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Shoulder Dystocia in the ED: Delivery, Resuscitation, Hemorrhage [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Shoulder Dystocia in the ED: Delivery, Resuscitation, Hemorrhage ================================================================== A case-based approach to three consecutive obstetric and neonatal emergencies [ MDster Editorial Team ](https://mdster.com/about) · Sep 18, 2026 · 6 min read · 288 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) \| [Corrections Policy](https://mdster.com/corrections) [ Emergency Medicine ](https://mdster.com/blog?tag=emergency-medicine) [ Case Discussion ](https://mdster.com/blog?tag=case-discussion) [ Obstetric Emergencies ](https://mdster.com/blog?tag=obstetric-emergencies) [ Postpartum Hemorrhage ](https://mdster.com/blog?tag=postpartum-hemorrhage) [ Shoulder Dystocia ](https://mdster.com/blog?tag=shoulder-dystocia) [ Neonatal Resuscitation ](https://mdster.com/blog?tag=neonatal-resuscitation) ![Shoulder Dystocia in the ED: Delivery, Resuscitation, Hemorrhage](https://mdster.com/storage/blog/images/shoulder-dystocia-in-the-ed-delivery-resuscitation-hemorrhage.jpg) Share this article Share this post On this page 1. [ Recognize Shoulder Dystocia Without Delaying Delivery ](#recognize-shoulder-dystocia-without-delaying-delivery) 2. [ Release the Shoulders, Not by Pulling Harder ](#release-the-shoulders-not-by-pulling-harder) 3. [ Immediate coordinated actions ](#immediate-coordinated-actions) 4. [ When McRoberts fails ](#when-mcroberts-fails) 5. [ The Newborn Is Apneic: Ventilation Comes First ](#the-newborn-is-apneic-ventilation-comes-first) 6. [ Actions within the first minute ](#actions-within-the-first-minute) 7. [ Maternal Bleeding: Distinguish Prevention From Treatment ](#maternal-bleeding-distinguish-prevention-from-treatment) 8. [ Update the traditional third-stage answer ](#update-the-traditional-third-stage-answer) 9. [ Treat hemorrhage in parallel ](#treat-hemorrhage-in-parallel) 10. [ Clinical Application: Close the Loop ](#clinical-application-close-the-loop) 11. [ Key Points for Board Exams ](#key-points-for-board-exams) 12. [ Frequently Asked Questions ](#blog-faqs) 13. [ References ](#references-heading) On this page 1. [ Recognize Shoulder Dystocia Without Delaying Delivery ](#recognize-shoulder-dystocia-without-delaying-delivery) 2. [ Release the Shoulders, Not by Pulling Harder ](#release-the-shoulders-not-by-pulling-harder) 3. [ Immediate coordinated actions ](#immediate-coordinated-actions) 4. [ When McRoberts fails ](#when-mcroberts-fails) 5. [ The Newborn Is Apneic: Ventilation Comes First ](#the-newborn-is-apneic-ventilation-comes-first) 6. [ Actions within the first minute ](#actions-within-the-first-minute) 7. [ Maternal Bleeding: Distinguish Prevention From Treatment ](#maternal-bleeding-distinguish-prevention-from-treatment) 8. [ Update the traditional third-stage answer ](#update-the-traditional-third-stage-answer) 9. [ Treat hemorrhage in parallel ](#treat-hemorrhage-in-parallel) 10. [ Clinical Application: Close the Loop ](#clinical-application-close-the-loop) 11. [ Key Points for Board Exams ](#key-points-for-board-exams) 12. [ Frequently Asked Questions ](#blog-faqs) 13. [ References ](#references-heading) The head delivers, retracts against the perineum, and the shoulders remain trapped. A 34-year-old G3P2 at 40 weeks has arrived crowning, without prenatal care; her previous infant weighed 4.5 kg. Routine traction fails, the head darkens, and the team must prepare for both a compromised newborn and maternal hemorrhage. Recognize Shoulder Dystocia Without Delaying Delivery ----------------------------------------------------- The **turtle sign**, absent restitution, and failure of shoulder delivery establish the clinical diagnosis. Usually, the anterior shoulder is impacted behind the pubic symphysis; posterior impaction is less common. Do not wait for a 60-second head-to-body interval to declare the emergency. [\[1\]](#cite-1 "Reference [1]") Previous macrosomia and gestational diabetes heighten concern but cannot reliably predict dystocia. Once the head has delivered, bedside recognition—not ultrasound or laboratory testing—drives management. Compression during the impaction threatens fetal oxygenation, making rapid, controlled release essential. [\[2\]](#cite-2 "Reference [2]") Release the Shoulders, Not by Pulling Harder -------------------------------------------- ### Immediate coordinated actions 1. Announce shoulder dystocia; summon obstetrics, neonatal resuscitation, and anesthesia. Assign a leader and timekeeper. 