Defining forces that are associated with shoulder dystocia: The use of a mathematic dynamic computer model

Objective: A computer model was modified to study the impact of maternal endogenous and clinician-applied exogenous delivery loads on the contact force between the anterior fetal shoulder and the maternal symphysis pubis. Study Design: Varying endogenous and exogenous loads were applied, and the contact force was determined. Experiments also examined the effect of pelvic orientation and the direction of load application on contact force behind the symphysis pubis. Results: Exogenous loading forces (50-100 N) resulted in anterior shoulder contact forces of 107 to 127 N, with delivery accomplished at 100 N of applied load. Higher contact forces (147-272 N) were noted for endogenously applied loads (100-400 N), with delivery occurring at 400 N of maternal force. Pelvic rotation from lithotomy to McRobertsʹ positioning resulted in reduced contact forces. Downward lateral flexion of the fetal head led to little difference in contact force but required 30% more exogenous load to achieve delivery. Conclusion: Compared with clinician-applied exogenous force, larger maternally derived endogenous forces are needed to clear the impacted anterior fetal shoulder. This is associated with >2 times more contact force by the obstructing symphysis pubis. McRobertsʹ positioning reduces shoulder-symphysis pubis contact force. Lateral flexion of the fetal head results in the larger forces that are needed for delivery but has little effect on contact force. Model refinements are needed to examine delivery forces and brachial plexus stretching more specifically. (Am J Obstet Gynecol 2003;188:1068-72.)