Management of Shoulder Dystocia

The HELPERR Mnemonic

Basic and immediate intervention in management of shoulder dystocia.

H - Call for help.

This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labor and delivery unit.

E - Evaluate for episiotomy.

Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation maneuvers are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder. Because most cases of shoulder dystocia can be relieved with the Mc Roberts maneuver and supra pubic pressure, many women can be spared a surgical incision.

L - Legs (the Mc Roberts maneuver).

This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. Nurses and family members present at the delivery can provide assistance for this maneuver.

P - Supra pubic pressure.

The hand of an assistant should be placed supra pubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction.

E - Enter maneuvers (internal rotation).

These maneuvers attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. These maneuvers can be difficult to perform when the anterior shoulder is wedged beneath the symphysis. At times, it is necessary to push the fetus up into the pelvis slightly to accomplish the maneuvers.

R - Remove the posterior arm.

Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the fetus to drop into the sacral hollow, freeing the impaction. The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall. Grasping and pulling directly on the fetal arm may fracture the humerus.

R - Roll the patient.

The patient rolls from her existing position to the all-fours position. Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction. In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the fetal shoulders.