GENDER MEDICINE/VOL. 7, NO.

1, 2010

Infant Male Sex as a Risk Factor for Shoulder Dystocia But

Not for Cephalopelvic Disproportion: An Independent or
Confounded Effect?
Jayanton Patumanond, MD, DSc1; Chamaiporn Tawichasri, MS1;
and Suthit Khunpradit, MD2
1Academic Division of Clinical Epidemiology and Medical Statistics, Faculty of Medicine, Chiang Mai

University, Chiang Mai, Thailand; and 2Department of Obstetrics and Gynecology, Lamphun Hospital,
Lamphun, Thailand

ABSTRACT
Background: Shoulder dystocia (ShD) and cephalopelvic disproportion (CPD) share some common risk
factors. Whether infant male sex is an independent risk factor for ShD, or if the risk is confounded by
other known factors, is uncertain.
Objective: The aim of this study was to explore the unconfounded effect of infant male sex on the risk
for ShD and its interaction with other risk factors compared with CPD.
Methods: A retrospective data analysis was conducted of deliveries in Lamphun Hospital, Lamphun,
Thailand. All vaginal deliveries complicated by ShD were collected as ShD cases. All labors terminated by
cesarean delivery (CD) due to CPD were collected as CD/CPD cases. Vaginal deliveries that took place
immediately before or after the index ShD cases were collected as controls. Multivariable adjusted odds
ratios (AORs) for infant male sex and its 95% CI in cases of ShD and CD/CPD were computed by multi-
chotomous logistic regression controlling for other obstetric risks. The effects of maternal height, gesta-
tional age, and birth weight on the risk for ShD or CD/CPD among male or female infants was also
explored. Stability of the effect of the risk between male and female infants was tested with Chow tests.
Results: Thirty-five ShD cases and 199 CD/CPD cases were collected, as were 586 controls. Infant male
sex was a significant independent risk factor for ShD (AOR = 5.00; 95% CI, 1.83–13.61; P = 0.002), but not
for CD/CPD (AOR = 1.09; 95% CI, 0.75–1.59; P = NS). For CD/CPD, the effects of maternal height, gesta-
tional age, and birth weight were similar for male and female infants, but the corresponding effect on ShD
was more pronounced in male than in female infants (P < 0.001 for all comparisons).
Conclusions: Infant male sex is a risk factor for ShD independent of other known risks. Male sex also
amplified the existing effects of short maternal height, extended gestational age, and greater birth weight.
If infant sex is known to be male before delivery, the obstetrician may consider avoiding vaginal delivery
in mothers who have other strong risks for ShD. (Gend Med. 2010;7:55–63) © 2010 Excerpta Medica Inc.
Key words: shoulder dystocia, cephalopelvic disproportion, cesarean delivery, male, infants, sex.

