Shoulder Dystocia:​Managing

an Obstetric Emergency
D. Ashley Hill, MD, AdventHealth Graduate Medical Education Program, Orlando, Florida
Jorge Lense, MD, AdventHealth Orlando Hospital, Orlando, Florida
Fay Roepcke, MD, MPH, AdventHealth Orlando Family Medicine Residency Program, Orlando, Florida

Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the
shoulders. This can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder,
anal sphincter, and rectum, and postpartum hemorrhage. Although fetal macrosomia, prior shoulder dystocia, and preex-
isting or gestational diabetes mellitus increases the risk of shoulder dystocia,
most cases occur without warning. Labor and delivery teams should always be
prepared to recognize and treat this emergency. Training and simulation exer-
cises improve physician and team performance when shoulder dystocia occurs.
Unequivocally announcing that dystocia is happening, summoning extra assis-
tance, keeping track of the time from delivery of the head to full delivery of the
neonate, and communicating with the patient and health care team are helpful.
Calm and thoughtful use of release maneuvers such as knee to chest (McRoberts
maneuver), suprapubic pressure, posterior arm or shoulder delivery, and inter-

Illustration by Christy Krames

nal rotational maneuvers will almost always result in successful delivery. When
these are unsuccessful, additional maneuvers, including intentional clavicular
fracture or cephalic replacement, may lead to delivery. Each institution should
consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal
rescue and practice this during simulation exercises. (Am Fam Physician. 2020;​102(2):​84-90. Copyright © 2020 American
Academy of Family Physicians.)

Shoulder dystocia is an obstetric emergency in which Risk Factors and Prevention

gentle downward traction of the fetal head does not lead to Risk factors for shoulder dystocia include fetal macro-
delivery and additional maneuvers are required to deliver somia (odds ratio = 16.1), prior shoulder dystocia (odds
the fetal shoulders.1 Shoulder dystocia is usually attributed ratio = 8.25), and preexisting or gestational diabetes melli-
to impaction of the anterior shoulder against the maternal tus (odds ratio = 1.8).6-8 Other risk factors include maternal
symphysis after delivery of the fetal head;​less commonly, it obesity, excessive maternal weight gain during pregnancy,
is caused by impaction of the posterior shoulder against the oxytocin (Pitocin) use, prolonged first or second stage
sacral promontory.2 labor, and operative vaginal delivery (forceps or vacuum);​
Shoulder dystocia complicates 0.3% to 3% of all vag- however, these are poorly predictive of shoulder dystocia.9
inal deliveries.3,4 The exact incidence can be difficult to There are no accurate models to predict or prevent shoulder
determine because the diagnosis is subjective and there dystocia.10,11
are no agreed upon diagnostic criteria for shoulder dysto- Fetal macrosomia is difficult to accurately predict. At
cia. Objective criteria of a head-to-body delivery interval term, fetal sonography has at least a 10% margin of error
of 60 seconds or the need for additional delivery maneu- for diagnosis of macrosomia.11 Although the incidence of
vers are proposed based on the incidence of significantly shoulder dystocia increases with increasing fetal weight
more birth injuries and lower Apgar scores during these and maternal diabetes, one study of pregnancies compli-
deliveries.5 cated by shoulder dystocia found that half of the neonates
weighed less than 4,000 g (8 lb, 13 oz) and that only 20% of
CME This clinical content conforms to AAFP criteria for the patients had diabetes.12 Results from studies evaluating
CME. See CME Quiz on page 81. labor induction for suspected macrosomia are inconsistent,
Author disclosure:​ No relevant financial affiliations. and induction is not recommended to prevent shoulder dys-
tocia.13 Given the increased risk of shoulder dystocia with

