You are the second responder to a shoulder dystocia emergency. What do you do first?

CASE: Unexpectedly high fetal weight, shoulder dystocia

A nurse midwife is managing the labor of a 41-year-old, G3P2 woman who had two prior spontaneous vaginal deliveries. Results of her glucose-loading test were normal. The midwife estimates the fetal weight as 7 lb 8 oz, but the birth weight proves to be 10 lb 6 oz. After delivery of the head, a turtle sign is obvious, and a shoulder dystocia is declared.

An emergency call for help is made to the front desk. The mother is asked to stop pushing. The obstetric nurse and midwife perform a McRoberts maneuver and apply suprapubic pressure without success. The woman is placed in the Gaskin’s all-fours position, but delivery cannot be accomplished.

Roused from your call room, you quickly proceed to help the team. At 3 minutes into the shoulder dystocia, you enter the room. As the emergency responder, what sequence of maneuvers will you use to resolve the shoulder dystocia?

In response to a shoulder dystocia emergency, most of us have practiced a sequence of actions:

1. recognize shoulder dystocia early and communicate with staff
2. instruct the mother to stop pushing and move the mother’s buttocks to the edge of the birthing bed
3. ensure there is not a tight nuchal cord
4. commit to avoid using excessive force on the fetal head and neck
5. call for emergency help from other expert clinicians
6. perform the McRoberts maneuver combined with suprapubic pressure
7. consider performing an episiotomy
8. use a rotational maneuver such as the Woods screw or Rubin maneuver
9. deliver the posterior arm
10. consider rarely used “salvage maneuvers,” such as the Zavanelli maneuver with cesarean delivery.¹

When you are called to a shoulder dystocia as the emergency responder, the sequence of maneuvers is likely dependent on the actions already attempted by the primary clinician and the length of time from identification of the shoulder dystocia to the responder’s arrival at the patient’s bedside.

Based on my experience, if the primary clinician already has attempted the McRoberts maneuver, suprapubic pressure, and other advanced maneuvers without success, it is best for you to immediately move to the advanced maneuvers with which you are most comfortable. These advanced maneuvers typically include:

• consider an episiotomy and then a rotational maneuver (Woods screw or Rubin maneuver)
• attempt to deliver the posterior arm.

Woods screw and Rubin rotational maneuvers

Woods screw: Removing a well-placed screw requires a rotational maneuver. The Woods screw maneuver is based on the idea that a large baby is like a screw that must maneuver through pelvic threads. You cannot easily directly pull a well-set screw from its threads.

In Woods’ original description of the maneuver, the fetal spine was toward the mother’s right. Woods described a rotational maneuver that is performed by placing the left hand on the mother’s abdomen to provide judicious downward thrust on the fetal buttocks while simultaneously using the fingers of the right hand, placed on the ANTERIOR aspect of the shoulder, to create a clockwise rotational force on the fetus. Using the right hand, the fetal shoulder is moved through >180°, past the 12 o’clock position. At the same time, the fundal pressure and the fingers of the right hand are used to guide the fetus down the birth canal. This maneuver moves the anterior shoulder to the posterior position.

If delivery cannot be completed, a second step in the procedure is to then place the fingers of the right hand on the ANTERIOR aspect of the posterior shoulder (previously the anterior shoulder) and rotate the fetus in a counter-clockwise arc to the 12 o’clock position while gently guiding the fetus down the birth canal.²

Rubin rotational maneuver. Rubin observed that if you adduct the shoulders, the diameter of the shoulders are reduced, thereby easing the passage of the fetus through the birth canal. Adduction is the movement of a body part toward the MIDLINE sagittal plane.

Rubin recommended applying pressure to the POSTERIOR surface of the posterior (6 o’clock) fetal shoulder to help push the shoulder toward the midline of the chest (adduction). If the fetal spine is toward the mother’s left side, you place your right hand on the POSTERIOR surface of the shoulder at the 6 o’clock position, rotating the shoulder in a clockwise arc to the 12 o’clock position while simultaneously guiding the fetus down the birth canal.

Rubin also recommended the use of judicious fundal pressure after the anterior shoulder is disimpacted, if necessary, to facilitate delivery.³ Although both Woods and Rubin recommended the use of judiciously applied fundal pressure, most modern textbooks of obstetrics do not endorse the use of fundal pressure.