Accepted for publication September 3, 2009. doi:10.1016/j.genm.2010.01.001

© 2010 Excerpta Medica Inc. All rights reserved. 1550-8579/$ - see front matter

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Gender Medicine
INTRODUCTION
Both shoulder dystocia (ShD) and cephalopelvic
disproportion (CPD) are types of fetal–maternal
disproportion, discrepancies between fetal size
and maternal pelvic size. Many obstetric and neo-
natal characteristics have been identified as known
risk factors for CPD, but risk factors for ShD are
still uncertain.1
Cases of ShD have been observed in a larger
proportion of male infants than female infants.2
However, very few studies observed similar find-
ings in its counterpart, CPD.3 The odds ratio (OR)
of ~1.2 to ~2.1 in these studies led researchers to
question whether infant male sex was an indepen-
dent risk factor for ShD, or if risk was confounded
by other known factors such as birth weight,
which appears to be the most powerful risk factor
for ShD.3,4 Researchers who found a statistically
significant difference in the proportion of male
infants in cases of ShD unfortunately did not supply
sufficient information to explain the reasons under-
lying their findings.2,5 Some studies associated infant
male sex with greater birth weight and/or larger
body size.6
Thus, the aim of the present study was to ex-
plore the independent effect of infant male sex on
the risk for ShD and its relationship to maternal
height, gestational age, and birth weight com-
pared with CPD.
METHODS
Deliveries performed in Lamphun Hospital,
Lamphun, Thailand, between 2004 and 2007 were
included in this retrospective data analysis. The fol-
lowing cases were excluded: deliveries by women
aged <18 years, deliveries of twins, preterm deliv-
eries, fetal presentation other than cephalic, and
deliveries of infants of low birth weight. Women
were screened for gestational and type 2 diabetes
at 27 weeks of pregnancy according to hospital
guidelines. No data from diabetic women were
included in this study.
All vaginal deliveries complicated by ShD dur-
ing the study period were collected as ShD cases.
All labors terminated by cesarean delivery (CD)
due to CPD were collected as CD/CPD cases. Vagi-
nal deliveries not complicated by ShD were col-
56
lected as controls. The hospital’s labor registry was
searched for obstetric and neonatal characteristics,
including maternal height, gestational age, and
birth weight.
ShD cases were defined as deliveries in which,
after the fetal head delivered, the fetal shoulder(s)
did not deliver within 60 seconds, requiring
obstetric attendants to perform manual or instru-
mental assistance.7 These were documented as
ShD cases in the obstetric notes. CD/CPD cases
were defined as labors in which CPD was con-
firmed according to the criteria of the Royal Thai
College of Obstetricians and Gynecologists and in
which labor was terminated by cesarean delivery.8
The criteria for CPD included cervical dilatation of
at least 4 cm and 80% effacement; regular uterine
contractions for at least 2 hours before decision
making; and abnormal partogram, such as that
detected by protraction disorders, arrest disorders,
or second-stage disorders. Controls were identified
from 9 vaginal deliveries occurring immediately
before or after each of the index ShD cases.
Numerical obstetric characteristics that could be
presented as mean (SD), including maternal age,
gestational age, and birth weight, were catego-
rized according to their obstetric risk relevance or
their mean or median values, as appropriate, to fa-
cilitate computations of the adjusted ORs (AORs).
These characteristics were compared between ShD
cases, CD/CPD cases, and vaginal delivery con-
trols, and were tested with exact probability tests.
Multivariable AORs and 95% CIs of infant male
sex for ShD and CD/CPD were calculated by mul-
tichotomous logistic regression with full control
for all possible known obstetric risk factors includ-
ed in the same model. Analyses were conducted
using Stata 11 software (StataCorp LP, College
Station, Texas).
The effects of maternal height, gestational age,
and birth weight on the risk for ShD or CD/CPD
among male and female infants were explored and
contrasted by binary logistic models for ShD and
for CD/CPD as dependent variables and maternal
height, gestational age, or birth weight as inde-
pendent variables, analyzed separately for male
and female infants. Predicted logistic probability
functions (predicted y-variable) for ShD or CD/CPD
 J. Patumanond et al.

were plotted against each of the 3 independent
variables (x-variable). The stability of effects of
maternal height, gestational age, and birth weight
on the risk of ShD or CD/CPD for male and female
infants was tested with Chow likelihood ratio
tests. The sample sizes had ~80% power at the 5%
level to detect a difference in the proportion of
male infants in cases of ShD versus control cases
of at least 0.77 versus 0.52.
The research proposal and data collection were
approved by the Lamphun Hospital Clinical
Research Ethical Committee, Lamphun, Thailand.
No informed consent was required in this retro-
spective data collection.
RESULTS
During the study time frame, there were 8743 de-
liveries in Lamphun Hospital, of which 6462
were vaginal deliveries and 2281 were CDs. Of
the vaginal deliveries, 35 were complicated by
ShD (0.4% of total deliveries; 0.5% of all vaginal
deliveries), and of the CDs, 207 were required
due to CPD (2.4% of total deliveries; 9.1% of all
CDs).
All 35 ShD cases were simple dystocia resolved
using the McRoberts’ position. Brachial plexus
injuries were observed in 4 of 35 (11.4%) of the
ShD cases. After excluding 8 CD/CPD cases (3.9% of
the 207 CDs) and 44 controls (7.0% of the 630 con-
trols) due to missing key variables, 199 CD/CPD
cases and 586 controls were analyzed. The mean
fetal weight was 3650.3 g (range, 2765–4455 g) for
the ShD group, 3529.4 g (range, 2655–5565 g) for
the CD/CPD group, and 3084.2 g (range, 2500–
4544 g) for the control group.
All characteristics except maternal age were sig-
nificantly different across the 3 groups (Table I).
Infant male sex was identified in 85.7% of ShD
cases, a significantly greater proportion than that
observed in the control and CD/CPD groups
(54.3% and 56.8%, respectively; P = 0.001).
With all possible obstetric risk factors in the
same multichotomous logistic regression model,
the multivariable AOR of infant male sex for ShD
was 5.00 (95% CI, 1.83–13.61; P = 0.002). The AOR
of infant male sex for CD/CPD was 1.09 (95% CI,
0.75–1.59; P = NS). Other risk factors for ShD and
CD/CPD are presented in Table II.
The risk of ShD in male infants increased by
8.0% as maternal height decreased by 1 cm; this
same increase was not observed in female infants
(AOR = 1.08 vs 0.97, respectively; P < 0.001). For
CD/CPD, the risk among both male and female
infants increased with shorter maternal height to
a similar degree (AOR = 1.06 vs 1.08, respectively;
P = NS) (Table III, Figure 1).

