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EVIDENCE- BASED CARE SHEET ICD-9 660.4 ICD-10 O66.0 Authors Amy E. Beddoe, RN, PhD Cinahl Information








Amy E. Beddoe, RN, PhD

Cinahl Information Systems, Glendale, CA

Debra Balderrama, RN, MSCIS

Glendale Adventist Medical Center, Glendale, CA


Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA

Tanja Schub, BS

Cinahl Information Systems, Glendale, CA

Nursing Practice Council

Glendale Adventist Medical Center, Glendale, CA


Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

January 20, 2017

Shoulder Dystocia: Staff Education

What We Know

› Shoulder dystocia (SD) during childbirth requires additional maneuvers following failure of gentle downward traction on the fetal head to deliver the shoulders. It is often an

unpredictable and unpreventable obstetric emergency (1,3,4) • SD occurs when the anterior fetal shoulder is stuck behind the maternal pubis symphysis or when the posterior fetal shoulder cannot pass the sacral promontory. Failure of the shoulders to emerge spontaneously during delivery places both the mother and fetus/

infant at risk for injury and other complications. (1,4) (For general information on SD, see

Quick Lesson About


Dystocia, Shoulder )

–Potential injuries and complications to the infant as a result of SD include brachial

plexus damage, fracture of the clavicle, hypoxia, and death (1,4) - Staff member knowledge about the management of SD reduces the occurrence of

birth injuries, including brachial plexus injury (3) Potential maternal complications include hemorrhage and laceration (1,4)

The incidence of SD in vertex presentation vaginal birth is 0.6−1.4%. (1,3,4) The incidence of SD began to increase in the United States in the 1980s, not long after the start of the

use of “active management” of the birthing process (2) –Antenatal risk factors are maternal obesity or diabetes; maternal history of large infants, difficult delivery, or previous SD; a large fetus; and postdate (i.e., past the

predicted due date) pregnancy (1,3,4) –Intrapartum risk factors are dysfunctional labor, prolonged first and/or second stage of labor, cephalopelvic disproportion, slow progress or advancement in vertex

presentation, use of oxytocics, and an instrumental delivery (1,3,4) • Signs of SD are the fetal head retracting with the chin tight against the perineum after delivery of head, the fetal head not spontaneously realigning with the body after delivery of the head (called restitution), and the fetal shoulders failing to descend › Several maneuvers have been developed to release the affected shoulder during delivery.

Fewer birth injuries occur when fetal maneuvers are used initially (1,3,4) • Common fetal maneuvers include the Rubin maneuver, the Woods screw maneuver, and

the Zavanelli maneuver (4) • Common maternal maneuvers include the McRoberts maneuver, suprapubic pressure,

and the Gaskin maneuver (1,3,4) • Maneuvers should be performed immediately, one after the other, until delivery is

complete (1,3,4)

Education, training, and simulations can prepare staff for an SD emergency (1,3,4) • Proper training, education, and simulation is associated with improved maternal and fetal outcomes. It improves confidence levels and clarifies roles and the sequence of appropriate outcomes during an SD emergency • The roles of team members during a delivery involving SD should be considered and reviewed; teamwork is essential

–All staff members should know their roles and responsibilities; nurses should be able and prepared to take either of the nursing roles

  • - One nurse is dedicated to recording delivery events

  • - Two nurses assist with the McRoberts position and suprapubic pressure or other position changes, as needed

  • - An obstetric or other trained clinician (e.g., midwife, family medicine clinician) delivers the baby

  • - Pediatricians/neonatologists, a neonatal intensive care team, and an anesthesiologist are often part of the team • Communication between the delivering clinician, nurses, and patient/parentsis essential (1,3,4)

–Learn to clearly communicate in order to elicit maternal cooperation

  • - Speak to the mother/parents in simple lay terms with simple instructions (e.g., “We are moving your legs to give the baby more room,” “I am helping to get the baby’s shoulder lined up for birth,” “Don’t push until we say to…”)

• The chain of events leading to SD during the delivery process should be considered and reviewed (1,3,4) –Before the emergency, if labor is not progressing or the fetus is not descending,

  • - empty the maternal bladder (e.g., straight catheterization might be needed)

  • - have local anesthesia, instruments, and lidocaine ready so an episiotomy can be quickly performed if necessary

  • - have all emergency equipment available and ready for use

–When the potential for SD is identified, state the problem to colleagues clearly when calling for help

  • - Call the neonatologist or pediatrician, notify the nursery, and prepare the neonatal resuscitation equipment for immediate use › Treatment of SD when the mother is on her back involves the following steps: (1,3,4)

