Shoulder Dystocia on the NCLEX
Shoulder dystocia: recognition, McRoberts maneuver, suprapubic pressure, and the interventions that are contraindicated.
Shoulder dystocia gives you seconds to act, and the exam tests both the right maneuvers and the forbidden one.
Recognize it
The head delivers, then retracts against the perineum (turtle sign) and the anterior shoulder wedges behind the symphysis. Risk factors: fetal macrosomia, maternal diabetes, prolonged second stage, prior shoulder dystocia. It also occurs with no risk factors at all, so know the drill.
First-line maneuvers
Call for help and note the time of head delivery. McRoberts maneuver: hyperflex the maternal hips sharply onto the abdomen (two assistants, one leg each). This flattens the sacrum and rotates the symphysis, freeing the shoulder in many cases. Suprapubic pressure: downward pressure just above the symphysis to push the anterior shoulder under the bone. Combined with McRoberts, this resolves most cases.
What NOT to do
Never apply fundal pressure. It drives the shoulder harder into the symphysis and raises the risk of uterine rupture and worse impaction. Excessive lateral traction on the head is also avoided: it stretches the brachial plexus. If first-line maneuvers fail, the provider moves to internal rotational maneuvers or delivery of the posterior arm; the nurse's job is positioning, pressure on request, and timekeeping.
After the delivery
Assess the newborn for brachial plexus injury (Erb palsy: absent Moro on the affected side, arm adducted and internally rotated) and clavicle fracture (crepitus, asymmetric Moro). Assess the mother for postpartum hemorrhage and lacerations. Document the timeline and every maneuver used.
Frequently asked
Is suprapubic pressure the same as fundal pressure?
No, and the exam loves the distinction. Suprapubic pressure is applied low, just above the pubic bone, to dislodge the shoulder. Fundal pressure is applied at the top of the uterus and is contraindicated.
Why note the time the head delivered?
Cord compression during dystocia limits fetal oxygenation. The team tracks head-to-body interval to guide escalation and to document the emergency accurately.
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