A practical clinical review of those aspects of shoulder dystocia management that are directly relevant to birth injury is presented. In contrast to more popular viewpoints, the tenets of this paper are that, with few exceptions, clinically relevant, permanent brachial plexus injury is nearly universally associated with shoulder dystocia, injury is causally related to mechanical stresses induced during shoulder dystocia delivery, and management algorithms can be optimized to reduce the incidence of mechanical birth injury from shoulder dystocia. Advantages of direct rotational manipulation of the fetus within the birth canal are emphasized, supported by critical analysis of maneuver-related outcomes research. The competing issue of potential asphyxial insult with prolonged shoulder dystocia is addressed in light of evidence for differential time-dependency between central and peripheral nerve injury as head-to-body interval increases. The importance of proper execution of shoulder dystocia maneuvers for maximizing favorable outcome of shoulder dystocia is iterated, as is coordination of teamed response by multiple healthcare providers. To avoid permanent neurologic sequelae from shoulder dystocia, clinicians are encouraged to be ever mindful of traction applied to the fetal head and neck, to become adept at performance of alternative maneuvers that instead concentrate on finesse rather than force, and to be more favorably disposed to the use of such maneuvers early and often in shoulder dystocia management algorithms.