Remote Primary Health Care Manuals

Shoulder dystocia (stuck shoulder)

Baby’s head born but shoulder stuck behind mother’s pubic bone

  • Emergency situation if shoulder stuck too long — risk that baby will develop hypoxia (not get enough oxygen) and have brain damage
  • Only use gentle traction on baby's head or neck — force will not move shoulders and may injure baby
  • Aim is to release stuck shoulder by moving shoulders so they fit through the birth canal

Check

  • Signs of shoulder dystocia
    • Baby’s neck and chin retract back into woman’s body, face looks squashed (‘turtle sign’) — Figure 1.41
    • Babies body does not birth with next contraction

Figure 1.41   

Baby's head retracts back against the mother's perineum, like a turtle pulling its head back into its shell. Cheeks bulge out.

Do

  • Explain to woman what is happening — she will be more able to help if she understands what is going on
  • Call for help
    • Get midwife/doctor/obstetrician on speaker phone, if none locally
    • Have helper read each step out to you
  • Consider episiotomy, if skilled
  • Try each step for no longer than 30 seconds before going to next 
  • Start steps with or without contraction
  • Try each step in order until one works. After first shoulder is released the other shoulder should follow and baby's body will be born

Step 1 (knees-to-nipples — McRoberts manoeuvre)

  • Help woman onto back with bottom at edge of bed if possible. Lay flat on back with 1 pillow under head
  • Have helper push on woman's feet to push bent knees toward chest
    • OR have woman hold legs at knees and pull knees toward chest (knees-to-nipples) — Figure 1.42
  • Ask woman to push. At same time, using palms of your hands, apply gentle steady traction (pull) to baby’s head in direction of baby's spine — Figure 1.42

Figure 1.42   

While mother holds knees as close to body as possible, attendant uses gentle traction to guide baby's head out and down.

If doesn’t work (no progress) — Step 2 (suprapubic pressure)

  • Woman in same position as Step 1 — on back, knees-to-nipples
  • Keep applying gentle traction (pull) to baby
  • At the same time have helper stand on same side of bed as baby’s back, interlock hands as for CPR and put hands just above pubic bone — push baby’s back down and forward — Figure 1.43
    • Helper is trying to push baby’s shoulder toward its chest and out from under pubic bone
    • Apply continuous pressure for 30 seconds
    • If no progress — try same pressure in up and down rocking motion for another 30 seconds

Figure 1.43   

Attendant 1 applies gentle traction to baby's head while attendant 2 attempts to move baby's top shoulder forward to clear pubic bone.

If this doesn’t work — Step 3 (roll onto all fours)

  • Help woman onto all fours in knees-to-nipples position
  • Using palms of your hands apply gentle axial traction (pull) on baby’s head in direction of baby's spine — Figure 1.44

Figure 1.44   

Repeat gentle traction guiding baby's head out and down with mother in low all fours position with knees as close to chest as possible.

If this doesn’t work — Step 4 (deliver posterior arm)

  • Woman in same position as Step 3 — on all fours, knees-to-nipples
  • Try to release uppermost arm (internal procedure)
    • Entering near anus, put fingers into vagina along baby’s face
    • Find baby’s uppermost hand — may be in front of face or chest. Grab hand between your fingers — Figure 1.45, sweep hand forward toward baby's nose and over face — Figure 1.46
    • If you can’t find hand — try to bend elbow to bring hand forward

Figure 1.45   

Attendant grasps baby's top hand at the wrist between index and middle finger.

Figure 1.46   

Attendant draws baby's hand across the front of its face and out of the vagina.

  • Once arm outside vagina — using palms of your hands apply gentle traction (pull) on baby’s head in direction of baby's spine. Top shoulder should come out

If this doesn’t work — Step 5 (internal rotation of shoulders)

  • Roll woman onto her back and try to rotate (turn) baby's shoulders
    • Put 2 fingers into vagina near anus — Figure 1.47. Slide fingers up baby's back and find scapula (shoulder blade) behind top shoulder
    • At same time put 2 fingers of your other hand in front of bottom shoulder — Figure 1.48
    • Push forward on top shoulder and backward on bottom shoulder at the same time — Figure 1.49

Figure 1.47   

Attendant slides 2 fingers into vagina along baby's back and locates top shoulder blade.

Figure 1.48   

Attendant slides 2 fingers of second hand into vagina near anus and to front of bottom shoulder.

Figure 1.49   

Attendant appliess pressure with both hands in an attempt to rotate shoulders in an anticlockwise direction, freeing the upper shoulder.

  • If you feel shoulders turn — using palms of your hands apply gentle traction (pull) on baby's head again in direction of baby's spine (axial)

If these steps don’t free baby’s shoulder — breathe in, stay calm and do them again from the beginning

When shoulder released

  • Support baby as it births — it will be slippery so use gentle but firm grip. Can use warm towel
  • See Labour and birth After the birth