Shoulder dystocia occurs when a fetal shoulder becomes impacted, most commonly on the maternal symphysis pubis, or the sacral promontory of the maternal pelvis (Royal College of Obstetricians and Gynaecologists (RCOG), 2012). The RCOG reports that it is not common, occurring in between 0.58% and 0.70% of vaginal births. This does, however, constitute an obstetric emergency, as the bony dystocia will result in failure of delivery of the fetal shoulders following delivery of the head (Coates, 2014). The figures reported by RCOG may not truly reflect the occurrence of shoulder dystocia because some situations are managed by midwives before they become an obstetric emergency and, as such, may not be reported.
HELPERR in midwifery practice
The Standards for pre-registration midwifery education (Nursing and Midwifery Council, 2009) require the newly registered midwife to be able to ‘identify and safely manage appropriate emergency procedures’. The management of shoulder dystocia is therefore taught and assessed in pre-registration midwifery training.
It is common practice to use mnemonics to enable recall of information relating to the management of this obstetric emergency; however, the meanings of these logical steps are often elicited incorrectly (Jan et al, 2014). The authors have therefore considered the cognitive impact of enhancing students' understanding of the HELPERR mnemonic, and this article aims to show, in pictorial form, what we see in practice, mirrored against internal views of the pelvis in an attempt to aid learning and absorption of information. An open educational resource of a video demonstrating the management of a shoulder dystocia is also provided at http://www.kaltura.com/tiny/rt05t.
Recognition of shoulder dystocia
The midwife attending the birth should observe for the following signs (RCOG, 2012):
Shoulder dystocia becomes obvious after the head emerges and then retracts up against the perineum; this is known as turtle sign and/or head bobbing (Figure 1).
Once shoulder dystocia has been recognised, it is important to advise the woman to stop pushing (RCOG, 2012) because this may result in the shoulder becoming further impacted.
The midwife should now instigate the HELPERR mnemonic (Table 1) to assist with the mech anisms and management of shoulder dystocia. The mnemonic was devised by the American Academy for Family Physicians (AAFP) for the Advance Life Support in Obstetrics course, which originated in the USA in 1991 and has been licensed in England since 1996.
| ALSO HELPERR | Adapted HELPERR | ||
|---|---|---|---|
| Call for help | H | Call for help | 1st line |
| Evaluate for episiotomy | E | End pushing | |
| Legs (the McRoberts' manoeuvre) | L | Legs (the McRoberts' manoeuvre) | |
| Suprapubic pressure | P | Suprapubic pressure | |
| Enter manoeuvres (internal rotation) | E | Enter—remove posterior arm/rotate baby into the oblique | 2nd line |
| Remove the posterior arm | R | Roll the woman to her hands and knees | |
| Roll the woman to her hands and knees | R | Refer | 3rd line |
ALSO — Advance Life Support in Obstetrics
— From: Jenkins, 2014
The following mechanisms and management of shoulder dystocia can be used to assist with the birth when the fetus is in the left occipital anterior position. It is important to note that if the fetus is in the right occipital anterior position, the manoeuvres will need to be carried out in the opposite direction.
Using the HELPERR mnemonic
H: Help
Firstly, call for help, as appropriate personnel will be required to assist. The use of the mnemonic SOAPS may be helpful in the allocation of roles:
These roles will need to be allocated appropriately and a local pro forma should be used.
E: Evaluate for episiotomy
Although this is a bony problem, consider performing an episiotomy to provide additional room to carry out internal manoeuvres. Be sure of the position of the fetal back, as this will determine the directions in which the manoeuvres will be performed.
Each manoeuvre should be carried out for a maximum of 30–60 seconds, and if the shoulders are not felt to dislodge, it is necessary to move on to the next manoeuvre (Winters et al, 2012). If the shoulders are felt to dislodge then routine axial traction can be applied to deliver the baby (Winters et al, 2012).
L: Legs into McRoberts' position
Lie the woman flat in a supine position and remove pillows. With one assistant on each side of the woman, hyperflex her legs against her abdomen and bring her knees towards her ears (Figure 2).
