Shoulder dystocia is a complication during vaginal childbirth that occurs when the baby’s shoulder becomes stuck behind the mother’s pelvic bone. Shoulder dystocia can be one of the most catastrophic events in modern-day delivery rooms causing great anxiety even for experienced doctors. The main reason for this is that shoulder dystocia must be overcome quickly. There is often a short window of time to dislodge and deliver the baby before they suffer brain damage from oxygen deprivation. At the same time, however, rushing and using too much force or traction in attempting to overcome the shoulder dystocia will likely result in injury the brachial plexus nerves. In most cases, delivery can be accomplished without injury to the baby so long as the doctor is familiar and skilled with certain well established manipulative and operative techniques for overcoming shoulder dystocia. This page with discusses most widely utilized manipulative techniques for handling shoulder dystocia.
Individual cases of shoulder dystocia range in severity depending on the severity or difficulty of overcoming the dystocia. There are 4 different recognized grades or levels of shoulder dystocia: Grade I (mild); Grade II (moderate); Grade III (severe); Grade IV (undeliverable). The chart below lists the suggested treatment techniques for each stage or grade of shoulder dystocia.
| Stage | Treatment Techniques |
|---|---|
| I. Mild | Suprapubic Pressure (with or without rotation) Woods Screw Maneuver Rubin Maneuver |
| II. Moderate | Posterior Shoulder Delivery Hibbard Maneuver |
| III. Severe | McRoberts Maneuver McRoberts Maneuver with rotations or suprapubic pressure |
| IV. Undeliverable | Cepahlic Replacement |
The first step in the treatment of mild dystocia (Grade I) is usually the application of direct suprapubic pressure in the midline area using the palm. The goal of this pressure is to help push the anterior shoulder down and back so it dislodges from the pelvic bone. Suprapubic pressure is usually applied by a nurse or assistant and is usually only successful on its own with very mild cases of dystocia.
The Woods’ Screw Maneuver is another well-utilized technique for Grade I dystocia. The Woods technique is a rotational maneuver that attempts to deliver the baby by maneuvering them into a screwing or twisting motion. The key to the Woods’ Corkscrew Maneuver technique is exerting rotational force by applying pressure to the posterior shoulder toward the neonate’s belly or front side (not the head which can injure the baby).
The Rubin Maneuver, also called the reverse Woods maneuver, is another technique recognized by obstetricians to relieve shoulder dystocia. This technique emphasizes the importance of maneuvering both of the baby’s shoulders forward toward the chest. With the shoulders in this position, the circumference of the baby’s body is reduced. The Rubin technique is accomplished by gently rocking the baby’s shoulder from side to side by pushing on the mother’s abdomen. The intention is that the motion will adduct the neonate’s shoulder girdle. The resulting reduction in the diameter will get the baby past the roadblock. This effectiveness of this technique is greatly increased when done in combination with suprapubic pressure.
There is a Rubin I and a Rubin II. Rubin I is the rotation of anterior shoulder under pubic symphysis, located in front and below mother’s bladder, by giving suprapubic pressure. Rubin’s II involves the posterior arm, pushing the posterior aspect of the shoulder.
Barnum maneuver is another delivery that is very common today. This is simply the delivery of the posterior arm. This technique may require an episiotomy. Some experts tell us this has a 75 to 80 percent success rate.
For Grade II dystocia cases, more aggressive techniques are required such as the Hibbard Maneuver or Posterior Shoulder Delivery. The Hibbard technique involves pushing the baby back into the vagina and birth canal by pushing on the top of the head. Once pushed back up the birth canal and assistance applies suprapubic or fundal pressure to rotate the baby’s shoulder rotated downward to dislodge it from the pelvic bone. The Hibbard Maneuver is somewhat controversial within the obstetrical community. It is one of the most frequently used methods by less experienced doctors because it is easy to learn but the technique comes with a high level of risk to the baby. Any improper angulation of the baby’s neck when pushing back up the birth canal can easily damage nerves in the neck and shoulder.
An alternative delivery technique for Grade II dystocia is known as Posterior Shoulder Delivery. This technique focuses on first delivering the posterior arm and shoulder (i.e., the arm that is free and not stuck behind the pelvic bone). The doctor reaches in and grasps the wrist of the posterior arm, then pulls that arm through the birth canal. Once the posterior arm is brought down the doctor can then use it to rotate the anterior shoulder down and back and dislodge the baby from the pelvic bone. This widely employed technique is less controversial than the Hibbard Maneuver but comes with its own risks of injury to the baby. The nerves in the cervical spine are particularly at risk of damage when twisting with the posterior arm is excessive.
For more severe cases of shoulder dystocia (Grade III), the McRoberts Maneuver is the general standard of care. The McRoberts maneuver is safe and can be rapidly performed but does require the help of 2 assistants. To accomplish the McRoberts maneuver, the mother’s legs are removed from the stirrups and sharply flexed against the abdomen. This helps reposition the mother’s pelvis to facilitate dislodgement of the shoulder. Repositioning of the mother’s legs is done in combination with subprapubic pressure and other manipulative techniques.
The most severe cases of dystocia, including bilateral shoulder dystocia or dystocia that fails to respond to the various delivery techniques, as classified as undeliverable (Grade IV). For these cases, the appropriate response is a cephalic replacement and emergency C-Section. Cephalic replacement is a technique where the baby’s head and rotated and pushed back into the vagina. The goal is to reestablish blood circulation through the umbilical cord to allow time for an emergency C-section to be performed without oxygen deprivation.