• An episiotomy can facilitate delivery of the shoulders by providing room for the hands of the clinician to perform additional internal maneuvers if needed • To institute the McRoberts maneuver, two staff members hyperflex the mother’s legs onto the abdomen; the mother’s legs should remain held in this position until the baby is delivered or the clinician delivering the baby gives other directions; this is usually the first intervention performed in SD –The McRoberts maneuver increases the pelvic diameter by 1 centimeter and allows the clinician more room to work, elevates the anterior shoulder, and reduces the amount of traction required to free the shoulder –The mother in the McRoberts position should be instructed to release the tension in her legs and let the nurses hold them in the hyperflexed position to make more room for the baby. She should also be instructed to push only when directed to do so –Performance of the McRoberts maneuver requires a minimum of two staff members to safely and evenly hyperflex both of the mother’s legs –During the maneuver, one of the two assisting staff members also applies firm suprapubic pressure

  • - Suprapubic pressure is gentle downward pressure with the palm or heel of the hand against the area above the pubic arch; it puts pressure on the fetal back to direct the pressure to the fetal midline. Fundal pressure should never be applied

  • - The clinician directs the baby first downward, then slightly upward following the pelvic curve. The McRoberts maneuver combined with suprapubic pressure results in the resolution of SD in 90% of cases • If the McRoberts maneuver does not free the anterior shoulder, the clinician might instruct the mother to squat or move to her hands and knees. These positions can help free the shoulder but are not possible if the mother has had an epidural –The hands and knees position increases the pelvic diameter by 1 centimeter • The next maneuver is the Woods screw maneuver, which is performed by the delivering clinician and consists of manually applying pressure to the posterior fetal shoulder and gently rotating the infant though a 180° counterclockwise turn in order to free the anterior shoulder –Never use traction or pull on the baby’s head and neck , which increases the risk of morbidity and mortality • The next maneuver is the reverse Woods screw maneuver, which is performed by the delivering clinician and consists of manually applying pressure to the posterior fetal shoulder and gently rotating the infant though a 180° clockwise turn in order to free the anterior shoulder › Documenting SD includes recording all birth details in the delivery medical record in real time, including time at identification of SD, maneuvers used and effects, maternal or newborn injury, and physical findings at birth, including the infant’s ability to move the arms (1,3,4)

What We Can Do

› Become knowledgeable about SD during childbirth so you can accurately assess your patients’ personal characteristics and health education needs; share this information with your colleagues

› Collaborate with your facility’s nursing education department and other nursing colleagues to develop an SD training

program, which should include


• goals and objectives for the training • clarity about when and how the training will be performed

–Options for training locations include the labor and delivery unit or a simulation center

  • - Simulation centers have high-tech mannequins, a prepared curriculum, and experienced staff educators; simulation centers can improve individual performance during an SD emergency

  • - In-house training can teach teamwork

  • - Force monitors that measure pressure on maternal/fetal mannequins can be particularly helpful

• clear SD protocols and a curriculum –A common management protocol includes the seven components of assessing the problem, calling for help, performing an episiotomy, performing the McRoberts maneuver, applying suprapubic pressure, birth of the posterior shoulder, and performing the Woods screw maneuver –Another management protocol is called HELPERR, which stands for call for h elp, e valuate for episiotomy, position the l egs (in the McRoberts maneuver), apply suprapubic p ressure, perform e nter maneuvers (e.g., internal manual rotation by the treating clinician, such as the Woods screw maneuver), r emove the posterior arm, and r oll the mother (e.g., position the patient on her hands and knees) • a list of roles to be performed during an SD emergency • requirements for staff attendance; plan to assess staff knowledge/competence before and after the training • how the course will be evaluated › Staff members need multiple practice sessions to develop SD management and team skills

Coding Matrix

References are rated using the following codes, listed in order of strength:

  • M Published meta-analysis

RV Published review of the literature

PP Policies, procedures, protocols

SR Published systematic or integrative literature review

RU Published research utilization report


Practice exemplars, stories, opinions

RCT Published research (randomized controlled trial)

QI Published quality improvement report

GI General or background information/texts/reports

R Published research (not randomized controlled trial)

L Legislation

U Unpublished research, reviews, poster presentations or

  • C Case histories, case studies

PGR Published government report

other such materials

G Published guidelines

PFR Published funded report

CP Conference proceedings, abstracts, presentation


  • 1. Allen, R. H., & Gurewitsch, E. D. (2016, August 22). Shoulder dystocia. Medscape. Retrieved October 22, 2016, from (RV)

  • 2. Iffy, L., Varadi, V., & Papp, Z. (2014). Epidemiologic aspects of shoulder dystocia-related neurological birth injuries. Archives of Gynecology and Obstetrics, 291(4), 769-777. doi:10.1007/s00404-014-3453-8 (R)

  • 3. Jenkins, L. (2014). Managing shoulder dystocia: Understanding and applying RCOG guidance. British Journal of Midwifery, 22(5), 318-324. doi:10.12968/bjom.2014.22.5.318 (GI)

  • 4. Draycott, T. J., Crofts, J. F., Ash, J. P., Wilson, L. V., Yard, E., Sibanda, T., & Whitelaw, A. (2008). Improving neonatal outcome through practical shoulder dystocia training. Obstetrics and Gynecology, 112(1), 14-20. (G)