Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Recognise impacted shoulders after birth of the head, apply current release manoeuvres without harmful traction, and organise maternal and newborn assessment afterwards.
Shoulder dystocia is diagnosed when the shoulders fail to deliver after the head with the usual gentle traction in line with the fetal spine, requiring additional obstetric manoeuvres. The anterior shoulder commonly lies behind the symphysis, although posterior impaction can contribute. The team must change the relationship between shoulders and pelvis rather than pull harder on the head. Effective action depends on clear leadership, adequate space and familiarity with several release techniques.
The RCOG third edition, published in August 2026, emphasises efficient progression: attempt a manoeuvre properly, then move to the next when it fails. Repeatedly maintaining an ineffective technique for an arbitrary thirty seconds prolongs the head-to-body interval. No fixed interval guarantees freedom from hypoxic injury, particularly when fetal compromise preceded the impaction, so rapid but controlled manoeuvres remain essential.
The shoulder girdle may not enter or rotate through a sufficiently wide pelvic diameter after the head delivers. Impaction can involve the anterior shoulder, the posterior shoulder or both.
Larger fetal dimensions and diabetic patterns of growth can increase shoulder dystocia risk. Nevertheless, size estimation and risk-factor combinations are insufficiently precise to identify all births that will be affected.
A previous shoulder dystocia increases recurrence risk but does not determine the outcome of a later birth. Its severity and any neonatal injury contribute to an individual antenatal discussion.
The head is delivered while the shoulder girdle remains constrained. Manoeuvres work by changing maternal pelvic orientation, rotating the shoulders or reducing the space occupied by the shoulder and arm complex.
A prolonged head-to-body interval can impair oxygenation through continuing compression and delayed effective newborn breathing. Pre-existing fetal compromise influences tolerance, so a seemingly short interval is not an absolute guarantee of safety.
Force across the fetal neck and brachial plexus can stretch or damage nerves. Maintaining routine axial traction and using release manoeuvres limits avoidable additional stress during a difficult birth.
Difficulty delivering the chin or face, a head held tightly against the vulva, retraction after head birth, absent restitution and failure of shoulder descent all raise concern. The classic turtle appearance may be present, but waiting for a dramatic sign is unnecessary.
Only the traction normally used for uncomplicated shoulder delivery, directed along the fetal spine, should be applied to assess release. Lateral, downward or suddenly increased force risks nerve and cervical injury and is not a diagnostic test.
Previous shoulder dystocia, diabetes and suspected fetal macrosomia increase risk, but fetal weight estimation is imperfect and many affected infants are not unusually large. Readiness at every vaginal birth is more useful than reassurance based on absence of risk factors.
After delivery, evaluate newborn breathing, heart rate, tone and symmetrical arm movement; examine for fractures or brachial plexus injury when stable. Simultaneously assess uterine tone, measured blood loss and the maternal genital tract for substantial trauma.
A brief normal pause between delivery of the head and shoulders should be distinguished from true failure with routine axial traction. Once impaction is apparent, further passive waiting is inappropriate.
A cord around the neck can complicate delivery and assessment but is not the same as shoulder impaction. Manage the actual mechanical problem without assuming one finding excludes another.
In breech birth, entrapment of the head occurs after the body and has a different anatomical mechanism. It requires a breech emergency response rather than a shoulder-dystocia sequence.
Weakness of an arm or restricted movement can reflect nerve injury or fracture. Timely neonatal examination, appropriate referral and follow-up are necessary to distinguish transient findings from persistent impairment.
Delayed completion of birth can cause acidosis, encephalopathy or death. Resuscitation requirements and neurological evolution should guide neonatal care instead of reliance on the delivery interval alone.
Postpartum haemorrhage and severe perineal injury may follow the birth. Once the shoulders are delivered, a deliberate maternal assessment prevents the dramatic neonatal event from distracting from treatable maternal morbidity.
The obstruction lies between fetal shoulders and the maternal bony pelvis. Cutting the perineum cannot enlarge that bony space, but it may allow a hand to perform internal rotation or posterior-arm delivery when access is restricted.
Internal rotation and posterior-arm delivery are both recognised options after external manoeuvres fail. There is no universal evidence-based requirement to force one sequence regardless of access, fetal orientation, operator experience or maternal mobility.
The operator identifies the posterior arm and delivers it carefully with controlled handling. Humeral fracture is a recognised complication; reducing impaction by a trained manoeuvre is different from using uncontrolled traction on the head.
Both planned vaginal birth and planned caesarean may be appropriate after a previous event. Review the severity, neonatal outcome, current fetal growth and maternal preferences; previous shoulder dystocia alone does not mandate one mode for everyone.
The 2026 RCOG guidance warns that a compromised newborn after shoulder dystocia may have apparently normal cord gases. Alert neonatal clinicians to the delivery circumstances and assess the baby directly rather than allowing gas results to overrule clinical illness.
Applying fundal pressure can increase impaction and maternal injury and must not be confused with correctly placed suprapubic pressure.
Repeatedly pulling harder after a failed manoeuvre substitutes injurious force for a change in fetal–pelvic geometry.
Performing routine prophylactic McRoberts before the head is born is not recommended as a preventive strategy.
Attributing every brachial plexus injury solely to a documented manoeuvre overlooks that injury can occur without recognised shoulder dystocia.
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During a shoulder dystocia, McRoberts positioning and correctly directed suprapubic pressure have been attempted without release. The fetal head has been born for ninety seconds. What should the team do next?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 7 Sept 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes