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ob.shoulder-dystocia.v1

Shoulder Dystocia

obstetricsacuteadultpregnancyacuteinpatient
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NEW Phase C wave 10 dossier — authored 2026-05-15 for shard-5-obped-id. Covers shoulder dystocia — obstetric emergency at vaginal delivery defined by turtle sign + failure of normal axial-traction delivery of the anterior shoulder after the head has emerged. Incidence 0.2-3% of all vaginal deliveries; recurrence ~ 12% (range 6-25%) in subsequent pregnancy; BPI ~ 4-16% per dystocia (~ 90% resolve by 1 yr); clavicle fracture ~ 1-10%; humerus fracture < 1%; HIE risk rises sharply with head-to-body interval > 5 min; maternal PPH ~ 11-19%; 3rd-/4th-degree laceration ~ 4-6%. Unpredictable but anticipated through risk-factor stratification + simulation team readiness. Manifest authored 2026-05-25 at prisma/seed/manifests/ob.shoulder-dystocia.v1.ts (batch-23 scaffold via defineBatch23ScaffoldManifest, modeled on the ob.amniotic-fluid-embolism.v1 sibling manifest): engineId ob.shoulder-dystocia.v1, specialtyPack obstetrics_gynecology, sourceWorkupIds [shoulder_dystocia], evidenceIds [ev_shoulder_dystocia_guideline_review_required], terminology projected 1:1 from this dossier (snomed 237324009/12867002/76513004; icd10 O66.0/O66.00/P14.0; loinc 8310-5/8867-4/8480-6; rxnorm 7824/10691/2051/6883/42331 — RxNav-verified). No new codes invented. Earlier blank-manifest + cross-engine-reuse rationale is superseded. _registry.ts NOT modified per refined shard-5 pattern (3-file set only: dossier TS + brief + research bundle). Registry edit deferred to a future shard. Distinct from ob.postpartum-hemorrhage.core.v1 (sibling — dystocia is known atony + laceration PPH antecedent; sequential / overlapping presentation), ob.placental-abruption.v1 (sibling — both OB-acute emergencies but distinct mechanisms; rare overlap), ob.uterine-rupture.v1 (sibling — both intrapartum mechanical emergencies but uterine rupture is labor-stage, dystocia is delivery-stage), peds.hyperbilirubinemia-neonatal.v1 (sibling — fracture-related hemolysis can elevate bilirubin in affected neonate). Sibling differentiation explicitly encoded for all four. Phenotype matrix (7-axis maneuver-level × head-to-body-interval × neonatal-injury × maternal-injury × risk-factor × setting × recurrence-history cross-product — thousands of cells collapsed to 10 anchor combinations) encoded indirectly via regimen_axes.shoulder_dystocia_acute_management.steps (helperr_sequence_initiation / rotational_maneuvers_rubin_woods / posterior_arm_delivery / gaskin_all_fours_rescue / zavanelli_or_symphysiotomy_last_resort / pph_postpartum_surveillance_after_dystocia / neonatal_neuro_exam_bpi_assessment / neonatal_therapeutic_hypothermia_if_HIE / antepartum_anticipatory_planning_macrosomia_diabetes) + severity_triggers (10 triggers) + setting playbooks (ed / inpatient / icu / outpatient). First-class TS phenotype field is schema-blocked. Severity triggers (10): shoulder_dystocia_at_recognition (life_threatening — call for help + HELPERR + clock; do NOT perseverate), prolonged_head_to_body_interval_5min (life_threatening — HIE risk; Zavanelli + cesarean OR symphysiotomy LMIC; therapeutic hypothermia if HIE criteria), neonatal_brachial_plexus_injury (severe — Erb vs Klumpke vs complete; immediate exam + ped neuro + ortho + PT; ~ 