Shoulder Dystocia Management (ACOG 2017)

Algorithm Steps

1. ▶

   Start

   SHOULDER DYSTOCIA Recognized

   Head delivered but shoulders do not follow with gentle traction - 'Turtle Sign'

   1. ⚠

      Warning

      CALL FOR HELP IMMEDIATELY

      H - Help: Call additional personnel NOW

      • Additional OB/midwife
      • Anesthesia
      • Neonatal team
      • Nursing support
      • Note the TIME - start clock
      1. ●

         Action

         E - Evaluate for Episiotomy

         Consider episiotomy if more room needed for maneuvers

         • Episiotomy does NOT relieve bony obstruction
         • May provide more room for rotational maneuvers
         • Consider if vaginal tissue is limiting access
         • Not required in all cases
         1. ●

            Action

            L - Legs: McRoberts Maneuver

            FIRST-LINE maneuver - sharply flex thighs on abdomen

            • Sharp flexion of maternal thighs onto abdomen
            • One assistant per leg
            • Flattens sacral promontory
            • Rotates pubic symphysis superiorly
            • Increases AP diameter of pelvis
            • Apply gentle downward traction on head - NO EXCESSIVE FORCE
            1. ●

               Action

               P - Pressure: Suprapubic Pressure

               Apply with McRoberts - helps dislodge anterior shoulder

               • Apply pressure SUPRAPUBICALLY (above symphysis)
               • NOT fundal pressure (increases impaction)
               • Continuous pressure OR rocking motion
               • Directed posteriorly and laterally
               • Goal: adduct and rotate anterior shoulder
               • May try from either side
               1. ◆

                  Decision

                  Shoulder Delivered?

                  Reassess after McRoberts + suprapubic pressure

                  1. ✓

                     Outcome

                     Delivery Achieved

                     Immediate neonatal and maternal care

                     • Note total head-to-body delivery time
                     • Neonatal team for resuscitation as needed
                     • Assess for brachial plexus injury
                     • Check for clavicle or humerus fracture
                     • Maternal assessment for lacerations, hemorrhage
                     • Cord blood gases
                     1. ●

                        Action

                        Documentation & Debrief

                        Thorough documentation is critical

                        • Time of head delivery
                        • Time shoulder dystocia recognized
                        • Maneuvers attempted and order
                        • Time of body delivery (head-to-body interval)
                        • Personnel present
                        • Neonatal condition at birth
                        • Debrief with team and patient/family
                  2. ●

                     Action

                     E - Enter: Rotational Maneuvers

                     Internal rotation to oblique diameter

                     • RUBIN II: Push posterior aspect of anterior shoulder toward fetal chest
                     • WOODS CORKSCREW: Push anterior aspect of posterior shoulder toward fetal back
                     • Goal: Rotate shoulders to oblique diameter
                     • May require 180° rotation
                     • Can combine maneuvers (Rubin + Woods)
                     1. ◆

                        Decision

                        Shoulder Delivered?

                        Reassess after internal maneuvers

                        1. ●

                           Action

                           R - Roll: Gaskin Maneuver (All-Fours)

                           Position change may dislodge shoulder

                           • Roll patient onto hands and knees
                           • May increase pelvic dimensions
                           • Gravity assists with delivery
                           • Repeat maneuvers in this position if needed
                           • Challenging in patients with epidural
                           1. ⚠

                              Warning

                              Last Resort Maneuvers

                              For severe, unresolved dystocia only

                              • ZAVANELLI: Cephalic replacement + cesarean
                              • - Flex head, push back into vagina
                              • - Emergency cesarean delivery
                              • CLEIDOTOMY: Deliberate clavicle fracture
                              • - Rarely performed on live fetus
                              • SYMPHYSIOTOMY: Cutting symphysis pubis
                              • - Rarely used in developed countries
                  3. ●

                     Action

                     R - Remove Posterior Arm

                     Delivery of posterior arm - often most effective

                     • Insert hand posteriorly along fetal chest
                     • Locate posterior arm and flex at elbow
                     • Grasp forearm/wrist and sweep across chest
                     • Deliver arm in front of fetus
                     • This shortens shoulder diameter by ~20%
                     • May cause humerus fracture (acceptable if needed)
               2. ⚠

                  Warning

                  ⚠️ DO NOT Apply Fundal Pressure

                  Increases impaction and risk of injury

            2. ⚠

               Warning

               ⚠️ Avoid Excessive Downward Traction

               Increases brachial plexus injury risk