This manoeuvre will rotate the angle of the symphysis pubis superiorly, straighten the lumbosacral lordosis and increase the diameter of the pelvic outlet. This procedure simultaneously flexes the fetal spine, often pushing the posterior shoulder over the sacral promontory, allowing it to fall into the hollow of the sacrum; the symphysis may now rotate over the impacted shoulder.
This will also increase the functional size of the bony pelvis, decrease the bisacromal diameter and change the direction of the maternal force to be perpendicular to the plane of the inlet (Gobbo et al, 2005).
If the woman is in lithotomy, her legs will need to be simultaneously straightened before being placed into McRoberts' position.
P: Pressure (suprapubic)
Rubin I
External suprapubic pressure, also known as Rubin I, is applied by an assistant, using a CPR-style hand position. Pressure should be applied to the posterior aspect of the anterior shoulder in a downward lateral direction.
The shoulders should adduct (reduce the bisacromial diameter) and rotate under the symphysis pubis.
Initially, pressure should be continuous. If unsuccessful, a rocking motion may be used to dislodge the shoulder from behind the symphysis pubis (Figure 3a; Figure 3b).
E: Enter manoeuvres
There are three separate Enter manoeuvres: Rubin II, Woods' screw and reverse Woods' screw.
Rubin II
Insert fingers of the right hand into the vagina (at 5 o'clock position) and apply anticlockwise pressure to the posterior aspect of the anterior shoulder. External suprapubic pressure can also be applied by an assistant to provide additional force (Figure 4a; Figure 4b).
Woods' screw
While maintaining the position of the right hand, insert the fingers of the left hand into the vagina (at 7 o'clock position) and apply anticlockwise pressure to the anterior aspect of the posterior shoulder. Both hands should be used to apply anticlockwise pressure simultaneously. External suprapubic pressure can also be applied by an assistant (Figure 5a; Figure 5b).
Reverse Woods' screw
Remove the left hand from the vagina (last hand in, first hand out). Keep the right hand in the vagina and slide the fingers down from the posterior aspect of the anterior shoulder to the posterior aspect of the posterior shoulder, and apply clockwise pressure (Figure 6a; Figure 6b). Do not apply external suprapubic pressure.
R: Remove the posterior arm
Insert a hand into the space created by the hollow of the sacrum and, with two fingers, apply pressure to the ante-cubital fossa of the posterior arm to flex the elbow. Then sweep the forearm across the chest and face and deliver the posterior arm (Coates, 2014) (Figure 7a; Figure 7b).
R: Roll over on to all fours
Roll the woman onto her hands and knees and/or attempt the manoeuvres again (Coates, 2011) (Figure 8a; Figure 8b).
Alternative management
There are different schools of thought as to which manoeuvres should be carried out and the order of these manoeuvres. Jenkins (2014) provided an alternative mnemonic that fits with the current RCOG guidelines, as shown in the right-hand column of Table 1.
“The authors have therefore considered the cognitive impact of enhancing students' understanding of the HELPERR mnemonic, and this article aims to show, in pictorial form, what we see in practice, mirrored against internal views of the pelvis in an attempt to aid learning and absorption of information.”
Points to note
When considering the management of shoulder dystocia, factors that may influence the outcome should be taken into consideration (e.g. the use of epidural, the mobility of the woman and the experience and expertise of the clinician). The person assisting the birth may alter the sequence in which they apply the HELPERR mnemonic (e.g. the application of suprapubic pressure may be followed by the delivery of the posterior arm) (RCOG, 2012).
The Pringle manoeuvre is an alternative way to remove the posterior arm. This can be achieved by inserting a hand into the sacral hollow; the hand is ‘scrunched up’ (as if reaching for the last Pringle in the tube) and internal rotation or delivery of the posterior arm is attempted (Winters et al, 2012).
Conclusion
This article has demonstrated, through the use of photographs that illustrate abdominal and pelvic views, the manoeuvres used to safely manage the obstetric emergency of shoulder dystocia. In conjunction with the HELPERR mnemonic, the authors hope that this will enrich student midwives' and practitioners' appreciation of these steps, and help to prepare them to appropriately manage this obstetric emergency in practice.