Shoulder Dystocia Management

Aka: Shoulder Dystocia Management, Shoulder Dystocia Maneuvers, McRoberts Position, Suprapubic Pressure on the Fetal Shoulder, McRoberts Maneuver, Wood-Screw maneuver, Freeing the Posterior Arm In Shoulder Dystocia, Rubin Maneuver, Zavanelli Maneuver, Gaskin Maneuver

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II. Approach

  1. On recognizing Shoulder Dystocia (e.g. delay in body delivery, turtle sign)
    1. Immediately notify surrounding staff of Shoulder Dystocia (e.g. "code Shoulder Dystocia")
    2. Muster additional help
      1. Provider qualified to perform Cesarean Section
      2. Provider qualified to perform Neonatal Resuscitation
    3. Assistant records interventions (code recorder) and announces time from head delivery every 30 seconds
      1. Change attempted maneuver (e.g. rotation) at each 30 second interval
    4. Lower the bed or provide a step for those performing subrapubic pressure
    5. Enlist help of patient, in pushing at the correct time
  2. Follow systemic approach in attempt to disimpact the anterior Shoulder
    1. See HELPER and PERSPIRE mnemonics below

III. Precautions

  1. Understand Fetal Position (where is the occiput and which direction is the fetus facing)
  2. Avoid harmful maneuvers
    1. Fundal pressure (use suprapubic pressure instead)
    2. Excessive lateral or downward traction on fetal head or neck (associated with Brachial Plexus Injury)
    3. Twisting or bending neck

IV. Definitions

  1. Suprapubic Pressure on the Fetal Shoulder
    1. Decreases fetal Shoulder breadth (distance between Shoulders or bisacromial distance)
    2. Avoid fundal pressure (risk of Uterine Rupture)
    3. Apply pressure over Bladder (never over fundus)
      1. Pressure is applied to bring the fetal Shoulder closer to the fetal anterior chest and Sternum
      2. Example: If fetus faces the mother's right side
        1. Pressure is applied from mother's left suprapubic region, down and toward the right
    4. Oblique downward and anterior pressure
      1. Initial attempt: Apply pressure for 30 to 60 sec
      2. Later: Rocking motion similar to CPR
  2. McRoberts Position
    1. Efficacy
      1. Among the most effective single measures in Shoulder Dystocia
      2. Resolves >40% of dystocias
      3. Resolves 50% when used with suprapubic pressure
    2. Technique
      1. Flex thighs
      2. Patient pulls knees toward ears
    3. Effect: Expands size of maternal Pelvis
      1. Flattens lumbar lordosis
      2. Symphysis rotates superiorly
  3. Episiotomy
    1. Cut a generous episiotomy
    2. May be delayed until after pressure and McRoberts
    3. Effect
      1. Does not effect Bony Pelvis obstruction
      2. Increases room to work for rotational maneuvers
  4. Posterior arm delivery
    1. Requires patient cooperation and practice
    2. Provider inserts hand between fetus and perineum
      1. Slide examiner hand across fetal chest (not the fetal back) down towards the fetal hip
      2. Grasp posterior arm at wrist, between examiners thumb and index finger (OK sign)
      3. Flex elbow and sweep Forearm across chest
      4. Avoid grasping upper arm (Humerus Fracture risk)
    3. When combined with other measures above (McRoberts, suprapubic pressure) results in delivery within 4 min in 95%
      1. Leung (2011) BJOG 118(8): 985-90 [PubMed]
  5. Rotational Maneuvers
    1. Perform maneuvers while maintaining downward traction
    2. Maneuvers described for left occiput position
    3. Rubin II Maneuver
      1. Two fingers placed behind anterior Shoulder
      2. Apply downward pressure around arc of rotation
      3. Rotate presenting part clockwise for 30-60s, approximately 30 degrees
    4. Wood-Screw maneuver
      1. Two fingers placed in front of posterior Shoulder
      2. Apply upward pressure around arc of rotation
      3. Rotate presenting part clockwise for 30-60 sec, attempting to rotate 180 degrees
    5. Rubin II Maneuver with Wood-Screw maneuver
      1. Maximizes torque for rotation
      2. Difficult due to limited vaginal space for maneuver
    6. Reverse Wood-Screw
      1. Reverse direction of rotation (counter-clockwise)
      2. Two fingers placed in front of anterior Shoulder AND two fingers placed behind posterior Shoulder
      3. Rotate counter-clockwise 180 degrees
  6. Gaskin Maneuver or all-fours position
    1. Patient rolls onto hands and knees
    2. Apply downward traction to deliver posterior Shoulder
    3. Above rotational maneuvers may be repeated if needed
    4. Effect: Increases pelvic diameters (TOC, Sagittal)
  7. Maneuvers of last resort
    1. Deliberate Clavicle Fracture
      1. Pull clavicles outward and Fracture one or both
      2. Risk of underlying vascular or lung injury
    2. Zavanelli Maneuver
      1. Cesarean Section with cephalic replacement
      2. One provider performs emergency cesarean
      3. Second provider replaces head
        1. Rotate fetal head into direct Occiput Anterior position
        2. Fetal neck is flexed with chin pressing into perineum
        3. Head pushed back into vagina (gently)
        4. Provider provides continuous pressure on head to hold the fetus within Uterus
        5. Uterine relaxation with IV Nitroglycerin or inhalational Anesthetic may be needed
    3. Symphysiotomy
    4. Abdominal surgery with hysterotomy

V. Management: Mnemonic PERSPIRE

  1. Preparation
    1. Delivery Room
    2. Nurses on steps
  2. Episiotomy
  3. (Mc)Roberts Position (See Above)
  4. Suprapubic Pressure
  5. Posterior arm delivery
  6. Internal Rotation
    1. Wood-Screw maneuver (rotate face towards floor)
    2. Try with patient positioned on all 4 extremities
  7. Emergency
    1. Fracture Clavicle
    2. Zavanelli Maneuver (See above)

VI. Management: Mnemonic HELPER (ALSO course)

  1. Help
    1. Call for Help
  2. Episiotomy
  3. Legs
    1. Position with McRoberts Maneuver for 30-60 seconds
    2. See description above
  4. Pressure at suprapubic area
    1. Only apply to suprapubic region (never apply to the uterine fundus)
  5. Enter
    1. Position hands in position
      1. Two fingers by anterior Shoulder
      2. Two fingers by posterior Shoulder
    2. Rubin Maneuver: Rotate counter-clockwise for 30-60s
    3. Wood-Screw maneuver: Rotate clockwise for 30-60 sec
  6. Remove the posterior arm
    1. Repeat the above procedure
  7. Rotate the patient
    1. Roll the patients to hands and knees
  8. Replace fetal head (Zavanelli Maneuver)
    1. Followed by Emergency C-Section

VII. References

  1. Warrington (2019) Crit Dec Emerg Med 33(8): 16-7
  2. Gherman (1998) Am J Obstet Gynecol 178:1126-30 [PubMed]
  3. Hill (2020) Am Fam Physician 102(2): 84-90 [PubMed]
  4. Baxley (2004) Am Fam Physician 69:1707-14 [PubMed]

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