CLINICAL PRACTICE GUIDELINE

Shoulder Dystocia
SCOPE (Area): Maternity
SCOPE (Staff): Midwifery & Medical

SHOULDER DYSTOCIA IS AN OBSTETRIC EMERGENCY

DESIRED OUTCOME/OBJECTIVE

The shoulder will be released allowing the baby to be born.

A team approach is applied to the management of shoulder dystocia.
DEFINITIONS
Shoulder dystocia: occurs when the anterior shoulder of the baby becomes impacted against the
symphysis pubis preventing the shoulders from descending through the pelvis. Additional
manoeuvres are then required to complete the delivery of the baby after routine downward traction
has failed to deliver the shoulders during a vaginal delivery. Less commonly the posterior shoulder
impacts on the maternal sacral promontory.
ISSUES TO CONSIDER
A majority of cases of shoulder dystocia occur in women with no risk factors however woman
at risk may be identified as follows:
Antenatal risk factors
Previous shoulder dystocia
Fetal Macrosomia (90th centile)
Maternal diabetes
Maternal obesity (BMI>30)
Post dates pregnancy
Short stature
Intrapartum risk factors
Prolonged first stage
Prolonged second stage
Labour augmentation
Instrumental delivery
Precipitate birth
Uterine hyperstimulation

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Complications of shoulder dystocia

Maternal
Ruptured uterus
Postpartum haemorrhage (PPH)
Perineal tears (3rd and 4th degree)
Emotional trauma

Neonatal

Brachial plexus injury

Fractured clavicle
Birth asphyxia
Neonatal death

Gaining internal vaginal access

During the emergency there may be a tendency is to try and gain access in the anterior aspect of
the vagina to perform manoeuvres however there is minimal room underneath the pubic arch and
access will be difficult. Vaginal access should be gained posteriorly in the sacral hollow where
there is more space and the accoucher must scrunch up their hand (like putting on a bracelet) and
insert it into the posterior aspect of the vagina. Suprapubic pressure must be stopped when gaining
internal vaginal access.
Episiotomy
Shoulder dystocia is a bony impaction, so episiotomy will not release the shoulders. Episiotomy
may be considered to facilitate internal manoeuvres however is not mandatory. An assistant will be
required to elevate the babys head to improve the view of the perineum and allow the accoucher to
use both hands when performing the procedure.
Last resort manoeuvres
As a last option an experienced clinician may attempt:
Deliberate fracture of the clavicle
The Zavanelli manoeuvre (restoring the fetus into the uterus and performing a caesarean
section)
Symphysiotomy
Documentation
Documentation of is essential and must include:
Time of delivery of the head
The manoeuvres performed, the timing and the sequence
The traction applied
The time of delivery of the body
The staff in attendance and the time they arrived
The condition of the baby
Umbilical cord blood acid-base measurements (cord pH)
The anterior fetal shoulder at the time of dystocia
A retrospective medical record must be completed in the client notes.

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Maternal Debriefing
It is essential that the mother and her support person(s) are debriefed after the event as the
experience can be extremely traumatic. Initial debriefing may occur in the immediate postpartum
period and formal debriefing may be required a few weeks following delivery. Counselling should
include planning and documentation of management of subsequent deliveries.
PROCEDURE
Recognition of shoulder dystocia
Turtle sign (chin retracts and depresses the perineum)
Failure of the fetal head to restitute
Failure of the shoulders to descend
Difficult delivery face and chin
Head when delivered may be tightly applied to the vulva
The anterior shoulder fails to deliver with routine traction
Please refer to appendix 1 Algorithm for the management of shoulder dystocia
When performing the manoeuvres the shoulders must be rotated using pressure on the scapula or
clavicle. Never rotate the head.
The manoeuvres are described in detail below:
McRoberts manoeuvre: increases the relative anteroposterior diameter of the pelvic inlet by
rotating the maternal pelvis cephaloid and straightening the sacrum relative to the lumbar spine. It
is then associated with an increase in uterine pressure and amplitude of the contractions. This
position is successful in 90% of cases of shoulder dystocia.
Procedure
1. Place the woman in a recumbent position and remove any pillows from under her back
2. Remove or lower the bottom of the bed and manipulate her buttocks to the edge of the
bed if able or if in lithotomy position removes her legs from the supports.
3. An assistant should be on each side of the woman and the procedure should be
coordinated.
4. The legs are then abducted and hyperflexed against the womens abdomen so that her
knees are upwards towards her ears.
Suprapubic pressure (Rubin 1): aims to reduce the diameter of the fetal shoulders (the
bisacromial diameter) and rotate the anterior shoulder into the wider oblique angle of the pelvis.
The shoulder is then free to slip under the symphysis pubis.
Procedure
1. An assistant should perform suprapubic pressure from the side of the fetal back.
2. Pressure (rocking or continuous) is applied in a downward and lateral direction, just
above the maternal symphysis pubis, to push the posterior aspect of the shoulder towards
the fetal chest
3. The adoption of a CPR position over the anterior shoulder will assist with maintaining
effective pressure
4. Routine traction should only be applied to the fetal head when assessing whether the
manoeuvre has been successful.