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 SHOULDER DYSTOCIA

increasing fetal weights,

the American College of SORT:​KEY RECOMMENDATIONS FOR PRACTICE
Obstetricians and Gynecol-
ogists (ACOG) recommends Evidence
consideration of cesarean Clinical recommendation rating Comments
delivery for a patient who Conduct team training simulation drills B Longitudinal study of a mandatory
does not have diabetes and that include identification to improve shoulder dystocia training program
is carrying a fetus with an performance during actual shoulder
estimated fetal weight of dystocia emergencies.18
5,000 g (11 lb). ACOG also Announce unequivocally that there is B Longitudinal study of a mandatory
recommends consideration a shoulder dystocia when it occurs.18 shoulder dystocia training program
of cesarean delivery for a
Elevate both knees to the chest (McRob- B Retrospective analysis of shoulder
patient who has diabetes erts maneuver) as the first therapeutic dystocia cases
and is carrying a fetus with maneuver during shoulder dystocia.10
an estimated fetal weight of
4,500 g (9 lb, 15 oz).10 Consider posterior arm delivery if C Clinical guidelines based on con-
McRoberts maneuver and suprapubic sensus, computer modeling, and a
ACOG and the Advanced pressure are unsuccessful.10,14,21 retrospective analysis of shoulder
Life Support in Obstetrics dystocia cases
program recommend that
labor and delivery teams Document precisely the head-to-body C Consensus-based clinical guidelines
delivery interval and maneuvers per-
conduct regular team train- formed after every shoulder dystocia.10
ing drills that include iden-
tification and management A = consistent, good-quality patient-oriented evidence;​B = inconsistent or limited-quality patient-oriented
evidence;​ C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For
of shoulder dystocia.10,14 information about the SORT evidence rating system, go to [Link] [Link]/afpsort.

Complications
Shoulder dystocia can cause several maternal and neona- neonatal injuries are brachial plexus injuries and clavicular
tal complications (Table 1).10 The most common maternal or humeral fractures.16 Transient brachial plexus injuries
complications are postpartum hemorrhage (11%) and may occur in up to 20% of deliveries complicated by shoul-
obstetric anal sphincter injuries (3.8%).15 The most common der dystocia.3 Most resolve without permanent disability,
although approximately 10% may result in permanent neu-
rologic injury.17 The head-to-body delivery interval does
TABLE 1 not predict fetal asphyxia or death.10 However, due to the
potential for serious maternal or neonatal harm, a system-
Complications of Shoulder Dystocia atic approach to expeditious delivery is necessary.10,15
Maternal
Initial Response
Lacerations of the bladder, urethra, vagina, anal sphincter,
or rectum Physicians should announce delivery of the fetal head so
Lateral femoral cutaneous neuropathy that an assistant can start a timer. If the fetus fails to deliver
Postpartum hemorrhage using normal traction or if retraction of the fetal head
Symphyseal separation against the perineum (turtle sign) occurs, the physician
Uterine rupture should announce that there is a shoulder dystocia, and the
delivery team should call for additional team members to
Neonatal assist. A longitudinal study of a shoulder dystocia simulation
Fetal death program found a significant reduction in neonatal brachial
Fetal hypoxic ischemic encephalopathy plexus injuries at discharge (7.6% to 1.3%) when the delivery
Fracture of the clavicle or humerus team performed specified actions during shoulder dystocia
Neurologic:​brachial plexus injury, diaphragmatic paraly- deliveries.18 These included an unequivocal announcement
sis, facial nerve injuries, Horner syndrome
of the shoulder dystocia, calling for additional assistance
Information from reference 10. from qualified personnel, and having an assistant announce
the time from delivery of the fetal head every 30 seconds.

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 FIGURE 1 TABLE 2

CALL FOR HELP

Delivery Maneuvers for Shoulder Dystocia
Additional nurses, surgical obstetrics specialist, operat- Initial maneuvers*
ing room team, anesthesia provider, and neonatal staff McRoberts
Suprapubic pressure
McRoberts maneuver Delivery of the posterior arm
Elevate both knees to chest Menticoglou posterior shoulder delivery
Posterior axillary sling traction

Suprapubic pressure Secondary maneuvers*

Assistant pushes above pubic bone Rubin II rotational
toward the side the fetus is facing
Woods corkscrew rotational
Reverse Woods corkscrew rotational
Consider episiotomy for exposure Gaskin all-fours

