Shoulder dystocia occurs when, after the baby’s head is born, the anterior shoulder becomes stuck behind the mother’s pubic bone and gentle downward traction fails to deliver the shoulders. It happens in a small percentage of vaginal births, often without warning. Delays can cause the baby to be deprived of oxygen, and injuries such as brachial plexus injury. Every midwife and labour ward nurse should be drilled in the response.
Risk factors
- Previous shoulder dystocia (the strongest risk factor).
- Large baby (macrosomia).
- Maternal diabetes, including gestational diabetes.
- Maternal obesity.
- Prolonged labour, instrumental delivery.
However, most cases occur in women with no risk factors, so all birth attendants must be prepared.
Recognising it
- Difficulty delivering the face and chin.
- The head is born but retracts tightly against the perineum (the “turtle sign”).
- Failure of restitution (the head doesn’t turn).
- The shoulders don’t deliver with routine gentle traction.
The response
Many units use a structured approach. Key steps (based on RCOG guidance) include:
- Call for help immediately: senior midwife, obstetrician, neonatal team, anaesthetist. State clearly: “Shoulder dystocia.” Note the time the head was born.
- Stop maternal pushing while manoeuvres are performed, and avoid fundal pressure (it can worsen impaction and cause uterine rupture).
- Avoid excessive or downward traction on the baby’s head; it increases the risk of brachial plexus injury.
- McRoberts manoeuvre: lie the mother flat, then flex and abduct her hips, bringing her thighs up towards her abdomen. This straightens the pelvis and resolves many cases.
- Suprapubic pressure: an assistant applies pressure just above the pubic bone, from the side of the baby’s back, pushing the anterior shoulder towards the baby’s chest. It can be continuous or rocking.
- Internal manoeuvres if the above fail: delivery of the posterior arm, or internal rotational manoeuvres (such as Rubin II or Woods’ screw), performed by trained practitioners. An episiotomy may be considered to allow access, but doesn’t relieve the bony obstruction itself.
- All-fours position (Gaskin manoeuvre) may help, particularly where assistance is limited or the woman is mobile.
- Rarely, second-line manoeuvres are needed by senior obstetricians.
The head-to-body delivery interval matters: the risk of hypoxic injury rises with delay, so move through manoeuvres efficiently.
After the birth: baby
- Be ready for neonatal resuscitation.
- Paired cord blood gases if possible.
- Examine for brachial plexus injury (reduced arm movement, e.g. Erb’s palsy), and fractured clavicle or humerus.
- Inform the neonatal team.
After the birth: mother
- Higher risk of postpartum haemorrhage and perineal trauma, including third- and fourth-degree tears.
- Check carefully and repair appropriately.
- Debrief the mother and her partner; it can be a traumatic experience. Offer follow-up.
Documentation
Record the time of delivery of the head and body, which shoulder was anterior, the manoeuvres used in order with timings, who was present, and the condition of the baby. Many units use a standard proforma. Shoulder dystocia is a common cause of litigation, so clear documentation protects everyone.
Practise, practise, practise
Regular multi-professional skills drills, such as PROMPT and other obstetric emergency training programmes, have been associated with improved outcomes. If your unit doesn’t run drills, advocate for them.
Based on RCOG Green-top Guideline No. 42 (Shoulder dystocia) and WHO intrapartum care guidance. Educational content: follow local protocols and training.