Shoulder Dystocia

The head delivers, then retracts against the perineum like a turtle pulling back into its shell. You have roughly 60 seconds before brachial plexus injury becomes permanent. Recognizing and responding to shoulder dystocia is a time-critical skill.

Shoulder dystocia occurs when the fetal head delivers but the anterior shoulder becomes impacted behind the maternal pubic symphysis. The hallmark sign is the "turtle sign" — the delivered head retracts tightly against the perineum. This is an unpredictable obstetric emergency; while risk factors include prior shoulder dystocia (the single strongest predictor, with recurrence up to 25%), fetal macrosomia (>4,000 g), gestational diabetes, maternal obesity, and prolonged second stage, it can occur without any warning. The nurse's immediate role is to recognize the emergency, call for help, and assist with maneuvers. McRoberts maneuver is first-line: sharply flex the mother's thighs against the abdomen (knees to chest), which straightens the sacrum and widens the pelvic outlet. Suprapubic pressure — not fundal pressure — is applied simultaneously by a second person to dislodge the anterior shoulder. If these fail, the provider may attempt delivery of the posterior arm or move the patient to hands-and-knees position (Gaskin maneuver). Document the time between head and body delivery. Neonatal complications include brachial plexus injuries (Erb palsy — limp arm, waiter's tip position), clavicular fracture, and hypoxia. Maternal complications include postpartum hemorrhage and third- or fourth-degree lacerations.

Key Distinctions

Never apply fundal pressure during shoulder dystocia — it worsens impaction and increases risk of fetal injury. Suprapubic pressure (above the pubic bone, directed downward) is correct; fundal pressure (top of uterus) is dangerous. Students confuse McRoberts (hyperflexion of maternal hips) with lithotomy position — McRoberts is far more extreme, with knees pressed to the chest. Shoulder dystocia is managed in the birth canal, not by cesarean section once the head has delivered.

Clinical Pearl

Think "HELPERR" — call for Help, Evaluate for Episiotomy, Legs up (McRoberts), suprapubic Pressure, Enter for rotational maneuvers, Remove posterior arm, Roll to hands and knees.