Obgyn · Year 3 · from Obgyn

Case 3: Shoulder Dystocia Management

Patient Demographics

  • Age: 31 years
  • Sex: Female
  • Occupation: Physical therapist

Chief Complaint

"I'm pushing but the baby isn't coming out!"

History of Present Illness

The patient is G2P1 at 40 weeks 2 days with gestational diabetes (A2GDM on insulin). She had an uncomplicated first vaginal delivery of a 3,600-gram infant. She has been pushing for 90 minutes. The fetal head delivered with the last push, but the body has not followed despite continued maternal pushing and routine maneuvers.

Prenatal Course

  • Gestational diabetes diagnosed at 26 weeks
  • Required insulin (NPH and lispro)
  • Glucose control: Fair (60% of values at goal)
  • 39-week growth ultrasound: EFW 4,100 grams (85th percentile)
  • Discussed risks of macrosomia, offered induction at 39 weeks; patient preferred spontaneous labor

Labor Course

  • Spontaneous labor at 40+2 weeks
  • Progressed normally to complete dilation
  • Second stage: 90 minutes of pushing
  • Fetal head delivered to perineum with gentle crowning

The Event: Shoulder Dystocia

Recognition:

  • Head delivered but immediately retracts against perineum ("turtle sign")
  • Failure of external rotation (restitution)
  • Gentle downward traction on head: no delivery of shoulders
  • Anterior shoulder impacted behind pubic symphysis

Time Noted: 14:32 (stopwatch started)

HELPERR Protocol Initiated

H - Help:

  • Called for additional nurses, obstetrician, pediatrics, anesthesia
  • Designated one person as timekeeper and documenter

E - Evaluate for Episiotomy:

  • Midline episiotomy performed to create room for maneuvers

L - Legs (McRoberts Maneuver):

  • Maternal thighs hyperflexed onto abdomen by assistants
  • Flattens sacrum, increases AP diameter of pelvis
  • Result: Shoulder still impacted

P - Pressure (Suprapubic):

  • Continuous suprapubic pressure applied by assistant
  • Heel of hand pressing downward and laterally above symphysis
  • Applied while McRoberts maintained
  • Result: No delivery after 30 seconds

Time Check: 14:34 (2 minutes)

E - Enter (Rotational Maneuvers):

  • Rubin maneuver attempted: Hand inserted behind anterior shoulder, pushed anteriorly toward fetal face
  • Result: Partial rotation achieved but shoulder still impacted
  • Woods screw: Fingers placed on anterior aspect of posterior shoulder, rotated 180 degrees
  • Result: Successful rotation of posterior shoulder to anterior position

Time of Delivery: 14:35 (3 minutes total)

Delivery Outcome

  • Male infant, 4,350 grams (macrosomic)
  • Apgar scores: 6/8/9
  • Initial assessment: Right arm limp, no spontaneous movement

Neonatal Evaluation

  • Right Erb's palsy identified:
  • Waiter's tip position (arm adducted, internally rotated, wrist flexed)
  • Decreased grip strength
  • C5-C6 brachial plexus injury
  • No clavicle or humerus fracture on X-ray
  • Pediatric neurology consulted

Maternal Outcome

  • Second-degree perineal laceration (repaired)
  • EBL: 450 mL
  • No other maternal injuries

Follow-up

Infant (2 weeks):

  • Right arm showing early recovery
  • Occupational therapy initiated
  • Family counseled that most Erb's palsies (80-90%) resolve within 3-12 months

Infant (3 months):

  • Near-complete recovery of arm function
  • Continued OT exercises
  • Good prognosis

Documentation

  • Detailed delivery note with times, maneuvers attempted, and order
  • Risk factors documented (GDM, macrosomia)
  • EFW and delivery discussions documented in prenatal chart

Teaching Points

  • Shoulder dystocia is unpredictable - occurs without risk factors in 50% of cases
  • HELPERR mnemonic provides systematic approach
  • McRoberts + suprapubic pressure resolve most cases
  • Do NOT apply fundal pressure (worsens impaction)
  • Document meticulously: time, maneuvers, personnel present
  • Brachial plexus injury occurs in 10-20% of shoulder dystocia; most resolve

Clinical Image

Image Description: Illustration demonstrating the McRoberts maneuver with maternal thighs hyperflexed onto the abdomen while an assistant applies suprapubic pressure. The diagram shows how these maneuvers flatten the sacrum, rotate the symphysis, and increase the anteroposterior diameter of the pelvis to facilitate delivery.

Attribution: Educational illustration. Adapted from ALSO (Advanced Life Support in Obstetrics) guidelines.

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