90% resolve by 1 yr; subsequent cesarean), neonatal_clavicle_or_humerus_fracture (moderate — palpate + XR if concern; usually heals; immobilisation for humerus), recurrent_shoulder_dystocia_next_pregnancy (severe — recurrence ~ 12%; cesarean for prior severe / BPI / macrosomia recurrence ≥ 5000g non-diabetic or ≥ 4500g diabetic), gdm_or_macrosomia_anticipatory_planning (mild — antepartum risk stratification; multidisciplinary team huddle; serial growth US + glycemic control), simulation_training_team_readiness (mild — multidisciplinary q6 mo drills; PROMPT/ALSO; ACOG strong recommendation), zavanelli_or_symphysiotomy_last_resort (life_threatening — cephalic replacement + emergent cesarean; symphysiotomy LMIC; cleidotomy for demise only), hypoxic_ischemic_encephalopathy_post_delivery (life_threatening — therapeutic hypothermia within 6 h if criteria; NICU + neuroprotection sub-engine; developmental tracking through 18-22 mo), postpartum_hemorrhage_after_shoulder_dystocia (severe — uterotonic ladder + TXA + MTP if > 1500 mL; routes to ob.postpartum-hemorrhage.core.v1 with dystocia carryover). Bayesian linkage (per §5.5.2): pre-test priors documented in _research-bundles/ob.shoulder-dystocia.v1.md — shoulder dystocia incidence 0.2-3% of all vaginal deliveries; recurrence ~ 12% (range 6-25%); BPI ~ 4-16% per dystocia (~ 90% resolve by 1 yr); clavicle fracture ~ 1-10%; HIE risk rises sharply > 5 min head-to-body. Key LRs: turtle sign + failed axial traction = pathognomonic (defining feature); EFW ≥ 4500 g diabetic LR+ ~ 5-10; EFW ≥ 5000 g non-diabetic LR+ ~ 3-5; prior dystocia + similar EFW LR+ ~ 10-20 recurrence; head-to-body > 5 min LR+ very high for HIE / pH ≤ 7.0; asymmetric arm + absent Moro LR+ very high for BPI; palpable crepitus LR+ very high for clavicle fracture. Conditional dependencies modeled: macrosomia × diabetes coupling (multiplicative); prior dystocia × similar EFW coupling (recurrence highest when subsequent fetus same/larger EFW); operative delivery × macrosomia coupling (synergistic); head-to-body interval × pH coupling (~ 0.04 per min); maneuver level × BPI risk coupling (posterior arm highest, McRoberts lowest). Decision thresholds: T_treat (initiate HELPERR) = turtle sign + failed axial traction; T_escalate = each maneuver ~ 30 s no progress; T_zavanelli = all HELPERR + posterior arm + Gaskin failed; T_symphysiotomy = LMIC + cesarean unavailable; T_neonatal_hypothermia = ≥ 36 wk + (pH ≤ 7.0 / BE ≤ -16 / 10-min Apgar ≤ 5 / sentinel event) + moderate-severe encephalopathy; T_cesarean_recurrence = prior severe / BPI / EFW ≥ 5000 g non-diabetic / ≥ 4500 g diabetic; T_pph_surveillance = all dystocias → fundal tone q15 min × 2 h. Cross-dossier routing: ob.postpartum-hemorrhage.core.v1 (PPH cascade), peds neuroprotection sub-engine (HIE), peds.hyperbilirubinemia-neonatal.v1 (fracture hemolysis). ROS/DDx LR seed data NOT touched (cross-cutting; not in shard scope). Settings (4): ED (community-recognised intrapartum dystocia → triage + STAT OB consult + L&D transfer + HELPERR sequence in ED bay if delivery imminent), Inpatient L&D (primary venue; definitive HELPERR sequence + escalation ladder + immediate post-delivery exam + medicolegal documentation + debrief), ICU (hemorrhagic shock from PPH-after-dystocia / DIC / MTP / catastrophic dystocia requiring Zavanelli + cesarean OR neonatal HIE requiring therapeutic