Catastrophic maneuvers
Abdominal rescue under general anesthesia
Deliver posterior Rotational maneuvers
Cephalic replacement (Zavanelli)
arm or shoulder Rubin II: Place two to four Intentional clavicular fracture
Place hand between perineum fingers along back of anterior
*—Listed in the suggested order that they should be performed.
and fetus and slide across fetal shoulder and rotate 30 degrees
chest, grasp posterior arm, Woods: Continue Rubin II and Information from references 10, 18, and 19.
and sweep arm across chest add fingers to front of posterior
or shoulder to rotate 180 degrees
Place fingers from both hands, Reverse Woods: Place fingers plexus.4 There are no randomized trials comparing the
or a suction catheter, under on the front side of the
the posterior axilla and deliver anterior shoulder and back
various maneuvers used to release an impacted shoul-
the posterior shoulder and arm side of the posterior shoul- der 10 (Table 210,18,19). ACOG, the Royal College of Obstetri-
der and rotate 180 degrees cians and Gynaecologists, and the Advanced Life Support
Gaskin all-fours maneuver in Obstetrics program recommend using the McRoberts
maneuver first, followed by suprapubic pressure if neces-
sary.10,14,19 The McRoberts maneuver, performed by flexing
the hips and bringing both knees toward the chest, rotates
Consider preparing operating room
or
the symphysis pubis cephalad and further opens the pel-
Repeat above maneuvers vic outlet (Figure 2). This is a simple and proven method to
manage shoulder dystocia, with a success rate of up to 42%
as the sole maneuver.10,15
Consider catastrophic maneuvers (abdominal rescue, If delivery does not occur, firm, steady suprapubic pres-
cephalic replacement, intentional clavicular fracture)
sure should be performed concurrently with the McRoberts
maneuver. An assistant should apply firm downward or
Management algorithm for shoulder dystocia. oblique pressure just above the symphysis pubis toward the
side the infant is facing. This decreases the distance between
the infant’s shoulders (bisacromial distance), potentially
Physicians should also obtain assistance from a physi- assisting anterior shoulder dislodgement (Figure 3). Fundal
cian qualified to perform cesarean delivery and someone to pressure increases the risk of uterine rupture.20
resuscitate the neonate. Additional helpful actions that have If the McRoberts maneuver and suprapubic pressure are
not been studied include communicating with the patient unsuccessful, delivery of the posterior arm should be con-
so that she knows when to push, lowering the bed, using sidered10,14,21 (Figure 4). A retrospective review revealed that
a stool for the assistant applying suprapubic pressure, and the combination of the McRoberts maneuver, suprapubic
having someone record events for precise documentation. pressure, and posterior arm delivery resulted in successful
delivery within four minutes in 95% of cases.21 Computer
Delivery Maneuvers modeling suggests that delivery of the posterior arm results
If the fetus does not deliver using gentle traction, release in the least amount of brachial plexus stretch compared
maneuvers can be used in a thoughtful and sequential with other maneuvers.22 Delivery of the posterior arm
manner to deliver the impacted shoulder (Figure 1). Aggres- requires patience and communication to keep the patient
sive lateral or downward traction on the fetal head and calm. Training with a birth simulator will likely improve
neck should be avoided because it can injure the brachial operator confidence and performance of this procedure.

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 SHOULDER DYSTOCIA
FIGURE 2

McRoberts maneuver. Flex the patient’s hips and bring her knees to her chest, which causes cephalad rotation of the
maternal pelvis and flattening of the sacrum.

Illustration by Christy Krames

An episiotomy may help depending on the size of the phy- Additional maneuvers include rotational methods (e.g.,
sician’s hands and ability to enter the posterior vagina, but it Rubin II, the Woods or reverse Woods [corkscrew] maneu-
is not mandatory for this or any release maneuver.23 The phy- vers) and rolling the patient to her hands and knees (Gaskin
sician should apply lubricant, compress all five fingers from
the appropriate hand into a “duck-bill” shape, and gently
maneuver the hand into the posterior vagina, under the baby FIGURE 3
(see video at [Link]
The physician should then slide the hand along the fetal chest,
not the back, up to the fetal hip, or until the posterior hand is
identified. Grasping the wrist by forming an OK sign with the
physician’s thumb and index finger (Figure 4), he or she should
flex the fetal elbow and slide the arm along the fetal chest to
deliver from the posterior vagina. Using the operator’s fifth
finger as a fulcrum by placing it along the fetal elbow may help.
If the posterior arm is tight against the vaginal sidewall
and cannot be delivered, other methods of delivering the
posterior shoulder can be used. The Menticoglou maneu-
ver involves placing one finger from each hand under the
posterior axilla and applying gentle traction along the curve
of the pelvis to deliver the posterior shoulder.24 After the
shoulder delivers, it should be easier to deliver the entire
posterior arm. The posterior axilla sling traction maneu-
ver uses a suction catheter or urinary catheter placed under
the posterior shoulder axilla to apply downward traction to
deliver the posterior shoulder.25 Alternatively, the physician Suprapubic pressure. An assistant applies firm down-
can use the sling to rotate the posterior shoulder 180 degrees ward or oblique pressure just above the symphysis
pubis toward the side the infant is facing.
to anterior, similar to the Woods maneuver. A description
and video of this technique can be accessed at [Link] ww. Illustration by Christy Krames

[Link]/article/S0002-9378(15)00161-1/fulltext.

