SHOULDER DYSTOCIA Recognized
Head delivered but shoulders do not follow with gentle traction - 'Turtle Sign'
All Pathways
Obstetrics & GynecologyEmergency
Shoulder Dystocia Management (ACOG 2017)
Shoulder Dystocia Management (ACOG 2017): SHOULDER DYSTOCIA Recognized → CALL FOR HELP IMMEDIATELY → E - Evaluate for Episiotomy → L - Legs: McRoberts M...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning CALL FOR HELP IMMEDIATELY
H - Help: Call additional personnel NOW
- Additional OB/midwife
- Anesthesia
- Neonatal team
- Nursing support
- Note the TIME - start clock
03Action 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
04Action 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
05Action 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
06Decision Shoulder Delivered?
Reassess after McRoberts + suprapubic pressure
07Outcome 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
08Action 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
09Action 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)
10Decision Shoulder Delivered?
Reassess after internal maneuvers
- Path rejoins step 07Shared downstream outcome
11Action 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
- Path rejoins step 07Shared downstream outcome
12Warning 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
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
13Action 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)
- Path rejoins step 10Shared downstream outcome
14Warning ⚠️ DO NOT Apply Fundal Pressure
Increases impaction and risk of injury
15Warning ⚠️ Avoid Excessive Downward Traction
Increases brachial plexus injury risk
Guideline Source
ACOG Practice Bulletin No. 178: Shoulder Dystocia
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Shoulder dystocia is unpredictable and cannot be reliably prevented
- No single maneuver is proven superior
- Requires hands-on training and simulation
- Time to delivery is critical - act quickly
Applicable Regions
USEUGlobal
UK: RCOG Green-top 42 has similar recommendations
US: Based on ACOG 2017 guidelines
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Shoulder Dystocia Management (ACOG 2017)?
The Shoulder Dystocia Management (ACOG 2017) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Practice Bulletin No. 178: Shoulder Dystocia.
What guideline is the Shoulder Dystocia Management (ACOG 2017) based on?
This algorithm is based on ACOG Practice Bulletin No. 178: Shoulder Dystocia (DOI: 10.1097/AOG.0000000000002043).
What are the limitations of the Shoulder Dystocia Management (ACOG 2017)?
Known limitations include: Shoulder dystocia is unpredictable and cannot be reliably prevented; No single maneuver is proven superior; Requires hands-on training and simulation; Time to delivery is critical - act quickly. Individual patient factors may require deviation from these recommendations.
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