Suspect shoulder dystocia and immediately announce it if resistance to delivering the shoulder is excessive or if, as seen here, the fetal head retracts after being delivered.

Among the various maneuvers used to try and achieve vaginal delivery, McRoberts maneuver is often the 1st. Try to deliver the shoulder while assistants hyperflex and slightly abduct the hips. An assistant should also apply suprapubic pressure in the direction of the fetal head.

Apply pressure to the suprapubic area. Do NOT apply pressure to the uterine fundus, as shown here. Fundal pressure tends to increase impaction of the shoulder against the pubic bone and increases risk of fetal injury.

If delivery is unsuccessful, assess whether the vaginal opening is wide enough to accommodate your hand for additional maneuvers. If not, consider episiotomy so that these maneuvers can be done.

The 1st such maneuver is usually a rotational maneuver to try to dislodge the shoulder. Rotate the anterior or posterior shoulder toward the face of the fetus.

Another option is delivery of the posterior arm, as shown here. This requires inserting your entire hand into the vagina. To do this, hold your hand with your thumb tucked in, as when putting a bracelet on.

Do NOT hold your hand with the thumb away from the fingers, as shown here. This common mistake will make it difficult or impossible to insert the entire hand into the vagina.

With your hand in the vagina, grab the wrist, flex the elbow, and move the entire arm up and over the head.

If rotational maneuvers and delivery of the arm are ineffective or can’t be done, position the mother on her hands and knees for delivery. This is called the Gaskin maneuver.

If all attempts have been unsuccessful and more than 4 or 5 min have elapsed since delivery of the head, consider putting the fetus back into the abdomen and doing an immediate cesarean delivery. Drugs that decrease contractions, such as terbutaline, may be helpful.