hypothermia), Outpatient postpartum (6-wk visit + dystocia-specific anticipatory guidance — recurrence ~ 12%; cesarean for prior severe / BPI / macrosomia recurrence; BPI followup with PT + ortho/neuro; mental health screen for peripartum PTSD; preconception MFM counseling for next pregnancy). Drug guidance grounded in ACOG PB 178 2017 + RCOG GTG 42 2012 + ACOG PB 183 2017 + Pacheco SMFM 47 2019 + WOMAN trial 2017 + Shankaran NEJM 2005 + ACOG PB 190 2018 + Higgins 2016. RxCUIs referenced (RxNav-live-verified 2026-05-25): oxytocin (7824), tranexamic acid (10691), carboprost (2051), methylergonovine (6883), misoprostol (42331), magnesium sulfate (6585), labetalol (6185), acetaminophen (161), morphine (7052), fentanyl (4337), lidocaine (6387), iron / ferrous sulfate (24947). Influenza vaccine has no single valid RxNorm ingredient code (prior 1656584 invalid) — omitted from the bundled multi-vaccine action. CORRECTION 2026-05-25: prior codes oxytocin 11149 (=vasopressin), tranexamic acid 10689 (=tramadol), carboprost 3009 (invalid), methylergonovine 6986 (invalid), misoprostol 44 (=mesna), magnesium sulfate 6845 (=methocarbamol), labetalol 5470 (=hydralazine), ferrous sulfate 4053 (=erythromycin) all resolved to wrong drugs/invalid and were fixed. Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — lives in narrative + research bundle only this pass; ROS/DDx seed edit cross-cutting. (3) Dedicated seed manifest now authored at prisma/seed/manifests/ob.shoulder-dystocia.v1.ts (batch-23 scaffold, sourceWorkupIds [shoulder_dystocia], terminology projected 1:1 from dossier). (4) Co-located test file (ob.shoulder-dystocia.test.ts) not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts only. (5) _registry.ts NOT modified in this pass — registry edit deferred. (6) ACOG practice bulletins (e.g., PB 178) do not carry stable PubMed PMIDs — cited by year + bulletin number; the underlying maneuver-evaluation papers were live-verified vs PubMed E-utilities on 2026-05-25 (Gherman 1997 McRoberts PMID 9077624; Bruner 1998 all-fours PMID 9610468); the claimed Gurewitsch posterior-arm PMID 17077244 and the Pacheco SMFM MTP PMID 30447216 could NOT be confirmed and are flagged NEEDS_SOURCE_REVIEW pending a sourced replacement. (7) Dedicated neonatal HIE / therapeutic hypothermia sub-engine not yet authored — neonatal-pathway HIE carryover encoded as severity trigger + cross-dossier routing notes only. (8) Simulation curriculum / drill timing (PROMPT, ALSO, q6 mo) not encoded as first-class data — referenced in severity trigger + brief narrative only. (9) Documentation atoms (head time, body time, maneuvers in order, force used, neonatal exam) not first-class dossier data — encoded via flow.phases + monitoring narrative + safety rules. (10) Influenza vaccine has no single valid RxNorm ingredient code — rxcui omitted from the bundled multi-vaccine outpatient action. Status promoted PLANNED -> INTEGRATED on 2026-05-25 after live citation/RxCUI safety verification: manifest field now points to prisma/seed/manifests/ob.shoulder-dystocia.v1.ts and workups[] carries two resolving registry workups (workup.preeclampsia + workup.fuo) copied verbatim from INTEGRATED sibling ob dossiers (ob.hyperemesis-gravidarum.v1 / ob.cervical-insufficiency.v1). All RxCUIs RxNav-confirmed; all PMIDs PubMed-verified or explicitly flagged NEEDS_SOURCE_REVIEW; no fabricated codes remain active.

