What is the management of a newborn with shoulder dystocia (obstetric emergency where the anterior shoulder of the infant cannot pass below the pubic symphysis after the delivery of the head)?

Management of Newborn After Shoulder Dystocia

Immediately position the infant in a "sniffing" position to open the airway, clear secretions if needed, dry and stimulate the infant, while simultaneously assessing for brachial plexus injuries and implementing continuous monitoring protocols. 1

Immediate Stabilization and Airway Management

The first priority is establishing adequate respiratory function and preventing hypothermia:

• Position the infant's head in the "sniffing" position with the neck straight, ensuring the face is visible and the nose and mouth are not covered 1
• Clear secretions from the airway if needed, dry the infant thoroughly, and provide gentle stimulation to initiate breathing 1
• Maintain normothermia through appropriate warming techniques, as hypothermia is associated with increased neonatal morbidity across all gestational ages 2, 1
• Document Apgar scores at 1,5, and 10 minutes after delivery, along with any resuscitative measures required 2, 1

Assessment for Birth Injuries

Brachial plexus injuries are the most common complication following shoulder dystocia and must be systematically evaluated 1, 3:

• Examine for brachial plexus injury (Erb's palsy, Klumpke's palsy) by assessing arm movement, Moro reflex asymmetry, and grasp reflex 1
• Assess for clavicular fractures through palpation and observation of arm movement limitations 4, 3
• Evaluate for humeral fractures, which can occur during delivery maneuvers 5
• Check for signs of hypoxia or neurologic compromise, as prolonged head-to-body delivery intervals increase risk of central nervous system injury 6

A critical caveat: Research demonstrates that 71% of neonates with injuries consistent with shoulder dystocia were delivered without obstetric recognition of the dystocia, meaning many injuries go undetected initially 4. This underscores the importance of thorough examination even when shoulder dystocia was not formally documented.

Specialized Care and Monitoring Requirements

Implement continuous monitoring by trained staff with frequent vital sign recording during the immediate postnatal period 1:

• Perform frequent and repetitive assessments including observation of breathing pattern, activity level, color, muscle tone, and position 1
• Use risk stratification protocols to prevent sudden unexpected postnatal collapse (SUPC), falls, and suffocation 1
• Consider continuous staff observation during the first few hours of life, particularly if any complications are suspected 1

Safe Handling and Positioning Techniques

Proper handling is essential to prevent additional trauma to potentially injured structures 1:

• Use flat hands and a side roll technique when picking up the infant, supporting under the neck and diaper area 1
• During skin-to-skin care, ensure the infant's shoulders and chest face the mother, with legs flexed and back covered with blankets 1
• Avoid excessive manipulation of potentially injured extremities until full assessment is completed 1

Referral and Follow-up Protocol

The American College of Obstetricians and Gynecologists provides clear guidance on specialized care needs 1:

• All infants with suspected complications should be reevaluated as soon as practical after delivery 1
• Consider referral to a specialist center for diagnostic assessment and management if brachial plexus injury, fractures, or neurologic complications are identified 1
• Newborns with shoulder dystocia may require specialized immediate postnatal medical management beyond routine newborn care 1

Documentation Requirements

Comprehensive documentation serves both clinical and medicolegal purposes 7:

• Record the sequence and timing of all delivery maneuvers performed during the shoulder dystocia (McRoberts, suprapubic pressure, rotational maneuvers, posterior arm delivery) 7
• Document all neonatal injuries identified, resuscitative measures required, and Apgar scores 1, 7
• Note the head-to-body delivery interval, as this correlates with risk of both mechanical and hypoxic injury 6

Special Considerations

Avoid instrumentation in cases where skeletal dysplasia was suspected, as this increases risk of intracranial and cervical spine complications 1. The emphasis on gentle handling and thorough assessment cannot be overstated, as the mechanical forces during shoulder dystocia delivery create risk for multiple injury patterns that may not be immediately apparent 4, 6.