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
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
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
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
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
- 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
- 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