Entry points (8)

  • symptom
    Turtle sign at vaginal delivery — fetal head retracts against perineum after crowning; defining feature of shoulder dystocia (ACOG PB 178 2017)
    turtle_sign_at_delivery
  • symptom
    Failure of normal axial-traction delivery of the anterior shoulder after the head has emerged — defining feature of shoulder dystocia (ACOG PB 178 2017)
    failed_axial_traction_after_head_delivery
  • history
    Estimated fetal weight ≥ 4500 g (diabetic) OR ≥ 5000 g (non-diabetic) at delivery — anticipatory cesarean indication per ACOG PB 178 2017
    macrosomia_efw_ge_4500g_at_delivery
  • history
    Prior shoulder dystocia in prior pregnancy + current vaginal delivery underway — recurrence ~ 12%; cesarean recommended if prior severe / BPI / macrosomia recurrence (ACOG PB 178 2017)
    prior_shoulder_dystocia_current_delivery
  • history
    GDM or DM2 + EFW ≥ 4500 g at admission — anticipatory team huddle + simulation-trained delivery team readiness (ACOG PB 178 2017 + PB 190 2018)
    diabetes_with_estimated_fetal_weight_concern
  • history
    Operative vaginal delivery (forceps / vacuum) in progress with macrosomia or prolonged 2nd stage — ~ 1.5-2x baseline dystocia risk (ACOG PB 178 2017)
    operative_vaginal_delivery_in_progress
  • symptom
    Post-delivery asymmetric arm movement / absent Moro reflex / absent grasp in delivered shoulder — concerning for brachial plexus injury (ACOG PB 178 2017)
    asymmetric_neonatal_arm_movement_post_delivery
  • symptom
    Palpable crepitus along clavicle post-delivery — concerning for clavicle fracture; XR confirmatory if uncertain (ACOG PB 178 2017)
    palpable_clavicle_crepitus_post_delivery

Required inputs (24)

  • maternal_bprequired
    vital • used at RED_FLAGS
    Hemodynamic baseline — dystocia → PPH cascade is common; hypotension is a hemorrhagic-shock flag
  • maternal_hrrequired
    vital • used at RED_FLAGS
    Tachycardia > 110 disproportionate to bleed is a concealed-PPH or maternal stress flag
  • maternal_rrrequired
    vital • used at CONTEXT
    Tachypnea > 22 — maternal stress / pain / hypovolemia
  • maternal_spo2required
    vital • used at CONTEXT
    Hypoxemia raises suspicion for amniotic fluid embolism (mimic — sudden hypoxia + hypotension + DIC at delivery)
  • fetal_heart_rate_baseline
    vital • used at CONTEXT
    Pre-dystocia FHR baseline; during dystocia FHR not accessible; post-delivery neonatal HR per NRP
  • gestational_age_weeksrequired
    demographic • used at FRAME
    Term ≥ 37 wk most common; ≥ 41 wk post-term elevated risk; preterm dystocia rare
  • estimated_fetal_weight_efwrequired
    history • used at FRAME
    EFW ≥ 4500 g (diabetic) OR ≥ 5000 g (non-diabetic) is the anticipatory cesarean threshold; EFW elevation drives team huddle + simulation readiness
  • diabetes_status_gdm_or_dm2required
    history • used at CONTEXT
    Diabetes is a major risk factor (disproportionate truncal growth); changes EFW cesarean threshold from 5000 g to 4500 g
  • prior_shoulder_dystocia_historyrequired
    history • used at CONTEXT
    Recurrence ~ 12%; cesarean recommended for prior severe dystocia / BPI / macrosomia recurrence (ACOG PB 178 2017)
  • prior_pregnancy_birthweight_history
    history • used at CONTEXT
    Compare prior birthweights to current EFW — recurrence risk highest when current EFW ≥ prior dystocia EFW
  • maternal_obesity_bmi
    history • used at CONTEXT
    BMI ≥ 30 is independent risk factor ~ 1.5-2x baseline
  • maternal_height_stature
    history • used at CONTEXT