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 FIGURE 4

Elbow

all-fours maneuver). To perform the Rubin II maneuver,

the physician places two fingers into the vagina to push the
scapula of the anterior fetal shoulder toward the fetal face to
attempt to rotate the fetus 30 degrees (Figure 5; see video at
[Link]
The Woods maneuver combines the hand placement for the
Rubin II maneuver with two fingers on the anterior aspect
of the posterior fetal shoulder with the intent of rotating the
1. Grasp wrist fetus 180 degrees (Figure 5; see video at [Link]
with thumb and
index finger
afp/2020/0715/[Link]). For the reverse Woods maneuver,
and flex elbow fingers or hands are placed on the front side of the anterior
2. Sweep hand shoulder and back side of the posterior shoulder to rotate
across chest the fetus 180 degrees. An episiotomy may be helpful for the
and deliver
Woods maneuvers to be able to gain access with two hands.
The Gaskin all-fours maneuver requires the patient to roll
Posterior arm release. The physician’s hand enters the onto her hands and knees. This had an 83% success rate as
pelvis posteriorly and travels along the fetal chest to the sole maneuver used in one series.26 This maneuver may
grasp the fetal posterior wrist using an OK sign. The
operator’s hand should slide along the fetal chest,
be more difficult if the patient is fatigued or has neuraxial
not the back, which may involve using the physician’s anesthesia.
nondominant hand depending on the direction the
fetus is facing. Hooking the little finger around the Maneuvers for Catastrophic Shoulder Dystocia
fetal elbow may facilitate the maneuver. The arm is If these maneuvers do not result in delivery, options include
then swept across the fetal chest.
performing the maneuvers again (Figure 1) or enlisting
Illustration by Christy Krames assistance from another experienced physician who might
try the previously attempted maneuvers again or who can

FIGURE 5

30° 180°

Rubin II maneuver (left):​Place two fingers on the back (posterior) side of the anterior shoulder and rotate 30 degrees
toward the fetal face. Woods maneuver (right):​Continue the finger placement for the Rubin II maneuver and add two
fingers to the front (anterior) of the posterior shoulder and rotate the fetus 180 degrees.

Illustration by Christy Krames

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 SHOULDER DYSTOCIA

TABLE 3 The Authors

D. ASHLEY HILL, MD, is the chair of the Department of
Delivery Maneuvers for Catastrophic Obstetrics and Gynecology at the AdventHealth Gradu-
Shoulder Dystocia ate Medical Education Program, Orlando, Fla.;​a professor
of obstetrics and gynecology at the University of Central
Abdominal rescue
Florida College of Medicine, Orlando;​and the medical direc-
Perform a hysterotomy incision and then manipulate the tor of the Multiprofessional Obstetrics Simulation Training
fetus to dislodge the shoulders, allowing vaginal delivery. 27 (M.O.S.T.®) program at AdventHealth Orlando.
Cephalic replacement (Zavanelli maneuver)
JORGE LENSE, MD, is the medical director of the Advent-
Rotate the fetal head to a direct occiput anterior position, Health Obstetric Hospitalists at the AdventHealth Altamonte,
flexing the neck so the chin presses against the perineum, Celebration, Orlando (Fla.) and Winter Park Hospitals and
then push the head gently into the vagina.28 Apply con- AdventHealth Gynecology Hospitalists at AdventHealth
tinuous pressure to hold the head in place while another Orlando Hospital.
physician performs a cesarean delivery to extract the baby
abdominally. Relaxing the uterus with oral or intravenous FAY ROEPCKE, MD, MPH, is a fellow at the Women’s Health
nitroglycerin or inhalational anesthetics will likely make this Junior Faculty Fellowship at AdventHealth Orlando Fam-
procedure more successful, although this is unproven. ily Medicine Residency and is an Advanced Life Support in
Obstetrics (ALSO) course instructor.
Intentional clavicular fracture
Pull the clavicles outward to fracture one or both, collaps- Address correspondence to D. Ashley Hill, MD, 235 East Prince-
ing the shoulders inward and allowing delivery. However, ton St., Ste. 200, Orlando, FL 32804 (email:​[Link]@​Advent
this can be difficult to perform because of the strength of [Link]). Reprints are not available from the authors.
the clavicles, and it may damage underlying vasculature.
Blunt manipulation is recommended; avoid the use of
scissors or other sharp instruments.10 References
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