Table I. Obstetric characteristics of vaginal deliveries with and without shoulder dystocia (ShD), and cesarean deliveries
due to cephalopelvic disproportion (CD/CPD). Data are number (%).

Vaginal Deliveries

ShD Without ShD* CD/CPD

Obstetric Characteristics (n = 35) (n = 586) (n = 199) P

Maternal age >35 y 3 (8.6) 35 (6.0) 21 (10.6) 0.082

Primigravida 13 (37.1) 302 (51.5) 135 (67.8) <0.001
Nullipara 19 (54.3) 372 (63.5) 163 (81.9) <0.001
Maternal height <155 cm 7 (20.0) 57 (9.7) 38 (19.1) 0.001
Prepregnancy weight <50 kg 22 (62.9) 240 (41.0) 99 (49.8) 0.007
Pregnancy weight gain >14 kg 22 (62.9) 275 (46.9) 133 (66.8) <0.001
Predelivery weight >65 kg 18 (51.4) 244 (41.6) 125 (62.8) <0.001
Gestational age >40 wk 7 (20.0) 34 (5.8) 21 (10.6) 0.003
Fundal height >33 cm 29 (82.9) 251 (42.8) 159 (79.9) <0.001
Birth weight >4000 g 13 (37.1) 20 (3.4) 31 (15.6) <0.001
Infant male sex 30 (85.7) 318 (54.3) 113 (56.8) 0.001

*Control group.

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Gender Medicine

Table II. Multivariable adjusted odds ratios (AORs) and 95% CIs of obstetric characteristics for shoulder dystocia (ShD)
and cesarean delivery due to cephalopelvic disproportion (CD/CPD), from multichotomous logistic regression
compared with vaginal deliveries without ShD.

ShD CD/CPD

Obstetric Characteristics AOR 95% CI P AOR 95% CI P

Maternal age >35 y 0.93 0.19–4.46 0.930 2.88 1.42–5.86 0.004

Primigravida 0.55 0.18–1.64 0.284 1.19 0.70–2.02 0.529
Nullipara 1.99 0.62–6.43 0.248 3.78 1.95–7.30 <0.001
Maternal height <155 cm 4.46 1.52–13.09 0.006 4.08 2.34–7.12 <0.001
Prepregnancy weight <50 kg 5.45 1.64–18.10 0.006 1.05 0.63–1.76 0.844
Pregnancy weight gain >14 kg 2.92 1.17–7.31 0.022 1.63 1.07–2.50 0.024
Predelivery weight >65 kg 0.19 0.06–0.65 0.008 1.80 1.06–3.05 0.030
Gestational age >40 wk 4.23 1.49–12.02 0.007 1.60 0.85–3.02 0.143
Fundal height >33 cm 3.61 1.34–9.67 0.011 3.83 2.51–5.86 <0.001
Birth weight >4000 g 11.15 4.05–30.66 <0.001 4.59 2.31–9.10 <0.001
Infant male sex 5.00 1.83–13.61 0.002 1.09 0.75–1.59 0.663

With an increase in gestational age of 1 week, the
risk for ShD in male infants increased by 26%; this
increase was not observed in female infants (AOR =
1.26 vs 0.95, respectively; P < 0.001). Likewise, the
AOR for male and female infants for CD/CPD due to
longer gestational age was also similar (AOR = 1.43 vs
1.30, respectively; P = NS) (Table III, Figure 2).
For ShD, the risk curve for male infants was high-
er than that for female infants throughout nearly
the entire range of birth weight (AOR = 1.28 vs 1.49,
respectively; P < 0.001) except for birth weights
>95th percentile (4100 g), where the risk for both
sexes eventually merged. The risk for CD/CPD due
to birth weight for male and female infants increased
with similar patterns (AOR = 1.25 vs 1.22, respec-
tively; P = NS) (Table III, Figure 3).
DISCUSSION
Infant Male Sex
After controlling for all possible risk factors, the
results of this analysis indicate that infant male
sex is an independent risk factor for ShD, but not
for CD/CPD. Very few studies describe infant male
sex as a risk factor for CD/CPD,3 but several stud-
ies do mention male sex as a risk factor for ShD.1,3,5
Unfortunately, in these studies, information to
clarify the reasons supporting these findings were
not provided.

Table III. Infant sex-specific adjusted odds ratios (AORs) and 95% CIs of maternal height, gestational age, and birth weight
on the risk for shoulder dystocia (ShD) or cesarean delivery due to cephalopelvic disproportion (CD/CPD).*

Male Sex Female Sex

Obstetric Characteristics Risk AOR 95% CI AOR 95% CI P*

Maternal height (1 cm shorter) ShD 1.08 1.01–1.15 0.97 0.85–1.12 <0.001

CD/CPD 1.06 1.02–1.10 1.08 1.04–1.13 0.642
Gestational age (1 wk longer) ShD 1.26 0.91–1.73 0.95 0.46–1.98 <0.001
CD/CPD 1.43 1.17–1.73 1.30 1.06–1.59 0.798
Birth weight (+100 g) ShD 1.28 1.17–1.39 1.49 1.20–1.86 <0.001
CD/CPD 1.25 1.18–1.32 1.22 1.15–1.30 0.409

*Chow tests for stability of parameters across subdivided groups of population.

58
 J. Patumanond et al.

Male, ShD
Female, ShD
Male, CD/CPD
0.6 Female, CD/CPD

Risk of ShD or CD/CPD

0.4

0.2

0
135 140 145 150 155 160 165 170 175 180

Maternal Height (cm)

Figure 1. Effect of maternal height on the risk for shoulder dystocia (ShD) versus cesarean delivery due to cephalopelvic
disproportion (CD/CPD) in male versus female infants.

Male, ShD
Female, ShD
Male, CD/CPD
0.6 Female, CD/CPD
Risk of ShD or CD/CPD

0.4

0.2

0
37 38 39 40 41 42 43

Gestational Age (wk)

Figure 2. Effect of gestational age on the risk for shoulder dystocia (ShD) versus cesarean delivery due to cephalopelvic
disproportion (CD/CPD) in male versus female infants.

59
Gender Medicine
1.0
0.8
Risk of ShD or CD/CPD
0.6
0.4
0.2
0
2500 3000
Figure 3. Effect of birth weight on the risk for shoulder dystocia (ShD) versus cesarean delivery due to cephalopelvic
disproportion (CD/CPD) in male versus female infants.
It is generally accepted that male infants weigh
more than their female counterparts9,10 and are
more likely to be macrosomic.6,11 These findings
were adopted as possible explanations of the in-
creased risk for ShD in male infants.2,5 Hormone
studies of cord blood from newborns have report-
ed that growth hormone levels in male infants
were significantly higher than in females, and
these levels were further increased by the length of
gestation.12 This may be one reason why male
newborns are often heavier and longer, and have
a larger head, shoulder width, chest size, and body
mass, but female newborns have greater skinfold
thickness.13,14 Large chest circumference is gener-
ally associated with greater birth weight,15 and
newborn shoulder width is reported to be an inde-
pendent indicator of ShD.4,16
Differences in male and female body structure and
composition are termed sexual dimorphism. These
differences are generally first observed at birth,14 but
sexual differentiation begins at the 30th week of
gestation and becomes more pronounced and sta-
tistically significant at 38 to 42 weeks.17,18
60
Male, ShD
Female, ShD
Male, CD/CPD
Female, CD/CPD
3500 4000 4500 5000 5500
Birth Weight (g)
These findings support the suggestion that
infant male sex is an independent risk factor for
ShD, at least from the epidemiologic perspective.
Differential Effect of Maternal Height in
Male Versus Female Infants
In human females, the bony pelvis must be
narrow to allow for efficient bipedal locomo-
tion, yet wide enough to accommodate a rela-
tively large newborn. There is evidence that, in
some small-bodied populations, adaptive mech-
anisms may protect the obstetric canal.19 These
findings may explain why smaller maternal stat-
ure or maternal height <155 cm were reported as
independent risk factors for dystocia.20,21 Dis-
crepancies between maternal height or weight
and infant weight also substantially increase the
risk for ShD.21
In the present study, shorter mothers had a
greater risk for CD/CPD. This finding was true for
both male and female infants. Short maternal stat-
ure appeared to increase the risk for ShD in the
delivery of male infants, but not of female infants