2. Perform McRoberts: lay the mother flat and hyperflex both hips, bringing her thighs against her abdomen. 3. Add suprapubic pressure from the fetal back toward the fetal chest, directed downward and laterally over the anterior shoulder. [\[3\]](#cite-3 "Reference [3]") Avoid fundal pressure and forceful or lateral head traction. Reassess release using only routine axial traction; if unsuccessful, change maneuvers promptly. [\[3\]](#cite-3 "Reference [3]") ### When McRoberts fails Enter posteriorly through the sacral hollow to reach the posterior arm. Grasp the wrist and gently withdraw the arm in a straight line, avoiding force on the humeral shaft. Internal rotation or an all-fours position are alternatives; access, maternal mobility, and operator experience determine sequencing. [\[3\]](#cite-3 "Reference [3]") > Clinical Pearl: Episiotomy does not relieve bony impaction. Consider it only when additional access is needed for internal maneuvers. [\[3\]](#cite-3 "Reference [3]") The Newborn Is Apneic: Ventilation Comes First ---------------------------------------------- Following posterior-arm delivery, the infant is limp, apneic, and has HR 80/min. Begin resuscitation immediately; repeated stimulation must not delay ventilation. [\[4\]](#cite-4 "Reference [4]") ### Actions within the first minute - Provide radiant warmth, dry, remove wet linens, and briefly stimulate. - Position the airway with slight extension; suction only for obstruction. - Start PPV promptly, within 60 seconds, initially using 21% oxygen for this term infant. - Deliver 30–60 inflations/min; attach right-hand/wrist pulse oximetry and ECG without delaying ventilation. - Assess heart-rate response and chest movement; correct mask leak, airway position, and inflation pressure if ineffective. [\[4\]](#cite-4 "Reference [4]") If HR falls to 50/min despite at least 30 seconds of effective ventilation, initiate synchronized **3:1 compressions-to-ventilation**, preferably through an ETT, using 100% oxygen. Deliver approximately 90 compressions and 30 breaths/min; if HR remains below 60/min after 60 seconds of coordinated resuscitation, give intravascular epinephrine. [\[4\]](#cite-4 "Reference [4]") After stabilization, arrange neonatal intensive care, glucose monitoring, and assessment for hypoxic-ischemic encephalopathy. Therapeutic hypothermia requires established eligibility criteria and specialist oversight. [\[4\]](#cite-4 "Reference [4]") Maternal Bleeding: Distinguish Prevention From Treatment -------------------------------------------------------- Ten minutes later, bleeding begins before placental delivery. A gush may accompany separation, but ongoing heavy bleeding demands treatment now—not waiting for a retained-placenta time threshold. Quantify blood loss and assess uterine tone, placental status, and hemodynamics. [\[5\]](#cite-5 "Reference [5]") ### Update the traditional third-stage answer Give prophylactic oxytocin after birth; 10 IU IM is an accepted regimen. Skilled attendants may use controlled cord traction with uterine counterpressure. Routine sustained massage is not recommended after prophylactic oxytocin, although repeated tone assessment remains essential. [\[5\]](#cite-5 "Reference [5]") Once the placenta delivers, persistent bleeding with a boggy uterus strongly suggests atony. Continue evaluating competing or concurrent causes: [\[6\]](#cite-6 "Reference [6]") - Tone: uterine atony. - Trauma: cervical, vaginal, or perineal injury. - Tissue: retained placental fragments. - Thrombin: