What is the immediate management for a newborn with shoulder dystocia (obstetric emergency where the anterior shoulder of the infant cannot pass below the pubic symphysis after the delivery of the head)?

Immediate Management of Shoulder Dystocia

When shoulder dystocia occurs, immediately call for help, announce the emergency clearly, perform the McRoberts maneuver with suprapubic pressure as first-line intervention, and avoid fundal pressure and excessive head traction to prevent catastrophic neonatal injury. 1, 2

Recognition and Initial Response

Shoulder dystocia is defined as a vaginal delivery requiring additional obstetric maneuvers after the head delivers and gentle traction fails, occurring when the anterior fetal shoulder impacts the maternal symphysis pubis 1. This complicates 0.5-1% of vaginal deliveries but carries significant risks including brachial plexus injury (4-16% of cases), clavicular/humeral fractures, perinatal asphyxia, hypoxic-ischemic encephalopathy, and rarely neonatal death 3, 1, 2.

Critical first actions:

• Unequivocally announce "shoulder dystocia" to activate the team 2
• Call for immediate assistance (additional nurses, anesthesia, pediatrician/neonatology) 1, 2
• Note the time from head delivery to track the head-to-body delivery interval 2
• Communicate clearly with the patient and team throughout 2

Sequential Maneuver Algorithm

First-Line Intervention (Perform Immediately)

McRoberts maneuver with suprapubic pressure is recommended as the initial intervention 1:

• Position maternal thighs in extreme flexion (knees to chest) to rotate the pelvis and increase the pelvic outlet diameter 2
• Apply suprapubic pressure (not fundal pressure) to dislodge the anterior shoulder from behind the symphysis 1, 2
• This combination resolves most cases of shoulder dystocia 2

Second-Line Interventions (If McRoberts Fails)

All providers must know at least two additional maneuvers beyond McRoberts 1. The choice depends on whether the posterior shoulder is engaged:

If posterior shoulder is engaged:

• Perform Wood's maneuver (internal rotation of the posterior shoulder) preferentially 1

If posterior shoulder is not engaged:

• Attempt delivery of the posterior arm first 1
• This involves reaching into the vagina, grasping the posterior arm, and sweeping it across the fetal chest for delivery 2

Third-Line Interventions (If Above Maneuvers Fail)

Additional maneuvers when standard approaches are unsuccessful 2:

• Intentional clavicular fracture to reduce shoulder diameter 2
• Cephalic replacement (Zavanelli maneuver) with emergency cesarean delivery 2
• Each institution should practice the time required to prepare for general anesthesia and abdominal rescue during simulation exercises 2

Critical Actions to AVOID

Three maneuvers are contraindicated and increase injury risk 1:

• Excessive traction on the fetal head - increases brachial plexus injury risk 1
• Fundal pressure - worsens shoulder impaction and increases injury 1, 2
• Inverse rotation of the fetal head - provides no benefit and wastes time 1

Immediate Neonatal Management

A pediatrician or neonatology team must be immediately informed when shoulder dystocia occurs 1. The Enhanced Recovery After Surgery Society emphasizes that all settings performing deliveries must have capacity for immediate neonatal resuscitation 4.

Initial neonatal assessment and interventions:

• Assess Apgar scores at 1,5, and 10 minutes 4
• Approximately 85% of term infants initiate spontaneous respirations within 10-30 seconds; 10% respond to drying and stimulation; 5% require assisted ventilation 4
• Dry and stimulate the infant for first breath/cry 4
• Maintain body temperature between 36.5°C and 37.5°C through drying, covering the head, and using prewarmed blankets 4
• Immediate cord clamping is indicated when immediate resuscitation is needed - do not delay for cord clamping protocols in compromised infants 4

Specific examination for shoulder dystocia complications:

• Check immediately for brachial plexus injury (Erb's palsy, Klumpke's palsy) 1
• Examine for clavicle or humeral fracture 1
• If no complications are observed, standard neonatal monitoring protocols apply 1

Critical Pitfall: Hypovolemic Shock

A fatal case report describes neonatal death despite head-to-body delivery within 5 minutes and normal fetal heart tracing, with severe metabolic acidosis and anemia found at 9 minutes of life 5. This supports the hypothesis of hypovolemic shock from acute placental retention of fetal blood during prolonged shoulder impaction 5. This underscores why rapid, systematic maneuver progression is essential - time is critical even when fetal heart tones appear reassuring.

Team Preparedness

Simulation training significantly reduces neonatal injury rates (though not maternal injury rates) when shoulder dystocia occurs 1. All physicians and midwives must know and be able to perform obstetric maneuvers quickly but calmly 1, 2. The unpredictable nature of shoulder dystocia - with 50-70% of cases occurring without identifiable risk factors - means every delivery team must maintain readiness 1.