Shoulder Dystocia With a Prior Consent Refusal for Episiotomy
A 31-year-old G2P1001 at 40 weeks 1 day is in active labor with an epidural. Her first delivery was a 4.1 kg infant with a documented shoulder dystocia requiring the McRoberts maneuver and suprapubic pressure, with no neonatal injury. Current estimated fetal weight is 4.3 kg. She has been pushing for 50 minutes; the fetal head has delivered but the chin is retracting against the perineum and the head does not restitute. The fetal heart rate was 95 bpm before the last push. The room has a nurse, a resident, and an attending. In her prenatal record, she declined episiotomy and wrote that she wants 'no cutting unless the baby is dying.' She is alert and asking what is happening.
1. Walk through your management in the first 60 seconds, including how you handle her prior refusal of episiotomy.
Read the worked answer
Recognize and declare shoulder dystocia: the turtle sign and failure to restitute are the cues. Call for help, note the time, and start a structured maneuver sequence. Do not apply fundal pressure or traction.
First 60 seconds:
- McRoberts maneuver - hyperflex and abduct the maternal hips; this alone resolves many cases.
- Suprapubic pressure - continuous or rocking, directed posteriorly, by a team member with the bladder empty.
- Reassess the fetal heart rate and the perineum; keep the patient informed in plain language.
Episiotomy question: an episiotomy is not recommended as a routine shoulder dystocia maneuver and does not reliably relieve the bony impaction; it may be considered only to gain access for internal maneuvers (e.g., posterior arm delivery) or if the perineum is obstructing. Her advance statement - 'no cutting unless the baby is dying' - actually authorizes episiotomy in a life-threatening emergency, and this is exactly such a situation if internal maneuvers are needed. Because she is alert and competent, you should briefly state what you are doing and why; in an emergency you may proceed, but document the conversation and the indication. Do not let the prior refusal paralyze you when the fetus is bradycardic.
If McRoberts + suprapubic pressure fail: proceed to internal rotational maneuvers (Rubin II, Woods screw), then delivery of the posterior arm, then the Gaskin/all-fours position, and consider the Zavanelli maneuver or symphysiotomy as last resorts. Have the neonatal resuscitation team present and document each maneuver and the times.
2. The shoulder delivers after posterior arm delivery, but the infant is limp with a heart rate of 60. What do you do, and what documentation and disclosure obligations follow?
Read the worked answer
Neonatal resuscitation: move the infant to the warmer, dry and stimulate, and follow NRP: positive pressure ventilation for HR <100 or apnea, chest compressions if HR <60 after effective ventilation, and consider volume/medications per NRP. Have the neonatal team lead; the obstetric team continues to manage the mother.
Maternal care: inspect for perineal and vaginal lacerations, assess uterine tone and blood loss, and monitor for postpartum hemorrhage. Consider whether a clavicle fracture or brachial plexus injury occurred - examine the neonate's arms and document.
Documentation (contemporaneous, factual):
- Time of head delivery and time of shoulder delivery; which shoulder was anterior.
- Each maneuver in order with times, who performed it, and the response.
- Personnel present, the fetal heart rate trend, and the rationale for any episiotomy.
- The patient's statements and your explanations.
- The neonate's condition and resuscitation.
Disclosure: shoulder dystocia is an unpredictable emergency, but a prior shoulder dystocia is a major risk factor and the patient should be counseled about recurrence risk (roughly 10–15%) and about the possibility of brachial plexus injury or fracture. If an injury occurred, disclose it promptly and honestly, explain what happened, express empathy, and arrange follow-up. Do not speculate about blame in the record. Offer a postpartum debrief and plan for future pregnancy counseling, including discussion of elective cesarean versus trial of labor.