Of all the birth-injury cases we review, shoulder dystocia is the one parents most often misunderstand — and the one where the misunderstanding cuts both ways. Some parents assume that because a doctor caused their baby's arm injury by pulling, the doctor must be liable. Others assume that because shoulder dystocia is a recognized emergency that "just happens," no one could be at fault. Both assumptions skip the question that actually decides these cases: not whether the shoulder got stuck, but what the delivery team did in the sixty seconds after it did.
When Herb Borroto, M.D., J.D., reviews a shoulder dystocia case, he is not looking for the dystocia. Shoulder dystocia is largely unpredictable and, in most instances, unpreventable. He is reading the delivery note for a different thing entirely — the sequence of maneuvers, the language describing how the head was handled, and the timing. Here is a plain-English read on what shoulder dystocia is, why the emergency itself is rarely the negligence, what the standard of care requires, and what these cases look like from inside the records.
What Is Shoulder Dystocia?
Shoulder dystocia is an obstetric emergency in which, after the baby's head delivers, one of the shoulders becomes lodged behind the mother's pubic bone (or, less often, the sacral promontory) and does not deliver with normal, gentle downward traction. The head is out, but the body is stuck. The classic warning sign is the "turtle sign" — the head emerges and then retracts back against the perineum, like a turtle pulling into its shell.
It is uncommon, complicating roughly 0.2% to 3% of vaginal deliveries depending on how it is defined, and it is a time-critical emergency. Once the head is delivered and the body is trapped, the umbilical cord can be compressed against the birth canal, so the clock on the baby's oxygen supply starts running. A competent delivery team is trained to recognize the impaction immediately and move through a deliberate set of maneuvers — not to pull harder.
Why the Shoulder Dystocia Itself Is Usually Not the Negligence
This is the single most important idea in a shoulder dystocia case, and it is the one most competitor pages gloss over. The American College of Obstetricians and Gynecologists (ACOG) has been explicit that shoulder dystocia cannot be reliably predicted or prevented. Most cases occur in women with no risk factors at all, and most babies with recognized risk factors deliver without any dystocia. There is no screening test that catches it in advance and no maneuver that prevents it.
That matters legally, because medical malpractice is not "a bad outcome happened." It is "a provider deviated from the standard of care, and that deviation caused the harm." Since the dystocia itself is generally not a deviation, the analysis moves to the response. A shoulder dystocia that is recognized promptly and worked through with calm, correct technique frequently ends with a healthy baby and no permanent injury. The cases that end in a lifelong brachial plexus injury are, disproportionately, the cases where the response went wrong.
The central insight of a shoulder dystocia case. The question is almost never "should this dystocia have been avoided?" It is "once the shoulder was stuck, did the team do the right things in the right order — or did someone pull too hard, push in the wrong place, or waste the window?" That reframing is what separates a viable claim from a tragic but non-negligent event.
What Does the Standard of Care Require When It Happens?
ACOG Practice Bulletin No. 178 (Shoulder Dystocia) sets out the framework the standard of care follows. There is no single mandatory script, but there is a well-recognized set of maneuvers that a trained team is expected to move through efficiently:
- Call for help and stop pushing. The team should immediately summon additional staff, note the time, and instruct the mother to stop pushing so no additional force is added to a stuck shoulder.
- McRoberts maneuver first. The mother's legs are sharply flexed back toward her chest, which rotates the pelvis and flattens the lumbar spine to open the outlet. It is simple, fast, and effective — studies show it resolves a large share of shoulder dystocias on its own, and it is the standard first step.
- Suprapubic pressure. An assistant presses just above the pubic bone (not on the top of the uterus) to nudge the impacted shoulder under the bone. This is usually combined with McRoberts.
- Escalation maneuvers. If those fail, the team escalates through recognized techniques: delivery of the posterior arm, rotational maneuvers (the Rubin and Woods "screw" maneuvers), and the Gaskin all-fours position. The order can vary with the clinician's judgment and what is working.
