Patient Safety Authority and Department of Health Final Recommendations to Mitigate Risk of Harm Related to Shoulder Dystocia

Shoulder dystocia is a rare but serious condition that occurs when one or both shoulders become stuck during a vaginal delivery and can result in serious injury to the neonate. Among all neonatal serious events related to labor and delivery reported into the Patient Safety Reporting System in 2022, shoulder dystocia was the most common. These events were associated with fractures, brachial plexus injuries, respiratory distress and unanticipated admissions to a neonatal intensive care unit.

The Patient Safety Authority (Authority) is responsible for submitting recommendations to the Department of Health (Department) for changes in healthcare practices and procedures which may be instituted for the purpose of reducing the number and severity of serious events and incidents. After reviewing public comments, the draft recommendations issued in the Pennsylvania Bulletin (55 Pa.B. 888) earlier this year, were revised and adopted as final recommendations by the Authority's Board of Directors and the Secretary of the Department.

The final recommendations to all hospitals and birthing centers licensed to provide obstetrical care in this Commonwealth are as follows:

1. Training and Competency Assessment. Hospitals and birth centers should include shoulder dystocia as part of comprehensive training for obstetric care and obstetric emergencies for credentialed providers and staff involved in the care of labor and delivery patients.

2. Debriefing. Hospitals and birth centers should develop and implement a policy on debriefing the labor and deliveries that involve obstetric emergencies, including shoulder dystocia.

3. Documentation. Hospitals and birth centers should standardize shoulder dystocia documentation in patient medical records.

For more information, please review the November 29, 2025 edition of the Pennsylvania Bulletin.