Layered prevention
Effective prevention layers:
- Maternal health management (diabetes, hypertension)
- Fetal growth and position monitoring
- Delivery method planning
- Skilled labor team trained on emergency maneuvers
- Clear protocols for assisted delivery
Most shoulder dystocias cannot be predicted. What can be controlled is the response, and ACOG Practice Bulletin No. 178 sets out that response in a specific order: McRoberts first, then suprapubic pressure, then delivery of the posterior arm, with traction on the infant’s head avoided throughout.
This page covers those maneuvers and why the sequence matters, what prenatal care can realistically identify, and why simulation training is the prevention measure with the clearest mechanism behind it.
In this article
Preventing Erb's palsy during childbirth
Prevention focuses on minimizing the risk of brachial plexus injuries through effective management of shoulder dystocia. Adopting strategies during labor (including specific maneuvers and techniques) plays a vital role in prevention.
What shoulder dystocia is
The baby’s head delivers and the anterior shoulder catches behind the mother’s pubic bone. It is an obstetric emergency, recognized in seconds, and the cause of most cases of Erb’s palsy, and how the next two or three minutes are handled largely determines whether the brachial plexus is injured.
Preparation, not prediction
Because shoulder dystocia is largely unpredictable, prevention of the nerve injury rests on how the team responds in the moments after it is recognized. That means calling for help, avoiding traction, and moving through the maneuvers in sequence rather than improvising.
Strategies to reduce risk of Erb's palsy
Effective strategies combine careful risk assessment with evidence-based medical guidelines. Obstetricians identify at-risk pregnancies and ensure appropriate measures are in place to mitigate potential injuries.
What actually raises the risk
The strongest single predictor is a previous shoulder dystocia. Maternal diabetes and fetal macrosomia raise risk, as does instrumental delivery with forceps or vacuum. None of these is predictive enough to act on alone, which is the central difficulty: the majority of shoulder dystocias happen in pregnancies with no identified risk factor at all.
Where the protocol comes from
Prevention here does not mean a novel technique. It means the delivery team doing the established sequence, in order, under time pressure, which is why hospitals run drills on it. A documented protocol also produces a record of what was done, which matters afterwards for entirely separate reasons.
Safe delivery techniques for preventing Erb's palsy
Safe delivery techniques involve meticulous planning and execution. Prenatal care sets the foundation for identifying potential complications early. Obstetricians must be vigilant in risk assessment and prepared to implement safe-delivery guidelines.
The maneuvers, in the order they are used
ACOG Practice Bulletin No. 178 describes McRoberts as the initial step: the mother’s legs are sharply flexed onto the abdomen, which rotates the pelvis and frees the shoulder without touching the baby. It resolves up to 42% of shoulder dystocia on its own, and around 54% when combined with suprapubic pressure, applied just above the pubic bone to nudge the shoulder out of its wedged position.
Across two large multicenter studies, McRoberts with or without suprapubic pressure relieved roughly two-thirds of cases. Where they fail, delivery of the posterior arm is the next step. The point of the sequence is that the early maneuvers are external and put no force on the baby’s neck.
The one thing the guidance says not to do
ACOG states that traction on the infant’s head should be avoided. That is not a stylistic preference. Downward traction while the shoulder remains lodged is the mechanism that stretches the brachial plexus, and it is the single action most directly linked to the injury this page is about. Where it does occur, our page on the long-term effects of Erb’s palsy covers what follows.
Role of obstetricians in preventing Erb's palsy
Obstetricians lead efforts to educate, train, and implement early intervention strategies. Their expertise directly impacts childbirth outcomes, making their role pivotal in minimizing risk through scenario-based learning and simulation.
Why simulation training is the intervention with the best case
Shoulder dystocia is uncommon, unannounced, and resolved in minutes, which is the worst possible combination for a team relying on recall. ACOG recommends simulation exercises and shoulder dystocia protocols to improve team communication and maneuver use, noting this may reduce the incidence of brachial plexus palsy associated with shoulder dystocia.
That is the one prevention lever with a clear mechanism: not predicting which birth will go wrong, but making the response automatic when one does.
What prenatal care can and cannot do
Antenatal identification of risk is genuinely limited, and it is worth being honest about that. Estimated fetal weight is imprecise near term, most large babies deliver without a shoulder dystocia, and most shoulder dystocias occur in babies of ordinary size. Managing maternal diabetes is the clearest exception, because it affects fetal growth pattern.
What prenatal care does reliably is flag the pregnancies where a team should be prepared: a previous shoulder dystocia, diabetes, and an instrumental delivery in prospect. Our page on risk factors covers those in detail.
When prevention fails
Despite best efforts, some Erb’s palsy cases occur because prevention protocols weren’t followed. If your child’s Erb’s palsy resulted from preventable medical events, you may have legal options. Request a free case review.
Frequently asked questions about prevention strategies
Largely not. Most shoulder dystocias occur in pregnancies with no identified risk factor, estimated fetal weight is imprecise near term, and most large babies deliver without one. The strongest single predictor is a previous shoulder dystocia.
The McRoberts maneuver, in which the mother’s legs are sharply flexed onto the abdomen to rotate the pelvis. ACOG describes it as the initial step, and it resolves up to 42% of cases on its own.
Around 54% are resolved when suprapubic pressure is added, and across two large multicenter studies McRoberts with or without suprapubic pressure relieved roughly two-thirds. Delivery of the posterior arm is the next step where those fail.
Because downward traction while the shoulder is still lodged is the mechanism that stretches the brachial plexus. ACOG states that traction on the infant’s head should be avoided.
Shoulder dystocia, macrosomia, maternal diabetes, operative vaginal delivery and a previous delivery complicated by shoulder dystocia are the recognized associations. None of them predicts who is affected. The injury occurs in about 1.5 per 1,000 births, so most babies with a risk factor are unaffected and many affected babies have no risk factor at all.
ACOG recommends simulation exercises and shoulder dystocia protocols to improve team communication and maneuver use, noting this may reduce the incidence of associated brachial plexus palsy. It is the measure with the clearest mechanism: making the response automatic rather than predicting which birth will need it.
Managing maternal diabetes is the clearest example, because it affects fetal growth. Otherwise prenatal care mainly identifies which pregnancies warrant a prepared team, such as a previous shoulder dystocia or a planned instrumental delivery.
No. A shoulder dystocia can be managed correctly and still result in injury. What a claim examines is whether the recognized sequence was followed, which our page on legal options covers.
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