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Introduction
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Definition
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Incidence
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Risk Factors
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Morbidity and Mortality

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Management
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Developing an Institutional Plan

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E Enter - Internal manoeuvres

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R - Remove the Posterior Arm

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6RPHWLPHVWKHDUPLVGLVSODFHGEHKLQGWKHIHWXVDQGPXVWEHQXGJHGDQWHULRUO\2QFHWKH
IRUHDUPLVORFDWHGWKHHOERZVKRXOGEHIOH[HGVRWKDWWKHIRUHDUPPD\EHGHOLYHUHGLQDVZHHSLQJ
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SXOOHGGLUHFWO\DVWKLVPD\IUDFWXUHWKHKXPHUXV,IGRQHFRUUHFWO\ILUVWWKHSRVWHULRUKDQGWKHQ
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R Roll the Woman and Deliver the Posterior Shoulder

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Methods of Last Resort

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WKHIROORZLQJWHFKQLTXHVKDYHEHHQGHVFULEHGDVODVWUHVRUWPDQRHXYUHV
1. Deliberate clavicle fracture

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2. The Zavanelli manoeuvre

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3. Muscle Relaxation

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4. Abdominal Surgery and Hysterotomy

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5. Symphysiotomy

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FDSDELOLW\LVQRWDYDLODEOH

Documentation
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SHUIRUPHGDQGWKHGXUDWLRQRIWKHHYHQW7HUPVOLNHPLOGPRGHUDWHRUVHYHUHVKRXOGHUG\VWRFLD
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GRFXPHQWZKLFKDUPZDVLPSDFWHGDJDLQVWWKHSXELVDQGRQZKLFKDUPPDQRHXYUHVZHUH
SHUIRUPHGIRUUHPRYDO

Summary
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SHUFHQWRIVKRXOGHUG\VWRFLDVKDYHQRDQWHFHGHQWIDFWRUV$QWLFLSDWLRQDQGSUHSDUDWLRQDUHNH\
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7KHUHFRPPHQGHGPDQDJHPHQWRIVKRXOGHUG\VWRFLDLVEDVHGRQWKHPQHPRQLF+(/3(55
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VHTXHQFHDUHEHVWGHWHUPLQHGE\WKHFOLQLFDOFLUFXPVWDQFHVDQGWKHFOLQLFLDQVEHVWMXGJPHQW

Summary of Table Recommendations

Category A
%DVHGRQH[LVWLQJHYLGHQFHURXWLQHODWHSUHJQDQF\XOWUDVRXQGLQORZULVNRUXQVHOHFWHG
SRSXODWLRQVGRHVQRWFRQIHUEHQHILWLQSUHGLFWLQJPDFURVRPLDRUUHGXFLQJPRUELGLW\
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DOWHUWKHULVNRIPDWHUQDORUQHRQDWDOPRUELGLW\

Category B
7KHUHLVQRHYLGHQFHWRVXSSRUWHOHFWLYHELUWKDWWHUPLQSUHJQDQWZRPHQZLWKLQVXOLQUHTXLULQJ
GLDEHWHV:KLOHZRPHQZLWKLQVXOLQUHTXLULQJJHVWDWLRQDOGLDEHWHVKDYHDORZHULQFLGHQFHRI
PDFURVRPLDZKHQHOHFWLYHELUWKLVGRQHWKLVGLGQRWUHGXFHWKHULVNRIPDWHUQDORUQHRQDWDO
PRUELGLW\

Category C
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PDQRHXYUHWRFRQWLQXHWKHPRPHQWXPDQGDOORZWKHIHWXVWRGHOLYHUWKURXJKXQWLOWKHDQWHULRU


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References
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Shoulder Dystocia

Objectives
Recognize risk factors for shoulder
dystocia
Utilize a systematic approach to
managing shoulder dystocia
Demonstrate appropriate manoeuvres
to reduce a shoulder dystocia using the
HELPERR mnemonic

Background
Impaction of the anterior shoulder
against the symphysis after birth of the
fetal head
Incidence - varies by birthweight
0.3% in infants weighing 2500-4000 grams
5-7% in infants weighing 4000-4500 grams

