⚡ Shoulder Dystocia
1 RECOGNIZE
- The fetal head has delivered but the shoulders do not deliver with normal gentle axial traction; head retraction/turtle sign may be present.
- This is a mechanical birth emergency: drugs do not release the impacted shoulder.
2 CALL FOR HELP
- Declare shoulder dystocia and start timing; call senior obstetrician, additional midwives, anaesthetist and neonatal team.
- Ask an assistant to record the sequence and announce elapsed time; explain briefly and ask the mother to stop pushing while manoeuvres are organised.
3 IMMEDIATE ACTION
- Stop oxytocin and avoid fundal pressure, excessive downward traction or lateral bending of the fetal neck.
- McRoberts: assistants hyperflex the maternal hips toward the abdomen; combine with correctly directed SUPRAPUBIC pressure to adduct/rotate the anterior shoulder.
- If unsuccessful, a trained operator proceeds to internal rotation (Rubin/Woods/reverse Woods as appropriate) and/or posterior-arm delivery. Episiotomy may make room for a hand but does not itself remove bony impaction.
- Change to all-fours when feasible and try the appropriate manoeuvre again. Move between effective manoeuvres promptly rather than repeating forceful traction; allow roughly 30–60 s for an attempted manoeuvre while tracking elapsed time.
- If standard manoeuvres fail, the most experienced obstetrician selects rescue options in an equipped setting; these are not routine junior bedside procedures.
4 INVESTIGATIONS (never delaying treatment)
- No scan or laboratory test should delay delivery manoeuvres. Record times and call neonatal resuscitation support.
5 DEFINITIVE MANAGEMENT
- After delivery, hand the baby to the neonatal team for assessment/resuscitation and obtain cord gases when feasible.
- Assess the mother for PPH and genital-tract injury, including severe perineal/anal-sphincter injury; treat identified bleeding and injury.
6 ESCALATION
- Failed standard manoeuvres: immediate senior rescue with anaesthetic/theatre readiness.
- Neonatal depression or suspected injury: neonatal resuscitation and appropriate NICU/paediatric assessment.
7 POST-EVENT CARE
- Document head/body delivery times, personnel, traction and manoeuvres in order, and maternal/neonatal findings.
- Examine/document newborn limb movement and possible brachial-plexus injury/fracture; arrange follow-up. Debrief and discuss implications for a later pregnancy.
Admission & discharge after the acute event
Care setting: Emergency intrapartum care; post-event observation and newborn assessment
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Manage in an emergency birth setting with obstetric/neonatal help; admit/continue care for maternal trauma/haemorrhage or neonatal injury/compromise.
When clinic, day care or home care may be suitable
- An unresolved shoulder dystocia is not an outpatient problem. After resolution, mother and baby still need a post-event assessment.
Before going home
- Maternal bleeding and perineal/anal-sphincter injury assessment are complete, with a bladder, pain and mobility plan.
- The newborn has been examined for injury and neurological/respiratory compromise; any specialist assessment or follow-up is organised. Apply the postnatal observation pathway rather than discharging immediately because the shoulders delivered.
Discharge medicines and treatment changes
- Provide the actual perineal-trauma/analgesia/anaemia prescription; antibiotics or bowel treatment depend on the diagnosed injury and repair.
Tests, pending results and their reviewer
- Document the manoeuvres, time course, maternal injury and neonatal assessment; assign pending investigations.
Home care and counselling
- Explain what happened, offer a debrief and support, and record the recurrence discussion/future-birth planning needs.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before leaving | Confirm maternal injury/repair follow-up and the newborn team’s plan. |
Postnatal and future-pregnancy review | Review recovery, continence/pain concerns and a senior plan for future birth. |
Return urgently
- Heavy bleeding, fever, worsening perineal pain, inability to void, new bowel-control problems or newborn weakness/poor feeding needs prompt assessment.