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Internal manoeuvres: can be performed if McRoberts manoeuvre and suprapubic pressure has
been unsuccessful. The two categories include delivery of the posterior arm and internal rotational
manoeuvres. Evidence does not demonstrate that either is superior or that one should be attempted
before the other. Clinical judgement and experience should determine the most appropriate
management. Internal rotational manoeuvres aim to adduct the fetal shoulder girdle, reducing the
diameter and rotating the shoulders forward into the oblique diameter. The delivery of the posterior
arm aims to reduce the diameter of the fetal shoulders by the width of the arm.
Procedure
Rubin 2
1. The hand is inserted into the vagina posteriorly into the sacral hollow. Do not try to gain
access anteriorly initially as there is very little room under the pubic arch.
2. Sweep two fingers up to the posterior aspect of the anterior shoulder
3. Push the shoulder into the oblique diameter of the pelvis toward the fetal chest

Woods Screw Manoeuvre

1. While performing the Rubin 2 enter the posterior vagina with the second hand
2. Apply pressure with two fingers to the anterior aspect of the posterior shoulder and
maintain rotation in the original direction

Reverse Woods Screw

1. Apply pressure to the posterior aspect of the posterior shoulder in attempt to rotate it the
opposite direction to that described in the Woods Screw manoeuvre

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Delivery of the Posterior arm

1. The accoucher must scrunch up their hand (as if putting on a bracelet) and insert it into
the posterior aspect of the vaginal into the sacral hollow.
2. The fetal hand may be felt or pressure may be applied to the antecubital fossa of the
fetus to flex the elbow in front of the body, and/or grasp the posterior hand.
3. The fetal wrist is grasped and the arm is swept across the fetal chest and gently pulled
out in a straight line. Do not pull the upper arm as it may result in a humeral fracture
4. When the arm is delivered apply gentle traction to the fetal head to attempt delivery
5. If not successful support the head and gently rotate the baby through 180 and the
posterior shoulder will become the new anterior shoulder and should be below the
symphysis pubis.

All-fours position
1. Roll the mother on to her hands and knees so that the maternal weight lies evenly on all
four limbs (this movement may dislodge the anterior fetal shoulder)
2. The all fours position may also facilitate access to the posterior shoulder to enable
internal manoeuvres to be performed
3. It may be difficult for some women to assume this position including those with an
epidural infusion or large maternal size (high BMI) and therefore clinical judgment must
be used when attempting this maternal position.

RELATED DOCUMENTS
Internal
CPG/O011 Obstetric Emergency Response
CPGC0005 Cardio-Pulmonary Resuscitation - Neonatal Basic Life Support
REFERENCES
Draycott, T., Winter, C., Crofts, J. & Barnfield, S. (eds) (2008) PROMPT Course Manual. London:
RCOG Press
King Edward Memorial Hospital (2008) Clinical guidelines: 5.9.5 Shoulder Dystocia. Accessed on
4/2/11 from
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/5/b5.9.5.pdf
Southern Health (20100 Guidelines Shoulder dystocia. Accessed on 4/3/11 from
http://www.southernhealth.org.au/icms_docs/4136_Shoulder_dystocia.pdf
The Womens (2006) Clinical practice guidelines Shoulder dystocia. Accessed on 4/3/11 from
http://www.thewomens.org.au/ShoulderDystocia

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Reg. Authority: CEO, Executive Directors- Nursing,

Medicine, Allied Health & Psychiatric Services. Clinical
Director & DON-Women & Childrens Services
Review Responsibility: Maternity Unit

Date Effective: June 2011

Date Revised:Date for Review: June 2014

Original Author: Maternity project Officer (2010)

Updated by: ---

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Appendix 1
Algorithm for the management of shoulder dystocia
CALL FOR HELP
Obstetric Response
94444

Discourage pushing

McROBERTS MANOEUVRE

SUPRAPUBIC PRESSURE

Consider episiotomy if it will

make internal manoeuvres
easier

Try either manoeuvre first

depending on clinical
circumstances and operator
INTERNAL
ROTATIONAL
MANOEUVRES

DELIVER POSTERIOR
ARM

If above all manoeuvres fail to release the impacted

shoulder consider
ALL FOURS POSITION (if appropriate)
OR
Repeat all the above again

As a last resort an experienced

clinician may perform the following:
Cleidiotomy
Zavanelli manoeuvre
Syphysiotomy

DOCUMENTATION

CPG/S044: Shoulder Dystocia (2011)

Adapted from Draycott, T.,

Winter, C., Crofts, J. &
Barnfield, S. (eds) (2008)
PROMPT Course Manual
.London: RCOG Press

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