What is the management of a newborn with shoulder dystocia (obstetric emergency) after birth?

Management of Newborn After Shoulder Dystocia

Immediate assessment and resuscitation of the newborn are critical priorities after a shoulder dystocia delivery to minimize morbidity and mortality.

Initial Assessment and Stabilization

• Position the infant in a "sniffing" position to open the airway, clear secretions if needed, dry the infant, and provide stimulation 1
• Maintain normal temperature of the infant through appropriate warming techniques to prevent hypothermia 1
• Perform immediate evaluation for potential injuries related to the dystocia, including assessment of respiratory status, color, tone, and activity 2
• Ensure the infant's face is visible, head is in "sniffing" position, nose and mouth are not covered, and neck is straight 1

Assessment for Injuries

• Examine for potential brachial plexus injuries, which are among the most common complications of shoulder dystocia 1, 3
• Assess for possible clavicular or humeral fractures by gentle palpation of the clavicles and upper extremities 3, 4
• Evaluate for signs of hypoxic injury, which may have occurred during prolonged dystocia 3, 5
• Document Apgar scores and any resuscitative measures required 1

Specialized Care Requirements

• Newborns with shoulder dystocia might require specialized immediate postnatal medical management 1
• Consider referral to a specialist center for diagnostic assessment and management if complications are identified 1
• Implement continuous monitoring by trained staff members with frequent recording of vital signs during the immediate postnatal period 1
• Monitor for signs of respiratory distress, which may indicate pneumothorax or diaphragmatic paralysis secondary to phrenic nerve injury 3, 6

Safe Positioning and Handling

• Use proper handling techniques to prevent additional trauma:
  • Pick up using flat hands and a side roll technique, holding under the neck and nappy/diaper 1
  • Do not lift holding under the arms, which could exacerbate brachial plexus injuries 1, 4
• Ensure the infant's shoulders and chest face the mother during skin-to-skin care, with legs flexed and back covered with blankets 1

Monitoring Protocol

• Implement risk stratification and associated monitoring to avert sudden unexpected postnatal collapse (SUPC), falls, and suffocation 1
• Perform frequent and repetitive assessments, including observation of newborn breathing, activity, color, tone, and position 1
• Consider continuous staff observation with frequent recording of vital signs during the first few hours of life 1
• Monitor for signs of neurological injury, including asymmetric Moro reflex, decreased spontaneous movement of affected limb, or abnormal posturing 3, 5

Parent Education and Support

• Educate parents about the potential complications of shoulder dystocia and signs to watch for 4
• Assist mothers and families to review the shoulder dystocia and any newborn injuries in the postpartum period to reduce confusion and anxiety 4
• Provide guidance on safe handling techniques to prevent exacerbation of any injuries 1, 4

Follow-up Care

• Regardless of any previous diagnosis or indicator of prognosis, all infants with suspected complications from shoulder dystocia should be reevaluated as soon as practical after delivery 1
• Arrange appropriate follow-up with pediatric specialists if brachial plexus injury or other complications are identified 3, 6
• Consider physical therapy consultation for infants with brachial plexus injuries 3, 5

Prevention of Further Complications

• Avoid instrumentation of the fetal head in situations where skeletal dysplasia is suspected due to increased risk of intracranial and C-spine complications 1
• When mother wants to sleep, place infant in bassinet or with another support person who is awake and alert to prevent falls 1
• Implement safe positioning practices to prevent airway obstruction during skin-to-skin care 1