What is the initial management strategy for a shoulder dystocia with a suspected clavicle fracture?

Initial Management of Shoulder Dystocia with Suspected Clavicle Fracture

When shoulder dystocia is recognized with a suspected clavicle fracture, immediately announce the emergency, call for additional help, and perform the McRoberts maneuver as your first intervention. 1

Immediate Management Algorithm

1. Recognition and Team Mobilization

   • Announce "shoulder dystocia" to alert the team
   • Call for additional help including pediatrician
   • Position mother appropriately for interventions

2. Primary Maneuvers (in sequence)

   • McRoberts maneuver: Hyperflexion of maternal thighs tightly against abdomen
     • Success rate of approximately 25-42% when used alone 2, 3
     • Flattens sacrum relative to lumbar spine and rotates symphysis pubis
   • Suprapubic pressure: Apply pressure above pubic symphysis (NOT fundal pressure)
     • Combined with McRoberts, resolves approximately 58% of cases 4

3. Secondary Maneuvers (if primary fails)

   • Rotational methods (Woods screw maneuver)
     • Associated with lower rates of brachial plexus injury (4.4%) compared to posterior arm delivery (21.4%) 2
   • Posterior arm delivery
     • Consider if posterior shoulder is accessible

Management of Suspected Clavicle Fracture

If clavicle fracture is suspected during or after delivery:

1. Immediate Assessment

   • Perform gentle examination of the clavicle area
   • Note any crepitus, spongy feeling, or asymmetry of movement 5
   • Document findings thoroughly for medico-legal purposes 5

2. Diagnostic Confirmation

   • Obtain appropriate imaging to confirm the fracture 5
   • Clavicular fractures occur in approximately 10 times more frequently in macrosomic infants 6

3. Treatment Approach

   • Most clavicle fractures heal without intervention 5
   • No surgical intervention is typically required for neonatal clavicle fractures 6
   • Immobilization is generally not necessary 6

Important Precautions

• Avoid excessive traction on the fetal head as this increases risk of brachial plexus injury 1
• Never apply fundal pressure as this can worsen the impaction 1, 7
• Do not attempt to rotate the fetal head 180 degrees as this can cause cervical spine injury 1

Parent Communication

• Explain the diagnosis clearly to parents
• Reassure that healing without residual deformity will occur without medical intervention 5
• Explain that clavicle fractures are the most common birth-related bony injuries 5

Documentation Requirements

• Document all maneuvers performed in sequence
• Record timing of events and personnel present
• Note suspected clavicle fracture and subsequent confirmation
• Document parent communication regarding the injury 5

Follow-up Care

• Pediatric follow-up should be arranged
• Monitor for proper healing of the fracture
• Assess for any limitation in arm movement during recovery

Remember that shoulder dystocia is often unpredictable, and while macrosomia increases risk, shoulder dystocia can occur in infants of normal birth weight as well 6. Simulation-based training for all delivery room staff has been shown to reduce neonatal injury rates 7.