Shoulder dystocia: What is the legal standard of care?

Nevertheless, 4 specific standards apply to all delivery facilities:

1. The entire labor and delivery staff should know what to do and what each person’s role is when shoulder dystocia is diagnosed.
   
2. Labor and delivery nurses should know how and when to initiate McRoberts maneuver and apply suprapubic pressure.
   
3. The team should immediately obtain the assistance of another obstetrician, a pediatrician, and an anesthesiologist, even though they are not likely to arrive before the dystocia is resolved.
   
4. The obstetrician should be mentally prepared for the possibility of shoulder dystocia. This requires the ability to quickly recognize it, familiarity with the various techniques for resolving it, and avoidance of unnecessary traction. It also is vital for the obstetrician to remain composed and in charge, as the obstetrician becomes the leader of the medical team when this emergency arises.
   

How to recognize shoulder dystocia

There are 2 ways to diagnose dystocia.

• “Turtle sign.” The first is recognizing the pathognomonic “turtle sign,” in which, after delivery of the baby’s head, the head immediately retracts back up against the mother’s perineum, causing the baby’s cheeks to bulge.
  
• The second diagnostic sign is when, after delivery of the head, the moderate amount of traction usually used does not suffice to deliver the anterior shoulder. Cease attempts at routine traction as soon as shoulder dystocia is diagnosed.
  

The 4 main maneuvers

The 4 maneuvers generally used by obstetricians to resolve shoulder dystocia are considered the standard of care:

• McRoberts maneuver
  
• Suprapubic pressure
  
• Woods screw maneuver
  
• Delivery of the posterior arm
  

McRoberts maneuver is often the only one needed

In this maneuver, the laboring woman’s thighs are hyperflexed against her abdomen.³¹ This hyperflexion does not increase the diameter of the pelvis, as is sometimes claimed. Rather, it flattens the sacrum and changes the angle of the symphysis pubis in relation to the baby’s anterior shoulder, often freeing it. It is an extremely effective way to resolve shoulder dystocia and is often the only maneuver necessary.

Family members can assist—contrary to plaintiff attorney contentions. This maneuver can be performed by nurses or family members if they are properly instructed. Plaintiff attorneys will sometimes argue that the use of family members in this situation is inappropriate, but they are wrong. Family members are sometimes instructed to hold a mother’s legs in a certain position while she is pushing; they can certainly be instructed to hold the legs against the maternal abdomen during attempts to resolve a shoulder dystocia.

Suprapubic pressure with or without McRoberts

In this maneuver, a nurse or other attendant places direct pressure with an open hand or fist just above the mother’s symphysis pubis. The pressure can be directed straight down or to the left or right. Wherever it is directed, the aim of the pressure is to push the baby’s anterior shoulder out of its position behind the mother’s pubic bone.

The combination of McRoberts maneuver and suprapubic pressure can resolve shoulder dystocia in as many as 58% of cases.²²

Woods screw maneuver attempts to “spin” the baby

If the McRoberts maneuver and suprapubic pressure do not resolve the shoulder dystocia, the Woods screw maneuver is usually implemented next.³² In this maneuver, the obstetrician inserts a hand into the posterior vagina and pushes the front of the baby’s posterior shoulder in a spiral direction (clockwise or counterclockwise). The goal is to “unjam” the anterior shoulder from its trapped position behind the symphysis pubis.

The Woods screw maneuver is very effective. After it has been used, it is appropriate to apply moderate traction to the baby’s head to determine whether the baby can be delivered.

Variant: Rubens maneuver. In this maneuver, the obstetrician pushes on the posterior aspect of the posterior shoulder. In addition to spinning the shoulders, as in the Woods screw maneuver, the Rubens maneuver causes shoulder abduction, thus decreasing the biacromial diameter that has to pass through the pelvic outlet.

Attempts to deliver the posterior arm

If shoulder dystocia still persists, the next strategy is usually an attempt to deliver the baby’s posterior arm. This is done by placing a hand deep into the posterior aspect of the vagina, grabbing the baby’s posterior arm, sweeping that arm across the baby’s chest, and delivering it. Once the posterior arm and shoulder are delivered, it is almost always possible to deliver the baby directly from this position or to move the baby in a spiral direction (clockwise or counterclockwise) to free the anterior shoulder.