A. The diagnosis of shoulder dystocia is made after delivery of the head. The "turtle" sign is the retraction of the chin against the perineum or retraction of the head into the birth canal. This sign demonstrates that the shoulder girdle is resisting entry into the pelvic inlet, and possibly impaction of the anterior shoulder.

B. Macrosomia has the strongest association. ACOG defines macrosomia as an estimated fetal weight (EFW) greater than 4500 g.

C. Risk factors for macrosomia include maternal birth weight, prior macrosomia, preexisting diabetes, obesity, multiparity, advanced maternal age, and a prior shoulder dystocia. The recurrence rate has been reported to be 13.8%, nearly seven times the primary rate. Shoulder dystocia occurs in 5.1% of obese women. In the antepartum period, risk factors include gestational diabetes, excessive weight gain, short stature, macrosomia, and postterm pregnancy. Intrapartum factors include prolonged second stage of labor, abnormal first stage, arrest disorders, and instrumental (especially midforceps) delivery. Many shoulder dystocias will occur in the absence of any risk factors.

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