Shoulder Dystocia With a 4.2 kg Estimated Fetus
A 34-year-old woman, G2P1, is at 40 weeks and 1 day in spontaneous labour. She had diet-controlled gestational diabetes and a 36-week growth scan estimated fetal weight at 4.2 kg. First stage lasted 8 hours; she is now fully dilated and has been pushing for 25 minutes. The fetal head delivers at 14:05, but the chin retracts against the perineum and the shoulders do not deliver. The midwife is in the room with a first-year student; the call bell is within reach. The woman is anxious and pushing hard, and the fetal heart rate was 140 beats/min before the head delivered. There is no anaesthetist in the unit, but the obstetrician and neonatal team are on the labour ward. The midwife must act immediately and also plan for what to do if the shoulders remain undelivered after the first manoeuvres.
1. State your immediate actions in the first 30–60 seconds, including what you would delegate to the student and what you would avoid.
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Recognise shoulder dystocia from the turtle sign and failure of the shoulders to deliver with routine controlled traction. Call the emergency bell and state 'shoulder dystocia' and the time. Ask the student to summon the obstetrician and neonatal team, bring the resuscitaire, and note the time; the student should not pull on the baby. Immediately perform McRoberts manoeuvre: lie the woman flat, remove pillows, hyperflex and abduct the hips. Apply suprapubic pressure with the heel of the hand over the anterior shoulder, directed downwards and laterally, in a rocking motion. Reassure the woman and ask her not to push unless advised. Avoid fundal pressure, which worsens impaction and risks uterine rupture. Avoid excessive traction or twisting the neck. Do not cut an episiotomy routinely; consider it only if needed to gain access for internal manoeuvres. Keep the head supported and the baby's mouth clear.
2. The shoulders are still undelivered after 2 minutes. Outline the next manoeuvres in a safe order and the rationale for each.
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If the shoulders remain undelivered after 30–60 seconds of McRoberts and suprapubic pressure, move through internal manoeuvres in a logical order, spending about 30 seconds on each. Rubin II: insert a hand behind the anterior shoulder and push it towards the fetal chest to rotate. Woods screw: push the posterior shoulder anteriorly to rotate the shoulders. Reverse Woods screw if needed. Posterior arm delivery: sweep the posterior arm across the chest and deliver it, which reduces the shoulder diameter. Consider all-fours (Gaskin) if the woman can move safely. An episiotomy may help access but does not release the shoulder. Last-resort procedures such as cleidotomy or symphysiotomy are rare and require senior obstetric expertise. The neonatal team should be ready for resuscitation. Announce each manoeuvre and the elapsed time so the team can track progress and avoid repeated ineffective traction.
3. What documentation and postpartum or newborn assessments are required after a successful delivery?
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Document: time of head delivery, time of shoulder recognition, time of body delivery, the sequence and duration of each manoeuvre, who was present, direction and amount of traction, whether episiotomy was performed, cord blood gases if available, and maternal blood loss and trauma. Examine the newborn for clavicle fracture (crepitus, asymmetry) and brachial plexus injury (Erb's palsy: arm adducted, internally rotated, absent Moro on that side); check respiration, glucose because of gestational diabetes, and document a full neurological and musculoskeletal examination. Examine the mother for perineal or vaginal trauma and retained placenta. Debrief the woman and team, complete an incident report, and refer the baby for paediatric follow-up even if initially normal. Document the woman's understanding and follow-up plan.