coagulopathy. [\[6\]](#cite-6 "Reference [6]") ### Treat hemorrhage in parallel Institute uterine massage, oxytocin, IV fluids, genital-tract examination, and escalation together. Give TXA 1 g IV over 10 minutes within three hours of birth; repeat 1 g after 30 minutes if bleeding continues. Significant bleeding with an undelivered placenta requires urgent obstetric removal rather than repeated forceful cord traction. [\[5\]](#cite-5 "Reference [5]") Establish large-bore access, obtain CBC, coagulation studies, fibrinogen, and crossmatch, and activate blood-product support when indicated. Bimanual compression can temporize while arranging definitive control; refractory bleeding requires balloon tamponade or surgery in an appropriately supported setting. [\[6\]](#cite-6 "Reference [6]") There is no universally preferred second-line uterotonic. With BP 145/90 mmHg, avoid reflexive methylergonovine selection: hypertension is a contraindication. Carboprost 250 micrograms IM is an option if asthma and other contraindications are absent; misoprostol is another protocol-dependent alternative. [\[6\]](#cite-6 "Reference [6]") Clinical Application: Close the Loop ------------------------------------ Document head and body delivery times, shoulder orientation, maneuver sequence and timing, and personnel present. Include maternal injury and blood loss, neonatal condition, Apgar scores, resuscitation, limb examination, and paired cord gases when available. Debrief the family and team after stabilization. [\[2\]](#cite-2 "Reference [2]") Key Points for Board Exams -------------------------- - Change shoulder-release maneuvers rather than escalating traction. [\[3\]](#cite-3 "Reference [3]") - HR below 100/min requires ventilation; persistent HR below 60/min after effective ventilation requires compressions. [\[4\]](#cite-4 "Reference [4]") - Massage treats atony but is not routine sustained prophylaxis after oxytocin. [\[5\]](#cite-5 "Reference [5]") - Select additional uterotonics around contraindications, not a memorized drug hierarchy. [\[6\]](#cite-6 "Reference [6]") The practical lesson is to rehearse the transitions: shoulder release, neonatal ventilation, and maternal hemorrhage control. Each needs a designated team while the overall resuscitation remains coordinated. Frequently Asked Questions ---------------------------- ### Is posterior-arm delivery mandatory before internal rotation? No. RCOG supports selecting between these approaches according to access, operator experience, and clinical circumstances. [\[3\]](#cite-3 "Reference [3]") ### Should an apneic newborn with HR 80/min receive compressions? No. Start PPV; compressions require HR below 60/min despite effective ventilation. [\[4\]](#cite-4 "Reference [4]") ### Why avoid methylergonovine in this patient? Her elevated BP makes it unsuitable without further assessment; methylergonovine is contraindicated in hypertension. [\[6\]](#cite-6 "Reference [6]") References (7) ------------------ 1. 1. [ www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/shoulder-dystocia-green-top-guideline-no-42 ](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/shoulder-dystocia-green-top-guideline-no-42/) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ DGGG/OEGGG/SGGG. Shoulder Dystocia: S2k Guideline, October 2024. ](https://pmc.ncbi.nlm.nih.gov/articles/PMC11802195/) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ RCOG. Shoulder Dystocia. Green-top Guideline No. 42, third edition; 2026. ](https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.70258) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ AHA/AAP. 2025 Guidelines: Neonatal Resuscitation. ](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ www.ncbi.nlm.nih.gov/books/NBK619233 ](https://www.ncbi.nlm.nih.gov/books/NBK619233/) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ FIGO. Recommendations on Postpartum Hemorrhage Management; 2022. ](https://pmc.ncbi.nlm.nih.gov/articles/PMC9313855/) [↩](#cite-ref-6-1 "Back to text") 7. 7. [ WHO/FIGO/ICM. 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