometimes use the term "Erb's palsy" for this type of injury.

The most common complication that can occur in the mother is bleeding from soft tissue lacerations of the birth canal; more severe complications are very rare.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Apgar score

Type: rating scale

Purpose: assessment of the newborn's condition

Content:

Interpretation:

A score of 4–7 points at 1 minute after birth corresponds to moderate birth asphyxia (P21.1, ICD-10), and 0–3 points at 1 minute after birth corresponds to severe asphyxia (P21.0, ICD-10). Although according to ICD-10 a total score of 7 points at 1 minute after birth corresponds to moderate asphyxia, it is inadvisable to assign this diagnosis, since a 7-point Apgar score at the end of the 1st minute is not clinically and/or prognostically significant.

The prognostic value of the first Apgar score is extremely low in principle. Adverse short- and long-term outcomes correlate with a low Apgar score at 5 and 10 minutes after birth.

Note: The test is usually performed at 1 and 5 minutes after birth and may be repeated later if the score remains low.