Obgyn · Year 3 · from Obgyn
Case 3: Shoulder Dystocia
Patient Demographics
- Age: 34 years
- Sex: Female
- Occupation: Pharmacist
Chief Complaint
The fetal head has delivered but the anterior shoulder is impacted behind the pubic symphysis.
History of Present Illness
The patient is a G3P2 at 39 weeks with gestational diabetes (diet-controlled) who presented in spontaneous labor. Her estimated fetal weight by ultrasound last week was 4,100 grams. She has been pushing for 45 minutes and the fetal head has just delivered with significant difficulty ("turtle sign" noted - retraction of chin against perineum). The anterior shoulder will not deliver with routine maneuvers.
Risk Factors Present
- Gestational diabetes (associated with macrosomia)
- Estimated fetal weight >4,000 grams
- Prior macrosomic infant (4,200 grams at birth)
- Maternal obesity (BMI 32)
- Prolonged second stage
Clinical Recognition
- Turtle Sign: Fetal head retracts against perineum after delivery
- Failure of external rotation: Head does not rotate as expected
- Failed gentle downward traction: Anterior shoulder does not deliver
Emergency Management - HELPERR Mnemonic
H - Help
- Called for additional nurses, obstetricians, anesthesia, and pediatrics
- Activated shoulder dystocia protocol
E - Evaluate for Episiotomy
- Mediolateral episiotomy performed to allow room for maneuvers
- (Note: does not relieve bony obstruction but provides access)
L - Legs (McRoberts Maneuver)
- Maternal thighs hyperflexed against abdomen
- Flattens lumbar lordosis and rotates pelvis
- First-line maneuver, resolves ~50% of cases
- Result: Shoulder remains impacted
P - Pressure (Suprapubic)
- Assistant applied continuous suprapubic pressure in downward and lateral direction
- Attempts to dislodge anterior shoulder from behind symphysis
- Result: Partial descent but not delivered
E - Enter Maneuvers (Rotational)
- Rubin II Maneuver: Fingers behind anterior shoulder, pushed toward fetal chest to adduct and rotate
- Woods Corkscrew: Pressure on posterior shoulder in opposite direction to rotate fetus 180 degrees
- Result: Successful rotation and delivery of anterior shoulder
R - Remove Posterior Arm
- Not required in this case (reserved if rotation fails)
R - Roll Patient
- Not required (Gaskin maneuver - hands and knees position)
Delivery Outcome
- Time from head delivery to body delivery: 90 seconds
- Male infant, weight 4,350 grams
- Apgar scores: 6 at 1 minute (decreased due to initial cyanosis), 8 at 5 minutes
- Right arm limp at delivery - suspected brachial plexus injury
Neonatal Examination
- Right upper extremity weakness
- Absent Moro reflex on right
- Grasp reflex present bilaterally
- No clavicle fracture palpated
- Diagnosis: Right Erb palsy (C5-C6 brachial plexus injury)
Postpartum Management
Maternal:
- Careful examination for cervical and vaginal lacerations
- Estimated blood loss 500 mL
- Postpartum hemorrhage protocol on standby
Neonatal:
- Pediatric neurology consultation
- Physical therapy referral
- Counseling that >90% of Erb palsy cases resolve within 12 months
Documentation:
- Detailed documentation of maneuvers used and timing
- Risk factors identified
- Team members present
- Neonatal condition and disposition
Counseling Points
- Shoulder dystocia occurs in approximately 1% of vaginal deliveries
- Despite risk factors, it cannot be reliably predicted or prevented
- Future pregnancy counseling: increased recurrence risk (10-15%)
- Consider elective cesarean if estimated fetal weight >4,500 grams in diabetic patient
Clinical Image
Image Description: Illustration demonstrating the McRoberts maneuver with hyperflexion of maternal thighs and simultaneous suprapubic pressure applied to dislodge the impacted anterior shoulder from behind the pubic symphysis.
Attribution: Image from Wikimedia Commons. Educational illustration of shoulder dystocia management. Public domain.