Approach to shoulder dystocia

Notify nursing, anesthesia, obstetric, and pediatric staff to come to patient's room, if not already available, to provide assistance as needed.

Stop maternal pushing while preparations are made and maneuvers are undertaken to reposition the fetus.

Check for and release a tight nuchal cord, if present.

Position the patient with her buttocks flush with the edge of the bed to provide optimal access for executing maneuvers to affect delivery.

Consider performing a mediolateral or median third- or fourth-degree episiotomy to facilitate delivery of the posterior shoulder and other internal procedures. Episiotomy by itself does not help to release the anterior shoulder and increases perineal trauma.

Drain a distended bladder, if present.

Avoid excessive neck rotation, head and neck traction, and fundal pressure because this combination of maneuvers can stretch and injure the brachial plexus.

Perform maneuvers sequentially until shoulder dystocia is released. The sequence may be modified based on provider expertise with the various maneuvers.

Perform McRoberts maneuver
Perform McRoberts maneuver with suprapubic pressure
Deliver the posterior arm or Gaskin all-fours maneuver*
If the posterior arm cannot be delivered, deliver the posterior shoulder
Rotate the fetus (Rubin or Woods maneuver)
Fracture the fetal clavicle

Procedures of last resort:

Gunn-Zavanelli-O'Leary maneuver
Abdominal rescue
Symphysiotomy (potentially high maternal morbidity)

Document your evaluation, assessment, and management.

* Although most obstetricians do not perform the Gaskin all-fours maneuver, this is one of the initial group of maneuvers used my some midwives and other clinicians, particularly for the mother in a birthing bed with no, only local, or pudendal anesthesia. Some providers prefer to use it before attempting to deliver the posterior arm or shoulder since the latter require more technical expertise. The available literature on this maneuver is limited, and its role in the management of shoulder dystocia has not been firmly established; however, case reports support both the efficacy and low morbidity of this simple approach. Refer to the UpToDate topic on management of shoulder dystocia for more information.

Graphic 107812 Version 4.0

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Approach to shoulder dystocia