Quick Chart

Shoulder Dystocia occurs when the anterior shoulder of the baby lodges against the mothers pubic bone (symphysis pubis) and prevents further progress through the birth canal. 

Read the complete article; Shoulder Dystocia in the Medical Library > Pathophysiology > Obstetrics.

 Clinical Presentation
  • Difficulty with birth of  the face and chin
  • The fetal head retracts against the perineum referred to as ‘turtle’ sign
  • Failure of the fetal head to restitute
  • Failure of the shoulders to descend
 Exclusion Criteria
Exclusion Criteria
 Risk Assessment

Maternal Risk Factors

  • Increasing maternal age
  • Maternal obesity
  • Maternal birth weight
  • Short stature
  • Previous history of Shoulder Dystocia
  • Gestational Diabetes
  • Prolongued pregnancy/post dates/over due >40 weeks
  • Abnormal pelvic anatomy

Foetal risk factors

  • Suspected Macrosomia (>4.5kg)
  • Prolongued active 1st stage of labour
  • Prolongued 2nd stage of labour (>2hrs)
  • Anomalies
Primary Care
  • Primary Survey
  • Offer continuous support and reassurance
  • Position patient appropriately in a position of comfort (avoid supine positioning due to aortocaval compression)
  • Perform maternal vital sign survey
  • Consider oxygen if indicated as per CPG
Intermediate Care
Advanced Care
  • Apply cardiac monitor if trained and authorised
  • Establish vascular access
  • Consider pain relief
  • Consider anti-emetic
  • Proceed immediately to shoulder dystocia manoeuvres as per clinical skill (explanation)
  • Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Prepare for the resuscitation of mother and newborn
  • Transport 
    • Priority 1 to nearest obstetric unit if patient time critical
    • Priority 1 booked obstetric unit if patient stable
    • Pre-notify receiving facility in both circumstances
    • *If shoulder dystocia has occurred, the patient should be taken on Priority 1 even if now presenting well, due to high risk of complications
Critical & Extended Care
  • As per Advanced Care guidelines
 Additional Information
Management of shoulder dystocia

Please see Clinical Skill, Shoulder Dystocia

  • McRoberts position is flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen i.e. "knees to nipples"
  • Rubin manoeuvre is continuous suprapubic pressure applied in the McRoberts position to improve success rate.
  • Rockin rubin is then adopted in an attempt to deliver the impacted shoulder.
  • The mother is then positioned on all fours (reverse McRoberts) in an attempt to deliver the none impacted shoulder.
  • Manoeuvres should only be performed once each before extricating the patient and transporting Priority 1 to nearest obstetric facility. Manoeuvres should be continued en route as best as possible, whilst ensuring safe transport.

Possible complications:

  • Bracheal Plexus Injury
  • Perineal tears
  • PPH
  • Perinatal morbidity and mortality
  • Liaise with obstetrics unit in the metropolitan area, recording all advice on ePCR
  • Liaise with local hospitals in country areas, recording all advice given on ePCR
Key Terms & Links
Extended Care:
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