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The Difficult Delivery: Shoulder Dystocia

The first step is called McRobert’s maneuver: an assistant is directed to push mom’s thighs as close to her chest as possible. A second assistant then applies suprapubic pressure.

The next option is to slide your hand along superior head and above the superior shoulder to attempt to disimpact the shoulder manually.

If not successful, next use 2 fingers to firmly push on the scapula of the inferior shoulder and turn the baby 180 degrees to make it the superior shoulder (Wood’s corkscrew maneuver).

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  Shoulder Shimmy

Shoulder dystocia typically occurs when the anterior shoulder impacts on the pubic symphysis, less often when posterior shoulder impacts on the sacral promontory. Risk factors include abnormal maternal pelvic anatomy, gestational diabetes, post-dates pregnancy, previous shoulder dystocia, short maternal stature, and fetal macrosomia.

 How We Do What We Do: Shoulder Dystocia Delivery

Perform McRoberts maneuver. If the anterior shoulder doesn’t deliver, apply suprapubic pressure over the anterior shoulder with a downward and lateral motion on the posterior aspect of the shoulder. The provider who is performing suprapubic pressure should be standing on a CPR stool giving them the appropriate angle. These maneuvers are considered ineffective once they have been tried in quick succession without delivery of the baby. The Woodscrew maneuver may be considered next by applying the right hand to the back of the posterior shoulder and placing the L hand to the front of the anterior shoulder and rotating the child to face the rectum.

 McRoberts Maneuver

Recommended first maneuver by ACOG, Mother is lying supine with legs placed in “extreme lithotomy position” – hips hyperflexed with knees pressed to chest.n Assistants hold legs in position, one for each leg. Causes cephalic rotation of pubic symphysis and flattening of lumbar lordosis, allows for passage of one shoulder at a time. Resolves approximately 40% of shoulder dystocias (Del Portal 2014). Can be used in combination with suprapubic pressure.

 Rubin or Woods corkscrew maneuver

Rubin Maneuver - Insert fingers of hand behind the posterior aspect of the anterior shoulder and rotate shoulder toward fetal chest. Woods Corkscrew maneuver - Insert two fingers on anterior aspect of posterior shoulder. Pressure applied to rotate it posterolaterally. If unsuccessful continue to rotate 180 degrees. May combine maneuvers to increase rotation, may be limited secondary to space and patient tolerance.

Articles of Interest

#EMconf: Shoulder dystocia

-Most important (and first step) is recognition: “Turtle” Sign – retraction of the delivered fetal head against the maternal perineum; it is suggestive but not diagnostic. This is an unpredictable and unpreventable situation: Keep calm to help prevent complications.

Clamp the Cord: Emergency Department Deliveries – Part 1

It can be recognized by presence of the “turtle sign” during deliveries – when the fetal head retracts back toward the mother’s perineum immediately after its presentation. You can also look for fetal facial flushing and failure to deliver the anterior shoulder as other signs after the head is delivered.

Resources

Core EM

McRoberts Maneuver... Recommended first maneuver by ACOG.

emDocs

Shoulder dystocia is a subjective clinical diagnosis when gentle traction is insufficient to deliver the fetal shoulders after delivery of the fetal head. It occurs in 0.2–­3% percent of all births [2], but cannot usually be anticipated or prevented as most patients lack factors that would suggest increased risk.

Teach Me ObGyn

It is an obstetric emergency, with an incidence of approximately 0.6-0.7% in all deliveries.