- Last-resort maneuvers. Rarely, for a truly intractable dystocia, extraordinary measures such as the Zavanelli maneuver (replacing the head and moving to cesarean) or symphysiotomy are described.
Two cautions run through the entire guideline. First, traction on the fetal head should be gentle and directed along the normal axis — never aggressive lateral or downward pulling, because that is precisely what stretches and tears the brachial plexus. Second, fundal pressure — pushing down on the top of the uterus — is not an accepted maneuver; it drives the shoulder harder into the pubic bone and is associated with a higher rate of injury.
What Goes Wrong — The Negligence Patterns
Across shoulder dystocia cases, a handful of failure patterns recur. Each is a departure from the framework above:
- Excessive traction on the head. The most common allegation. Strong lateral or downward pulling on the head and neck to force the delivery, rather than working through maneuvers, is the classic mechanism of a negligent brachial plexus injury.
- Fundal pressure instead of suprapubic pressure. Pushing on the top of the uterus — sometimes by a panicked or undertrained assistant — worsens the impaction and can add to the force on the trapped shoulder.
- Failure to recognize the dystocia promptly. Missing the turtle sign or treating a genuine impaction as ordinary slow progress wastes the narrow window before oxygen deprivation begins.
- No organized maneuver sequence. Repeatedly attempting the same failed pull instead of escalating through the recognized techniques.
- Failure to call for help or to have a plan. ACOG and patient-safety bodies emphasize team drills; a unit with no rehearsed protocol tends to improvise under pressure.
- Delivering a high-risk baby vaginally without appropriate counseling in the narrow situations where the guideline supports discussing a planned cesarean.
Which Babies Are at Higher Risk?
Even though shoulder dystocia cannot be reliably predicted, certain factors raise the statistical risk and should heighten a team's readiness. They do not, by themselves, make a dystocia anyone's fault — but a team aware of them should be primed to respond:
- Fetal macrosomia (an estimated large baby), particularly in the setting of maternal diabetes.
- Maternal diabetes, gestational or pre-existing, which changes fetal body proportions.
- A prior shoulder dystocia in an earlier delivery.
- Operative vaginal delivery with vacuum or forceps (see our companion post on when each device is used and what goes wrong).
- Prolonged second stage of labor or a labor that required augmentation.
- Maternal obesity and excessive gestational weight gain.
The important nuance: most shoulder dystocias occur without any of these, which is exactly why the law does not treat the event itself as negligence. The factors matter mainly to the question of whether the team was, or should have been, prepared.
What Injuries Result?
The injuries that bring families to us after a shoulder dystocia fall into a few recognizable groups:
- Brachial plexus injury — stretching or tearing of the nerves that supply the arm. This produces Erb's palsy (upper nerves, C5–C6, the most common) or the less common Klumpke's palsy (lower nerves), and in the most severe cases a nerve-root avulsion that is pulled from the spinal cord. Our post on Erb's palsy versus cerebral palsy explains how a nerve injury differs from a brain injury.
- Clavicle or humerus fracture — sometimes an intended part of freeing the shoulder, sometimes a sign of force.
- Hypoxic-ischemic injury — if the dystocia is prolonged and the cord is compressed, the baby can suffer oxygen deprivation leading to HIE and birth asphyxia and, in the worst cases, permanent brain injury.
Many brachial plexus injuries improve, and some resolve within the first year with therapy. Others are permanent and require surgery, nerve grafting, and a lifetime of adaptation — the kind of long-term need documented through a life care plan.
What Records Decide These Cases?
Shoulder dystocia cases are won and lost in a specific set of documents. When Herb Borroto, M.D., J.D., reads a delivery chart alongside Alex Alvarez, Board Certified Civil Trial Lawyer (National Board of Trial Advocacy), these are the records that carry the weight:
- The delivery note and shoulder dystocia documentation form. Many hospitals use a dedicated form that records which maneuvers were used, in what order, which arm was affected, and how long the head-to-body interval was. Its presence — or absence — is itself telling.
- The exact times of head delivery and body delivery. The head-to-body interval is the clock the whole case runs on.
