Shoulder Dystocia
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
Shoulder dystocia is an emergency after birth of the head when the shoulders do not deliver normally. A prepared team response matters because it often occurs without a reliable antenatal prediction.
Assessment & interpretation
- Recognise the failure of the shoulders to deliver, announce the emergency and bring obstetric, anaesthetic and neonatal help.
- Communicate clearly with the mother about position changes and what the team is doing.
Decisions that change management
- McRoberts positioning and pressure just above the pubic bone are initial manoeuvres described by RCOG. Further internal manoeuvres or moving to all fours may be needed if the shoulder remains impacted.
- An episiotomy can improve access for an internal manoeuvre but does not directly remove the bony obstruction.
Follow-up & safety-netting
- Assess maternal bleeding and perineal trauma and examine the newborn for injury or compromise.
- Document the events and manoeuvres, explain what happened and arrange support. In a future pregnancy, discuss the previous event, any injury and individual birth options.
Clinical pitfalls
- Most babies with a higher birthweight do not experience shoulder dystocia, and many affected babies are not unusually large; size estimation cannot rule it out.
Admission & discharge
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.
Treatment
① Immediate stabilization — first minutes
③ First-line treatment & drug regimens
- 1. McRoberts + suprapubic pressure (majority resolve)
- 2. Episiotomy considered for internal access if needed
- 3. Rubin II (push anterior shoulder forward from behind) / Woods screw (posterior shoulder pushed anteriorly)
- 4. POSTERIOR ARM DELIVERY: hand to sacral hollow, flex posterior elbow, sweep arm across chest
- 5. All-fours (Gaskin) repositioning, repeat attempts
- 6. RESCUE: cleidotomy, Zavanelli replacement + caesarean, symphysiotomy
Definitive treatment
Birth by whichever step succeeds -> cord gases, neonatal resuscitation readiness, active third stage immediately.
Monitoring
| After birth | Action |
|---|---|
Neonate | Brachial plexus exam, clavicle check, asphyxia surveillance, cord gases |
Mother | PPH watch, genital tract exam incl. rectal assessment for occult OASIS |
Documentation | Times, personnel, sequence, traction described as gentle/axial only |
Debrief | Parents informed; incident form; recurrence counselling |
Escalation
- NICU transfer for HIE risk
- Theatre exploration for extensive tears
⑮ Complications & their management
Brachial plexus injury
Early physiotherapy; orthopaedic referral if no biceps recovery by 3 months
PPH
Standard pathway
Occult anal sphincter injury
Rectal exam after EVERY dystocia; theatre repair
Neonatal HIE
Cooling eligibility within 6 h
Post-treatment care
- Physiotherapy as indicated
- Recurrence (~10-15%) counselling documented
Diagnosis & assessment
- Turtle sign / head retraction
- Resolution clock: aim <5 min
Definition: Impacted anterior shoulder requiring additional manoeuvres after gentle axial traction fails.
Risk factors
Initial assessment
- CALL FOR HELP: senior obstetrician, neonatal team, anaesthetist - declare "SHOULDER DYSTOCIA", note time aloud
- STOP pushing; stop oxytocin; NEVER fundal pressure
- McRoberts hyperflexion + suprapubic pressure (continuous or rocking)
- Unresolved ~30 s -> internal manoeuvres
Investigations
| Test | Looking for |
|---|---|
None - clinical emergency | - |
Algorithm
Sources (7)
2023-09-29 · updated 2026-06-09 · checked 2026-08-23 · verified-live
Open source ↗
NICE overview + Update information page (dates above confirmed)
· checked 2026-10-18 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for shoulder-dystocia. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admission/discharg…
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.