II. Approach
- On recognizing Shoulder Dystocia (e.g. delay in body delivery, turtle sign)
- Immediately notify surrounding staff of Shoulder Dystocia (e.g. "code Shoulder Dystocia")
- Muster additional help
- Provider qualified to perform Cesarean Section
- Provider qualified to perform Neonatal Resuscitation
- Assistant records interventions (code recorder) and announces time from head delivery every 30 seconds
- Lower the bed or provide a step for those performing subrapubic pressure
- Enlist help of patient, in pushing at the correct time
- Follow systemic approach in attempt to disimpact the anterior Shoulder
- See HELPER and PERSPIRE mnemonics below
III. Precautions
- Understand Fetal Position (where is the occiput and which direction is the fetus facing)
- Avoid harmful maneuvers
- Fundal pressure
- Excessive lateral or downward traction on fetal head or neck (associated with Brachial Plexus Injury)
- Twisting or bending neck
IV. Definitions
- Suprapubic Pressure on the Fetal Shoulder
- Decreases fetal Shoulder breadth (distance between Shoulders or bisacromial distance)
- Avoid fundal pressure (risk of Uterine Rupture)
- Apply pressure over Bladder (never over fundus)
- Oblique downward and anterior pressure
- Initial attempt: Apply pressure for 30 to 60 sec
- Later: Rocking motion similar to CPR
- McRoberts Position
- Efficacy
- Among the most effective single measures in Shoulder Dystocia
- Resolves >40% of dystocias
- Resolves 50% when used with suprapubic pressure
- Technique
- Flex thighs
- Patient pulls knees toward ears
- Effect: Expands size of maternal Pelvis
- Flattens lumbar lordosis
- Symphysis rotates superiorly
- Efficacy
- Episiotomy
- Cut a generous episiotomy
- May be delayed until after pressure and McRoberts
- Effect
- Does not effect Bony Pelvis obstruction
- Increases room to work for rotational maneuvers
- Posterior arm delivery
- Requires patient cooperation and practice
- Provider inserts hand between fetus and perineum
- Slide examiner hand across fetal chest (not the fetal back) down towards the fetal hip
- Grasp posterior arm at wrist, between examiners thumb and index finger (OK sign)
- Flex elbow and sweep Forearm across chest
- Avoid grasping upper arm (Humerus Fracture risk)
- When combined with other measures above (McRoberts, suprapubic pressure) results in delivery within 4 min in 95%
- Rotational Maneuvers
- Perform maneuvers while maintaining downward traction
- Maneuvers described for left occiput position
- Rubin II Maneuver
- Two fingers placed behind anterior Shoulder
- Apply downward pressure around arc of rotation
- Rotate presenting part clockwise for 30-60s, approximately 30 degrees
- Wood-Screw maneuver
- Two fingers placed in front of posterior Shoulder
- Apply upward pressure around arc of rotation
- Rotate presenting part clockwise for 30-60 sec, attempting to rotate 180 degrees
- Rubin II Maneuver with Wood-Screw maneuver
- Maximizes torque for rotation
- Difficult due to limited vaginal space for maneuver
- Reverse Wood-Screw
- Gaskin Maneuver or all-fours position
- Patient rolls onto hands and knees
- Apply downward traction to deliver posterior Shoulder
- Above rotational maneuvers may be repeated if needed
- Effect: Increases pelvic diameters (TOC, Sagittal)
- Maneuvers of last resort
- Deliberate Clavicle Fracture
- Pull clavicles outward and Fracture one or both
- Risk of underlying vascular or lung injury
- Zavanelli Maneuver
- Cesarean Section with cephalic replacement
- One provider performs emergency cesarean
- Second provider replaces head
- Rotate fetal head into direct Occiput Anterior position
- Fetal neck is flexed with chin pressing into perineum
- Head pushed back into vagina (gently)
- Provider provides continuous pressure on head to hold the fetus within Uterus
- Uterine relaxation with IV Nitroglycerin or inhalational Anesthetic may be needed
- Symphysiotomy
- Abdominal surgery with hysterotomy
- Deliberate Clavicle Fracture
V. Management: Mnemonic PERSPIRE
- Preparation
- Delivery Room
- Nurses on steps
- Episiotomy
- (Mc)Roberts Position (See Above)
- Suprapubic Pressure
- Posterior arm delivery
- Internal Rotation
- Wood-Screw maneuver (rotate face towards floor)
- Try with patient positioned on all 4 extremities
- Emergency
- Fracture Clavicle
- Zavanelli Maneuver (See above)
VI. Management: Mnemonic HELPER (ALSO course)
- Help
- Call for Help
- Episiotomy
- Legs
- Position with McRoberts Maneuver for 30-60 seconds
- See description above
- Pressure at suprapubic area
- Only apply to suprapubic region (never apply to the uterine fundus)
- Enter
- Remove the posterior arm
- Repeat the above procedure
- Rotate the patient
- Roll the patients to hands and knees
- Replace fetal head (Zavanelli Maneuver)
- Followed by Emergency C-Section
VII. References
- Warrington (2019) Crit Dec Emerg Med 33(8): 16-7
- Gherman (1998) Am J Obstet Gynecol 178:1126-30 [PubMed]
- Hill (2020) Am Fam Physician 102(2): 84-90 [PubMed]
- Baxley (2004) Am Fam Physician 69:1707-14 [PubMed]