What is shoulder dystocia and how is it managed (HELPERR)?

Shoulder dystocia is failure of the anterior shoulder to deliver after the head (impaction behind the symphysis) - an emergency risking hypoxia, brachial plexus injury and fracture.

HELPERR: Help; Evaluate for episiotomy; Legs (McRoberts - hyperflex hips); Pressure (suprapubic); Enter (internal rotation); Remove the posterior arm; Roll onto all fours. Avoid fundal pressure and excessive head traction.

Clinical relevance. A rehearsed HELPERR sequence resolves most shoulder dystocia and prevents hypoxic/nerve injury.

More Detail

Shoulder dystocia

A true obstetric emergency requiring an immediate, rehearsed sequence.

Definition

After the head delivers, the anterior shoulder impacts behind the maternal symphysis and fails to deliver with normal traction (the head may retract - 'turtle sign'). Risk factors: macrosomia, maternal diabetes, prolonged/instrumental labour.

Why dangerous

Cord compression causes hypoxia; forced traction risks brachial plexus injury (Erb's palsy) and clavicle/humerus fracture; maternal PPH and perineal trauma.

HELPERR sequence

• H - call for Help.
• E - Evaluate for episiotomy.
• L - Legs: McRoberts manoeuvre (hyperflex hips onto abdomen) - first-line, resolves most cases.
• P - suprapubic Pressure.
• E - Enter for internal rotational manoeuvres (Rubin, Woods' screw).
• R - Remove the posterior arm.
• R - Roll onto all fours (Gaskin).

Avoid fundal pressure (worsens impaction) and excessive head traction (brachial plexus injury).