Shoulder Dystocia: 

-Most important (and first step) is recognition:

“Turtle” Sign – retraction of the delivered fetal head against the maternal perineum; it is suggestive but not diagnostic
-This is an unpredictable and unpreventable situation: Keep calm to help prevent complications

Complications:
       -Brachial plexus injuries can occur but the majority are transient
       -Hypoxic brain injuries are avoidable by delivering within 5 minutes

Steps for Success:
1. Call for help! Notify OB and NICU teams. Anesthesia may be considered as well

2. Start a timer and assign a nurse to documentation. Note the times of maneuvers

3. McRoberts Maneuver (see below): easiest and most successful maneuver:
         a. Sharply flex the maternal hips towards the abdomen
         b. Have a nurse apply suprapubic pressure (NOT fundal pressure)
         c. The positioning helps to straighten the sacrum relative to the lumbar spine to allow the baby to progress downward
         d. Do not abandon this flexed position throughout the other steps

4. Episiotomy: Making a midline cut allows for more space to help deliver the baby

5. Woods/Corkscrew Maneuver
         a. An episiotomy is typically required first to allow room for this maneuver
         b. Rotate the posterior shoulder 180 degrees to deliver the anterior shoulder

6. Attempt delivery of posterior shoulder
         a. Sweep the posterior arm of the fetus across the chest 
         b. Deliver the posterior arm 
         c. Rotate the shoulder girdle clockwise into an oblique position to allow for delivery

6. If your 5 minutes are up, it is time for the last resort efforts:
         a. Intentional clavicle fracture (pull UP on clavicle to avoid causing pneumothorax)
         b. Zavanelli Maneuver – cephalic replacement by pushing the baby back into the uterus for STAT C-section (not reccomended for the ED provider)

The HELPER Algorithm:
H – Help (call for it!)
E – Evaluate for Episiotomy
L – Legs (McRobert)
P – suPra Pubic Pressure
E – Enter (with your hand) to perform the Woods/Corkscrew maneuver
R – Remove the posterior arm by sweeping and delivering

References: 1 Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.