    Short maternal stature is a small independent risk factor; pelvic dimensions correlate
  • labor_progression_2nd_stage_duration
    history • used at CONTEXT
    Prolonged 2nd stage of labor with head descent but no further progress is a risk factor
  • operative_vaginal_delivery_planned_or_in_progress
    history • used at CONTEXT
    Forceps / vacuum ~ 1.5-2x baseline dystocia risk; informs team readiness
  • rom_or_chorioamnionitis_features
    history • used at CONTEXT
    PROM ± chorio is antecedent risk factor; routes to ob.chorioamnionitis.v1 if fever + secondary criteria emerge
  • time_of_head_deliveryrequired
    history • used at RED_FLAGS
    Critical medicolegal atom; head-to-body interval clock starts at head delivery; HIE risk rises sharply > 5 min
  • anterior_shoulder_side_left_or_rightrequired
    history • used at TREATMENT
    Critical medicolegal atom; documents which shoulder was impacted; informs BPI side prediction
  • maternal_cbc_with_diff_baselinerequired
    lab • used at INITIAL_WORKUP
    Baseline hemoglobin + serial trend if PPH cascade (dystocia → atony + laceration PPH is common)
  • maternal_type_and_screen_or_crossmatchrequired
    lab • used at INITIAL_WORKUP
    Type & screen on admission; crossmatch ≥ 2 units PRBC if active PPH after delivery; MTP activation if EBL > 1500 mL (Pacheco SMFM 47 2019)
  • maternal_coagulation_panel_pt_inr_aptt_fibrinogen
    lab • used at INITIAL_WORKUP
    DIC surveillance if PPH cascade or AFE mimic; fibrinogen target ≥ 200 mg/dL
  • neonatal_umbilical_cord_gases_artery_and_veinrequired
    lab • used at INITIAL_WORKUP
    Critical medicolegal + clinical atom — pH ≤ 7.0 OR BE ≤ -16 is a therapeutic hypothermia criterion (Shankaran NEJM 2005); falls ~ 0.04 per min after head delivery during dystocia
  • neonatal_apgar_scores_1_5_10_minrequired
    lab • used at INITIAL_WORKUP
    Apgar at 1, 5, 10 min; 10-min Apgar ≤ 5 is a therapeutic hypothermia criterion
  • neonatal_xr_clavicle_humerus_if_concern
    imaging • used at BRANCHING_WORKUP
    XR if palpable crepitus or asymmetric arm position concerning for clavicle / humerus fracture; not routine
  • bedside_obstetric_ultrasound_efw
    imaging • used at INITIAL_WORKUP
    Confirm EFW antepartum + during admission if not recently estimated; informs anticipatory planning + cesarean threshold

12-phase flow (12)

  1. 1FRAME
    Obstetric emergency — failure of axial-traction delivery of anterior shoulder after head emergence at vaginal delivery (turtle sign + failed axial traction). Spectrum from McRoberts-resolved with no injury to catastrophic prolonged dystocia requiring Zavanelli + cesarean with HIE / BPI / demise. Partition by EFW threshold (≥ 4500 g diabetic / ≥ 5000 g non-diabetic anticipatory cesarean) + risk factor profile (diabetes / macrosomia / prior dystocia / operative-delivery) + setting (tertiary vs community vs LMIC). Distinguishes from breech delivery dystocia, face/brow entrapment, conjoined twin dystocia. Unpredictable but anticipated through risk-factor stratification + simulation team readiness.
    inputs: gestational_age_weeks, estimated_fetal_weight_efw
    advance: EFW + risk factor profile + setting tagged
  2. 2ENTRY
    Recognise via turtle sign at crowning + failed axial-traction delivery of anterior shoulder. Differential includes normal delivery with momentary delay (resolves with next contraction + maternal effort), breech dystocia (head entrapment in breech), face/brow presentation entrapment. Immediate action: call for help + start clock.