(Figure 1). This implies that infant male sex may
be an independent risk factor for ShD, either by
amplifying or conditioning the effect of maternal
height on the risk of ShD. Whether short maternal
stature increased the risk of ShD in this analysis
depended on sex of the infant.
Differential Effect of Gestational Age in
Male Versus Female Infants
The association between postterm pregnancy
and the risk of ShD is still uncertain. However, ges-
tational age and chronological postterm pregnancy
have been reported as risk factors for macroso-
mia,5,6,22 CD/CPD,5 and ShD.1,20,23 Increased gesta-
tional age is also associated with greater birth
weight.2,9,10 Therefore, many researchers have con-
cluded that an increased risk for ShD can be par-
tially or completely explained by the influence of
extended gestational age and subsequently greater
birth weight.5
In the final weeks of pregnancy, male infants
lose more fat and gain more weight than do their
female counterparts.24 Anthropometric studies
on growth patterns of newborns observed that
the size of infants progressively increased with
gestational age and sexual dimorphism. The pat-
terns were first observed during the 3rd trimester
and reached statistical significance at term.17 It
is likely that the effect of gestational age on the
risk of ShD in this study was also modified by the
effect of sexual dimorphism observed in male
infants. In term pregnancies, an increase in gesta-
tional age from 39 to 40 weeks significantly
increased the risk of operative deliveries and
CD/CPD25 as a result of a more profound fetal–
maternal disproportion.
In the present study, an increased risk for
CD/CPD with increased gestational age was
observed in male and female infants. However,
an increased risk for ShD was also observed in
male infants (Figure 2). This implies that male
sex may be an independent risk factor for ShD,
either by means of amplifying or conditioning
the effect of extended gestational age on the risk
of ShD. Whether gestational age increased the
risk of ShD in this analysis depended on sex of
the infant.
J. Patumanond et al.
Differential Effect of Birth Weight in
Male Versus Female Infants
Birth weight and macrosomia are risk factors for
instrumental deliveries, ShD, and CD/CPD.2,5,13,26,27
Macrosomia is the result of increased maternal
age, obesity, parity, diabetes, and postterm preg-
nancy.2 It has been considered to be the most
powerful predictor of ShD.4 Newborn weight is
correlated with the diameter and circumference of
the chest.15 Heavier babies generally have larger
chest width, depth, and circumference, which cor-
responds to the theoretical etiology of ShD.
When considering birth weight as a continuous
variable, the risk for CD/CPD in male and female
infants increased as birth weight increased.
However, the risk for ShD in male infants was
greater than that in their female counterparts
throughout nearly the entire range of birth weights
(Figure 3). This implies that infant male sex may
be an independent risk factor for ShD through its
modification of the effect of birth weight on the
risk for ShD. This analysis showed that birth
weight was more likely to be a risk factor for ShD
in male than in female infants.
The risk for ShD increased from near 0 to near 1
through the entire range of birth weights with an
obvious S-shape relationship, which mathematically
confirmed that greater birth weight was a strong
predictor for ShD. Nevertheless, for any given birth
weight, male infants were at greater risk for ShD
than female infants weighing <4500 g. This implies
that female infants may be at risk for ShD only when
their birth weight exceeds certain limits, but male
infants may be at greater risk for ShD even when
their birth weight is within the normal range.
Some possible limitations of this analysis should
be considered. It is likely that some ShD cases were
not recorded as such in the obstetric notes. This
may have resulted in misclassification of ShD
cases as controls, which could under- or overesti-
mate the magnitude of the relationship. However,
such events might have been very rare.
CONCLUSIONS
Infant male sex is a risk factor for ShD indepen-
dent of other known risks. Male sex also amplified
the existing effects of short maternal height, extend-
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Gender Medicine
ed gestational age, and greater fetal weight. If
infant sex is known to be male before delivery, the
obstetrician may consider avoiding vaginal deliv-
ery in mothers who have other strong risk factors
for ShD.
ACKNOWLEDGMENTS
The authors wish to thank the staff of the Depart-
ment of Obstetrics and Gynecology, Lamphun
Hospital, for their assistance in the search of the
labor registry. The authors have indicated that
they have no conflicts of interest regarding the
content of this article.
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Address correspondence to: Jayanton Patumanond, MD, DSc, Academic Division of Clinical Epidemiology
and Medical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand. E-mail:
jpatumanond@yahoo.com

63