Learn shoulder dystocia maneuvers for safe delivery, shoulder dystocia is an obstetric emergency where the baby’s anterior shoulder becomes trapped behind the maternal pubic bone, or in rare cases, the posterior shoulder against the sacral promontory, after the head has been delivered. Though it occurs in only 0.2–3% of vaginal births, timely recognition and management are crucial for reducing maternal and neonatal complications.
Understanding Shoulder Dystocia Maneuvers for Safe Delivery
Shoulder dystocia is typically suspected when there is:
- Difficulty delivering the shoulders after the head emerges
- The “turtle sign” — the baby’s head retracts tightly against the perineum
- Failure of the shoulders to descend despite gentle traction
This condition requires immediate intervention using a stepwise approach that prioritizes proven maneuvers for safe and effective resolution.
Initial Response: The ALARMER Protocol
The mnemonic ALARMER is a lifesaving systematic response to shoulder dystocia:
- A – Ask for help: Call for additional staff and activate emergency protocols.
- L – Legs (McRoberts maneuver): Hyperflex the mother’s thighs toward her abdomen.
- A – Anterior shoulder disimpaction: Apply suprapubic pressure.
- R – Release posterior arm: Carefully deliver the baby’s posterior arm.
- M – Maneuvers: Use Rubin or Wood’s screw techniques if needed.
- E – Episiotomy: Perform only if it aids maneuver execution.
- R – Roll the patient: Use the Gaskin maneuver (all-fours position).
McRoberts Maneuver
What it is: Hyperflexion and abduction of the mother’s thighs toward her abdomen.
Why it works: This action straightens the lumbosacral angle, flattens the sacrum, and lifts the pubic symphysis upward, helping free the trapped shoulder.
Success rate: When combined with suprapubic pressure, it resolves about 42–90% of shoulder dystocia cases.
Suprapubic Pressure
What it is: Continuous or rocking pressure applied just above the pubic bone, directed downward and slightly lateral towards the fetal nose.
Why it works: It compresses and adducts the baby’s shoulder, reducing its diameter and allowing it to slip under the pubic bone.
Important note: Never apply fundal pressure, as it can worsen impaction and increase the risk of uterine rupture.
Delivery of the Posterior Arm
What it is: Insert a hand into the vagina to locate and gently sweep the baby’s posterior arm across the chest and out.
Why it works: It decreases the bisacromial diameter, creating more space for the anterior shoulder to pass under the pubic bone.
Risks: Handle gently to avoid humerus fractures.
Rubin Maneuver
What it is: Insert fingers into the vagina and push on the posterior aspect of the anterior shoulder toward the baby’s chest.
Why it works: It rotates the shoulder into an oblique position, reducing the bisacromial diameter and easing delivery.
Wood’s Screw Maneuver
What it is: Combine Rubin’s pressure with simultaneous pressure on the anterior aspect of the posterior shoulder, rotating the baby like turning a screw.
Why it works: This sequential rotation helps dislodge the impacted shoulders.
Gaskin Maneuver
What it is: Reposition the mother into an all-fours (hands-and-knees) position.
Why it works: Gravity, pelvic flexibility, and increased space in this position can free the baby’s shoulders when other maneuvers fail.
Limitations: Not always feasible with regional anesthesia or limited mobility.
Zavanelli Maneuver and Surgical Options (Last Resort)
When all other maneuvers fail:
- Zavanelli Maneuver: Push the baby’s head back into the uterus for an emergency cesarean section.
- Other options: Intentional clavicle fracture or, in rare cases, symphysiotomy.
Key Takeaways of Shoulder Dystocia Maneuvers for Safe Delivery
- Be prepared: Shoulder dystocia is unpredictable—readiness saves lives.
- Start with McRoberts and suprapubic pressure: These are the most effective first-line measures.
- Move quickly: Time is critical to prevent hypoxia and trauma.
- Document everything: Record the timeline, interventions, and outcomes.
- Debrief the team: Discuss the case with staff and the patient post-event for improvement and emotional support.
Further Reading and Resources
- ACOG Practice Bulletin No. 178: Shoulder Dystocia
- Simulation-based training: Enhance team preparedness for obstetric emergencies
- Maternal 911 Education System