- The language describing traction. Notes referencing "gentle" versus "strong" or "downward" traction are read closely.
- Nursing notes, which sometimes record what actually happened in the room more candidly than the physician's summary — including whether fundal pressure was applied.
- The neonatal exam, documenting which arm was affected, the pattern of weakness, any fracture, and the initial Apgar scores.
- Cord blood gas values, which reveal whether the baby also suffered oxygen deprivation during the impaction.
- Unit shoulder dystocia drill and protocol records, which speak to whether the team was trained to respond.
Because a shoulder dystocia is a documented, time-stamped emergency, these cases often turn on a careful reconstruction of a very short window — and on whether the documented response matches what the standard of care required.
Frequently Asked Questions
Is shoulder dystocia itself malpractice?
Usually not. Shoulder dystocia is largely unpredictable and unpreventable, and it happens even with careful, competent care. The malpractice question is almost never whether the dystocia occurred — it is whether the delivery team responded to it the way the standard of care requires. A calm, correct sequence of recognized maneuvers can resolve most shoulder dystocias without lasting injury. Excessive force, the wrong technique, or dangerous shortcuts are where negligence usually lives.
What causes the brachial plexus injury in a shoulder dystocia?
The brachial plexus is a bundle of nerves running from the spinal cord through the neck to the arm. When strong lateral or downward traction is applied to the baby's head while the shoulder is still stuck behind the mother's pubic bone, those nerves stretch or tear. Some brachial plexus injuries can occur from the forces of labor itself, but the pattern most associated with negligence is injury following excessive traction on the head. ACOG specifically warns against aggressive downward traction because of this risk.
What maneuvers are supposed to be used for shoulder dystocia?
The standard first step is the McRoberts maneuver — sharply flexing the mother's hips to rotate the pelvis — which resolves a large share of cases on its own. It is typically combined with suprapubic pressure. If those fail, the team escalates through recognized techniques such as delivery of the posterior arm, rotational maneuvers (Rubin and Woods screw), and the Gaskin all-fours position. Fundal pressure — pushing on the top of the uterus — is not an appropriate maneuver and can worsen the impaction.
My baby's arm weakness improved. Do I still have a case?
Many brachial plexus injuries do improve, and some resolve within the first year. Whether a case is viable depends less on the current level of function and more on what the delivery records show about how the shoulder dystocia was handled and whether the injury is permanent. Because the deadlines for injuries to a child often run much longer than parents expect, it is worth having the records reviewed even if the arm has partly recovered.
If Your Child Was Injured During a Difficult Delivery
If your baby was diagnosed with Erb's palsy, a brachial plexus injury, a fracture, or a brain injury after a delivery in which the shoulder got stuck, the medical record usually tells a clear story to someone trained to read it. A free case review looks at whether the delivery team responded the way the standard of care requires, and whether the filing deadlines are still open — which, for injuries to a child, often run far longer than parents expect.
- Understand the difference between a nerve injury and a brain injury: Erb's palsy vs. cerebral palsy.
- Learn about the firm's brachial plexus and Erb's palsy work: Erb's palsy & brachial plexus.
- Understand the deadlines: Birth injury statute of limitations.
Every birth is different, every chart is different, and every state's rules are different. Past results do not guarantee similar outcomes, and each case is evaluated on its own facts. If liability can be established, families of a child harmed by a mishandled shoulder dystocia may have a claim.
Sources
- American College of Obstetricians and Gynecologists (ACOG) — Practice Bulletin No. 178, "Shoulder Dystocia." acog.org
- American Academy of Family Physicians — "Shoulder Dystocia: Managing an Obstetric Emergency." American Family Physician, 2020. aafp.org
- Agency for Healthcare Research and Quality (AHRQ) — Labor and Delivery Unit Safety: Shoulder Dystocia. ahrq.gov
- National Library of Medicine / StatPearls — "McRoberts Maneuver." ncbi.nlm.nih.gov
- National Library of Medicine / PMC — peer-reviewed reviews of obstetric maneuvers and brachial plexus outcomes in shoulder dystocia. ncbi.nlm.nih.gov