Prepartum planning for route of birth at term

Clinicians should be aware of risk factors for shoulder dystocia, so they can discuss the possibility of scheduled cesarean birth with patients at highest risk of occurrence. The planned route of birth is a shared decision made by the clinician and patient, ideally after nondirective counseling about the risks of labor and vaginal birth, including a discussion about shoulder dystocia. If planned cesarean birth is being considered, the risks of this procedure should also be discussed. There is general consensus among experts that planned cesarean birth is appropriate in those pregnancies most likely to result in shoulder dystocia with long-term complications to reduce this potential outcome. Although this will prevent some shoulder dystocias and their associated complications, most cases of shoulder dystocia, including those that result in neonatal injury, cannot be predicted before birth, thus they cannot be prevented. Similarly, there is general consensus favoring a trial of labor when the risk of shoulder dystocia is very low, such as for a multiparous patient with no history of difficult vaginal birth and who has an estimated fetal weight under 4000 grams. However, most clinical settings fall into gray areas since at least 50% of pregnancies complicated by shoulder dystocia have no identifiable risk factors and most risk factors are weakly predictive of morbidity from shoulder dystocia. Refer to UpToDate content on shoulder dystocia for additional information.