The head is born but the shoulders do not deliver with routine traction (turtle-neck sign). This is an obstetric emergency: call for help, declare it, and do not apply fundal pressure or excessive traction.
Risk factors
- Previous shoulder dystocia, macrosomia, maternal diabetes
- Maternal obesity, high BMI
- Prolonged first or second stage, induction, instrumental delivery
- Note: it is often unpredictable, so always be prepared
HELPERR
- H: call for Help; E: Evaluate for Episiotomy
- L: Legs (McRoberts); P: suprapubic Pressure
- E: Enter manoeuvres (internal rotation: Rubin, Woods screw)
- R: Remove the posterior arm; R: Roll onto all fours
Call for help / McRoberts
- Declare, stop pushing
- McRoberts position
- Suprapubic pressure
Internal manoeuvres
- Rotational manoeuvres
- Deliver the posterior arm
- Episiotomy for access
Last-resort manoeuvres
- All-fours position
- Cleidotomy, symphysiotomy, Zavanelli
- Senior obstetric and neonatal team
Team response
1
1. Call and declare
Summon senior midwife, obstetrician, neonatal team and anaesthetist. Note the time the head delivered. Stop maternal pushing and fundal pressure.
Summon senior midwife, obstetrician, neonatal team and anaesthetist. Note the time the head delivered. Stop maternal pushing and fundal pressure.
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2
2. McRoberts and pressure
McRoberts position (hyperflex hips onto the abdomen) plus suprapubic pressure: this resolves most cases. Consider an episiotomy to allow internal manoeuvres.
McRoberts position (hyperflex hips onto the abdomen) plus suprapubic pressure: this resolves most cases. Consider an episiotomy to allow internal manoeuvres.
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3
3. Internal manoeuvres
If unresolved: internal rotation (Rubin II, Woods screw) and delivery of the posterior arm. Try all-fours if these fail. Use routine axial traction only.
If unresolved: internal rotation (Rubin II, Woods screw) and delivery of the posterior arm. Try all-fours if these fail. Use routine axial traction only.
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4
4. After
Check the baby (brachial plexus injury, fracture) and mother (postpartum haemorrhage, third- or fourth-degree tear). Document times and manoeuvres; debrief the parents and team.
Check the baby (brachial plexus injury, fracture) and mother (postpartum haemorrhage, third- or fourth-degree tear). Document times and manoeuvres; debrief the parents and team.
Fetal and maternal risks
- Baby: brachial plexus injury, clavicle or humerus fracture, hypoxia
- Mother: postpartum haemorrhage, perineal trauma
- Minimise time but stay systematic
Pitfalls
- Fundal pressure (worsens impaction)
- Excessive downward traction (brachial plexus injury)
- Not declaring the emergency and recording the time
- Forgetting to examine baby and mother afterwards
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026