Shoulder dystocia is an unpredictable and potentially devastating obstetric emergency. Once the baby’s head delivers, the anterior shoulder becomes trapped behind the maternal pubic bone, preventing delivery of the rest of the body.
While relatively rare, shoulder dystocia poses serious risks, including:
- Neonatal hypoxia
- Brachial plexus injuries
- Maternal trauma
The key to minimizing these complications? Rapid, coordinated intervention—and that’s exactly what the ALARMER protocol provides.
What Is the ALARMER Shoulder Dystocia Protocol?
The ALARMER protocol is a mnemonic-driven framework that helps obstetric teams act quickly and systematically when shoulder dystocia is suspected.
Each step progresses in complexity, starting with simple repositioning maneuvers and escalating to more advanced interventions when needed.
A – Ask for Help
Why it matters:
Time is critical. As soon as shoulder dystocia is suspected—often identified by the “turtle sign” (fetal head retracting against the perineum) or a prolonged head-to-body delivery interval—call for extra help.
Who to call:
- Obstetric colleagues
- Neonatal/pediatric team for immediate newborn care
- Anesthesia provider for pain management or emergency surgical needs
- Operating room staff in case surgical intervention is required
L – Legs (McRoberts Maneuver)
Technique:
- Hyperflex the mother’s thighs toward her abdomen
- Flatten the sacral promontory and rotate the pelvis upward
Goal:
Straighten the lumbosacral angle to free the trapped shoulder.
Effectiveness:
This maneuver alone or combined with suprapubic pressure resolves up to 90% of shoulder dystocia cases.
A – Anterior Shoulder Disimpaction (Suprapubic Pressure)
Technique:
- Apply firm, downward pressure just above the pubic bone
- Direct pressure at a 45° angle toward the fetal chest
Important:
Never apply fundal pressure—it worsens impaction and increases risks of uterine rupture or fetal injury.
Goal:
Adduct and rotate the fetal shoulders to reduce their diameter for delivery.
R – Release the Posterior Arm
Technique:
- Insert your hand into the posterior vagina
- Locate and gently sweep the baby’s posterior arm across the chest and out of the canal
Goal:
Reduce the shoulder diameter, making delivery of the anterior shoulder easier.
Note:
Be cautious—this maneuver carries a risk of humeral fracture if done forcefully.
M – Maneuvers (Rubin & Wood’s Screw)
Rubin Maneuver:
- Apply pressure to the posterior aspect of the anterior shoulder, pushing it toward the chest (adduction).
Wood’s Screw Maneuver:
- Combine Rubin’s maneuver with pressure on the anterior aspect of the posterior shoulder, “unscrewing” the shoulders from the pelvis.
Goal:
Rotate the fetus to relieve the impaction.
E – Episiotomy (If Needed)
Why?
While episiotomy does not remove the bony obstruction, it can:
- Increase space for internal maneuvers
- Facilitate delivery of the posterior arm
Use only when necessary to improve access for additional interventions.
R – Roll the Patient (Gaskin Maneuver)
Technique:
- Reposition the mother onto all fours (hands-and-knees).
Why it works:
- Alters pelvic dimensions
- Leverages gravity to assist in dislodging the shoulder
Often highly effective when McRoberts and suprapubic pressure fail.
Documentation & Post-Delivery Care
Thorough documentation is critical:
- Time of head and body delivery
- Maneuvers used (in sequence)
- Neonatal status at birth
After the event:
- Conduct a team debrief
- Provide emotional support to the patient and family
- Arrange follow-up to assess for neonatal injuries or maternal complications
Key Takeaways
- Stay calm and act decisively—shoulder dystocia is manageable with the right steps.
- The ALARMER mnemonic provides structure in chaotic situations.
- McRoberts + suprapubic pressure often resolve most cases.
- Clear team communication saves time and improves outcomes.
Quick Reference: ALARMER Protocol
| Letter | Maneuver | Purpose/Action |
|---|---|---|
| A | Ask for Help | Activate emergency response |
| L | Legs (McRoberts) | Reposition hips to free the shoulder |
| A | Anterior Shoulder (Suprapubic Pressure) | Dislodge shoulder using external pressure |
| R | Release Posterior Arm | Reduce shoulder diameter and allow rotation |
| M | Maneuvers (Rubin, Wood’s) | Rotate fetus to free shoulders |
| E | Episiotomy | Create space for internal maneuvers |
| R | Roll (Gaskin Position) | Use maternal position change to release the shoulder |