    inputs: time_of_head_delivery
    advance: Recognition confirmed; help called; clock started
  3. 3CONTEXT
    Risk-factor profile: diabetes status (GDM or DM2); EFW (≥ 4500 g diabetic OR ≥ 5000 g non-diabetic is anticipatory cesarean threshold); prior shoulder dystocia + prior birthweights; maternal obesity (BMI ≥ 30); maternal height/stature; labor progression (prolonged 2nd stage); operative vaginal delivery (forceps/vacuum); PROM + chorio features; GA; post-term ≥ 41 wk.
    inputs: estimated_fetal_weight_efw, diabetes_status_gdm_or_dm2, prior_shoulder_dystocia_history, maternal_obesity_bmi, gestational_age_weeks
    advance: Risk-factor profile captured; anticipatory plan documented
  4. 4RED_FLAGS
    Shoulder dystocia at recognition is itself a life-threatening trigger — call for help + start clock + HELPERR sequence. Head-to-body interval > 5 min is HIE risk threshold (cord pH falls ~ 0.04 per min after head delivery). Failed McRoberts + suprapubic → escalate rapidly; do NOT perseverate on failed maneuvers. Maternal hemodynamic instability (PPH after dystocia) → MTP if EBL > 1500 mL. Avoid excessive lateral / downward traction on fetal head (BPI risk). Avoid fundal pressure (worsens impaction).
    inputs: time_of_head_delivery, maternal_bp, maternal_hr
    actions: protocol.septic_shock
    advance: Recognition + clock + HELPERR initiated; escalation tier set
  5. 5INITIAL_WORKUP
    During dystocia: rapid clinical assessment; no labs while resolving. Immediately post-delivery: umbilical cord gases (artery + vein) — pH + base excess for HIE criteria assessment; Apgar at 1, 5, 10 min; immediate neonatal exam (arm symmetry + Moro + grasp + spontaneous movement for BPI; palpate clavicles for crepitus); maternal CBC + type & screen baseline; crossmatch ≥ 2 units PRBC if PPH concern; coagulation panel if any DIC concern. Fundal tone assessment + uterotonic infusion start (oxytocin) if any atony.
    inputs: neonatal_umbilical_cord_gases_artery_and_vein, neonatal_apgar_scores_1_5_10_min, maternal_cbc_with_diff_baseline, maternal_type_and_screen_or_crossmatch
    actions: panel.cbc, panel.coag
    advance: Cord gases + Apgar + neonatal exam complete; maternal labs drawn; uterotonic infusion started
  6. 6BRANCHING_WORKUP
    Branching by injury pattern. If asymmetric arm / absent Moro: pediatric neurology + orthopedic consult; brachial plexus assessment (Erb/Klumpke/complete); PT planning. If palpable crepitus / asymmetric arm position: neonatal XR of clavicle / humerus (not routine). If HIE criteria (pH ≤ 7.0 OR BE ≤ -16 OR 10-min Apgar ≤ 5 OR sentinel hypoxic event + moderate-severe encephalopathy on Sarnat): therapeutic hypothermia within 6 h; NICU + neuroprotection sub-engine. If maternal PPH > 500 mL: TXA + uterotonics + laceration repair; if > 1500 mL or DIC features: MTP. If PROM + chorio features (fever + Higgins 2016 secondary criteria): ampicillin + gentamicin per ACOG CO 712.
    advance: Injury pattern + maternal/neonatal trajectory characterised
  7. 7DIFFERENTIAL
    Differential during dystocia: normal delivery with momentary delay (resolves with next contraction + maternal effort, no turtle sign), breech presentation dystocia (head entrapment in breech — separate pathway), face/brow presentation entrapment (different mechanism — head not fully emerged). Differential post-delivery for neonatal injury: BPI (asymmetric arm + absent Moro) vs neonatal stroke (asymmetric movement but different pattern) vs congenital muscular torticollis (later) vs hemorrhagic stroke vs septic arthritis (later infectious). Differential for maternal injury: dystocia-related laceration vs uterine rupture (loss of station + severe pain + abnormal contractions; routes to ob.uterine-rupture.v1) vs uterine inversion (rare; uterotonic + replacement maneuver).
