Shoulder Dystocia: HELPERR, McRoberts & Internal Manoeuvres

Shoulder dystocia in one place: who is at risk, how to recognise it, and the manoeuvres in order. Based on the OLSS (Obstetric Life Saving Skills) lecture on shoulder dystocia at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh.

Definition

Shoulder dystocia is a vaginal cephalic delivery that needs additional obstetric manoeuvres to deliver the shoulders after the head has delivered and gentle traction has failed. It complicates 0.2-2.1% of vaginal deliveries.

Risk factors

It is difficult to predict.

Signs

• Difficulty delivering the face and chin.
• The head stays tightly applied to the vulva, or retracts (turtle-neck sign).
• The head fails to restitute.
• The shoulders fail to descend.

HELPERR

First-line manoeuvres

About 90% of babies with shoulder dystocia deliver with effective McRoberts and suprapubic pressure.

McRoberts manoeuvre

• Needs two assistants, one for each leg.
• Hyperflex the hips and knees (thighs pushed onto the abdomen), with the legs abducted and rotated outward.
• This flattens the lumbosacral angle and increases the anteroposterior diameter of the pelvis.
• Hyperflexion is more effective when the assistant presses on the back of the thigh rather than pushing the foot and knee towards her head, which is less effective and hurts the ankle. A successful McRoberts lifts the maternal buttocks.

Suprapubic pressure

• Press on the posterior aspect of the anterior shoulder, towards the fetal chest (towards the fetal face).
• This rotates the shoulder and reduces the bisacromial diameter.

Second-line: enter and posterior arm

Rubin II

• With one hand in the vagina, press on the back of the anterior shoulder.
• Push it gently towards the face to reduce the bisacromial diameter, then deliver with lateral traction.

Woods screw

• Bring the posterior shoulder anteriorly, adducting and rotating the shoulders into the oblique.
• Use both hands: one behind the anterior shoulder, the other in front of the posterior shoulder, and rotate about 180°.
• The reverse Woods screw rotates the other way.

Delivery of the posterior arm

Also called the Jacquemier or Barnum manoeuvre:

1. Insert your hand along the maternal sacral curve and slide it along the posterior shoulder to the elbow.
2. Reach the cubital fossa and flex the elbow if it is extended.
3. Bring the forearm towards the fetal chest.
4. Grasp the wrist and deliver the posterior arm.

Roll the patient: all fours (Gaskin)

• Roll her from her current position onto all fours.
• The act of turning and gravity may dislodge the shoulder.
• If the baby still won't deliver, repeat all the enter manoeuvres.

Third-line manoeuvres

• Cleidotomy: surgical division of the baby's anterior clavicle, or bending it with a finger, to reduce the width of the shoulders.
• Symphysiotomy: dividing the anterior fibres of the symphyseal ligament to enlarge the outlet.
• Zavanelli manoeuvre: push the head back into the uterus, with tocolysis, then proceed to caesarean section. A high proportion of fetuses already have irreversible hypoxia-acidosis by the time this is decided.

Complications

Sources

• Obstetric Life Saving Skills (OLSS) lecture: Shoulder Dystocia. Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.
• Lau. A critical evaluation of manoeuvres for resolution of shoulder dystocia. Am J Obstet Gynecol. 2023 (McRoberts figure, as reproduced in the lecture).