Shoulder Dystocia

HELPER 4

H Call for Help!

E Evaluate and Explain the clinical situation

L Legs — McRoberts maneuver

P Suprapubic Pressure

E Enter the birth canal posteriorly and

assess the need for an Episiotomy

R4 Remove the posterior arm

Rotational maneuvers
Roll the patient to hands and knees
Repeat

Copyright 2020 American Academy of Family Physicians

Revised November 2020 | CME20011811 | www.aafp.org/also

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 Shoulder Dystocia
Maneuvers
Combine McRoberts maneuver
with suprapubic pressure

Remove the posterior arm:

Follow the posterior Flex the arm Sweep the forearm

arm to the elbow. at the elbow. across the chest and
out of the vagina.
Rotational maneuvers: Roll the patient:

Rubin II Rubin II + Reverse

Woods Screw Woods Screw

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Revised November 2020 | CME20011811 | www.aafp.org/also

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 Postpartum
Hemorrhage (PPH)
AMTSL and The Four T’s
Active Management of the Third Stage of Labor (AMTSL) Includes:
❏ Administration of oxytocin 10 IU IM (or IV over 1-2 minutes) with delivery
of the infant, or as soon as possible
❏ Delayed cord clamping for 1-3 minutes
❏ Continuous, gentle cord traction (Brandt maneuver)
❏ Transabdominal uterine massage after the placenta delivers
Tone: Uterine Atony
❏ Perform uterine massage
❏ Perform bimanual compression
❏ Medications
– Oxytocin: 20 IU IM, or 20 IU/500 mL NS given IV (infused over 10 minutes),
then run at 250 mL/hour
– Methylergonovine: 0.2 mg IM, use cautiously in patients with hypertension
– Carboprost: 0.25 mg IM, use cautiously in patients with asthma or
significantrenal, hepatic, or cardiac disease
– Misoprostol: 600 mcg SL (PR, PV, PO)
– Tranexamic acid (TXA): 1 g/100 mL NS given IV infused over 10 minutes,
may repeat in 30 minutes if no response (if within 3 hours from the start
of the hemorrhage)
Trauma: Laceration (cervical or vaginal), Hematoma, or Uterine Inversion
❏ Examine and repair
Tissue: Retained Placenta
❏ Explore for fragments
❏ Manual removal or curettage
Thrombin: Coagulopathy
❏ Evaluate coagulation status
❏ Replace blood products: fresh frozen plasma (FFP)
Copyright 2020 American Academy of Family Physicians
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 ❏

Preeclampsia With
Severe Features
❏ New onset headache
❏ Visual disturbances
❏ Pulmonary edema
❏ Hepatic dysfunction
– Transaminase 2X normal
– Right upper quadrant (RUQ)
or epigastric pain
❏ Elevated creatinine
(>_1.1 mg/dL or 2X baseline)
❏ Systolic BP >_160 mm Hg
❏ Diastolic BP >_110 mm Hg
❏ Platelets <100,000/µL

Management of Preeclampsia With Severe

Features With Magnesium Sulfate:
❏ 4-6 g IV loading dose infused over 15-20 minutes,
followed by maintenance infusion of 2 g/hour
❏ Monitor serum magnesium levels if:
– Creatinine _> 0.9 mg/dL
– Urine output <30 mL/hour
– Loss of patellar reflexes
– Other symptoms of magnesium toxicity

Copyright 2020 American Academy of Family Physicians

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 VACUUM APPLICATION
A-J
A Ask for help
Address the patient G Gentle traction following the pelvic
curve, during contractions/with
Anesthesia adequate? maternal effort only

B Bladder emptied?
H Halt traction between contractions
Halt if:

C Cervix completely dilated 3 pop-offs

3 contractions/pulls with no progress
20 minutes of total application

D Determine position of the Hold cup with the thumb

head; consider and prepare (index finger on fetal head)
for shoulder Dystocia

E Equipment ready I Incision: Evaluate for episiotomy

(not routinely recommended)

F Place cup on Flexion point,

Feel for maternal tissue J Remove the vacuum when
the Jaw is reachable

Copyright 2020 American Academy of Family Physicians

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 FORCEPS APPLICATION
A B C D E F G H I J
A Ask for help,
Address the patient,
Anesthesia adequate?

B Bladder empty?
C Cervix must be completely dilated
D Determine position of the head. Think of shoulder
Dystocia. Review the HELPER Mnemonic. 4

E Equipment ready
F Forceps application
G Gentle traction
H Handle elevated to follow the J-shaped pelvic curve
I Incision: Evaluate for episiotomy (avoid if possible)
J Remove forceps when the Jaw is reachable

Copyright 2020 American Academy of Family Physicians

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 DR C BRaVADO
for the interpretation of FHR tracings
DR Determine Risk — “low” or “high”

C Contractions — comment on
pattern and intensity

BRa Baseline Rate — bradycardia, normal

110-160 bpm, or tachycardia

V Variability — marked (>25 bpm), moderate

(6-25 bpm), minimal (1-5 bpm), or absent.
Minimal and absent are concerning.

A Accelerations — present or absent

(at least _> 15 beat change from the
baseline lasting _> 15 seconds)

D Decelerations — “early,” “variable,” or “late”

O Overall — assessment (Category I/II/III)

and plan of management
Copyright 2020 American Academy of Family Physicians
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 Emergent Vaginal
Breech Delivery
CAREFUL
A
C Check for presenting part, dilation,
and cord prolapse

Ask for help

A Await delivery of umbilicus
Maintain sacrum Anterior
R

R Rotate the body for delivery

of arms (using Lovset maneuver)

E Enter vagina to perform

Mauriceau-Smellie-Veit
(MSV) maneuver
E
F Flex the fetal head

U Back Up (maintain sacrum anterior)

F

L Lift baby onto mother

Copyright 2020 American Academy of Family Physicians

Revised November 2020 | CME20011811 | www.aafp.org/also

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