>50% occur in normal weight infants

Impacted
Shoulder

Risk Factors
Previous shoulder dystocia Abnormal pelvic anatomy
Gestational diabetes

Prolonged 1st stage

Post-dates pregnancy

Prolonged 2nd stage

Macrosomia

Head bobbing in 2nd

stage

Maternal short stature

High pre-pregnancy weight Instrumental vaginal

and weight gain
delivery

Complications
Maternal
soft-tissue injuries
anal sphincter damage
post-partum
haemorrhage
uterine rupture
symphyseal separation

Neonatal

brachial plexus palsy

clavicular fracture
humeral fracture
fetal acidosis
hypoxic brain injury

Prevention
Elective caesarean delivery NOT indicated
Glycaemic control
Weight control
Pre-conceptual and during pregnancy

Deliver in alternative positions or McRoberts

Deliver anterior shoulder with momentum of
head delivery

Recognition
Fetal head retracts against perineum
(turtle sign)
Gentle traction does not effect delivery
Proceed to HELPERR

H = Help
Activate institutional protocol
Appropriate notification
Additional staff
Additional back-up
neonatal resuscitation personnel
obstetric / surgical backup
anaesthesia

E = Evaluate for Episiotomy

Shoulder dystocia is not a soft-tissue
dystocia
Consider when additional room needed
for advanced manoeuvres
Decision based on clinical judgement and
response to initial manoeuvres

L = Legs
McRoberts Manoeuvre:
Flex maternal hips so that thighs are on
abdomen

Effects:
Straightens the lumbosacral lordosis
Increases AP diameter of pelvis
Flexes the fetal spine

Reduces >40% of shoulder dystocias

P = Pressure
Supra-pubic pressure by assistant (Rubin I):
CPR-style hand position
Force should act to adduct anterior shoulder
Initially continuous, but can involve a rocking
motion
Attempt for 30-60 seconds
With McRoberts manoeuvre will reduce 50% of
shoulder dystocias

E = Enter
Rubin II Manoeuvre
Approach anterior fetal shoulder from
behind
Exert pressure on scapula to adduct most
accessible shoulder and rotate to oblique
position
Continue McRoberts manoeuvre

E = Enter (II)
Woods Screw Manoeuvre
Approach posterior fetal shoulder from
the front
Gently rotate shoulder toward
symphysis
Combine with Rubin II manoeuvre
Birth attendant has one hand on each
shoulder, rotating together

E = Enter (III)
Reverse Woods Screw manoeuvre:
Approach posterior shoulder from
behind
Rotate fetus in opposite direction from
Rubin or Woods Screw manoeuvres
May be successful when previous
manoeuvres fail

R = Remove the Posterior Arm

Follow posterior arm down to elbow
usually anterior to fetal chest

Flex arm at the elbow

Sweep forearm across fetal chest
grasping hand directly and pulling outwards
may lead to fractures

R = Roll the Woman

Roll woman to McRoberts all-fours
position
Increases pelvic diameters
Movement and gravity may also
contribute to dislodging the impaction
Deliver posterior shoulder with gentle
downward traction
May attempt all Enter manoeuvres in
this position

HELPERR
Remember the manoeuvres aim to:
increase the functional size of the bony
pelvis
decrease the bisacromial diameter
change the relationship of the bisacromial
diameter with the bony pelvis

Manoeuvres of Last Resort

Deliberate clavicle fracture
Zavanelli manoeuvre
Muscle relaxation
Abdominal surgery with hysterotomy
Symphysiotomy

Symphysiotomy
Used primarily in developing nations
Local anaesthetic injected over symphysis
Skin incision down to symphysis
Vaginal hand displaces urethra laterally
Scalpel blade to cut ligaments
Symphysis will then spread, allowing delivery

Summary
Shoulder dystocia is a common and lifethreatening emergency
Risk factors helpful, but difficult to predict
Anticipation and preparation are keys to
successful management
Institutional protocol is recommended
HELPERR provides a structured approach