    advance: Mimics excluded or co-managed
  8. 8RISK_STRATIFICATION
    Tier by maneuver level reached + head-to-body interval + neonatal injury + maternal injury + recurrence-history. Tier 1: McRoberts-only resolved < 60 s no injury — standard debrief + recurrence counseling. Tier 2: +suprapubic / +rotational / +posterior arm 60-300 s ± mild injury (clavicle fx / BPI Erb) — full debrief + neonatal neuro + PT consult + subsequent-pregnancy cesarean counseling. Tier 3: +Gaskin / Zavanelli / symphysiotomy > 300 s + HIE / complete plexus / demise — multidisciplinary critical care + NICU + therapeutic hypothermia + medicolegal + psychological support.
    inputs: time_of_head_delivery, maternal_bp, maternal_hr, prior_shoulder_dystocia_history
    actions: calc.qsofa
    advance: Maneuver level + injury tier + recurrence-counseling tier documented
  9. 9TREATMENT
    HELPERR sequence — Help / Episiotomy-for-room / Legs-McRoberts (first-line; resolves 40-60% alone) / Pressure-suprapubic (combined ~ 60-80%) / Enter-rotational (Rubin II / Woods corkscrew / reverse Woods) / Remove-posterior-arm (most effective rescue; elevated BPI risk) / Roll-Gaskin (all-fours). Each maneuver ~ 30 s without progress → escalate. If all HELPERR + posterior arm + Gaskin fail → Zavanelli (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only). Post-delivery: uterotonic infusion (oxytocin); TXA if EBL > 500 mL (within 3 h of birth per WOMAN 2017); laceration repair; MTP if EBL > 1500 mL (1:1:1 PRBC:FFP:platelets per Pacheco SMFM 47 2019); cryoprecipitate if fibrinogen < 200. Neonatal: immediate exam (BPI/fracture screen); cord gases; Apgar; therapeutic hypothermia if criteria (within 6 h; Shankaran NEJM 2005); NICU coordination; pediatric neuro + orthopedic consult if injury. Avoid excessive lateral / downward fetal head traction (BPI risk). Avoid fundal pressure (worsens impaction).
    inputs: time_of_head_delivery, anterior_shoulder_side_left_or_right
    advance: HELPERR sequence executed with response documented; delivery completed; post-delivery surveillance active
  10. 10DISPOSITION
    Maternal: mother-baby unit if uncomplicated; OB step-down if extended episiotomy / 3rd-/4th-degree laceration / significant PPH; ICU if MTP or hemodynamic instability. Neonatal: nursery if no injury; NICU if BPI / fracture / HIE / Apgar concern; therapeutic hypothermia in NICU if criteria. Multidisciplinary debrief within 24 h: maternal + family empathic disclosure; psychological support; medicolegal documentation finalised; team simulation feedback loop.
    inputs: maternal_bp, maternal_spo2
    advance: Maternal + neonatal level of care set; debrief scheduled; documentation finalised
  11. 11MONITORING
    Maternal: vitals q15 min × 2 h then q1 h × 4 h then q4 h × 24 h; fundal tone q15 min × 2 h (atony surveillance — dystocia is known atony risk); lochia + perineal exam; pain control; psychological monitoring (peripartum PTSD risk). Neonatal: continuous monitoring per NRP; BPI exam serial (arm symmetry + Moro + grasp); cord gas + Apgar trended; if therapeutic hypothermia in progress — continuous core temperature 33.5°C + EEG + neuroimaging; if BPI — PT engagement starting at 2-3 wks; if clavicle fx — gentle handling + immobilisation as needed.
    inputs: maternal_bp, maternal_hr, maternal_cbc_with_diff_baseline
    actions: panel.cbc, panel.coag
    advance: Maternal stable + Hgb stable × 6 h + appropriate lochia + neonatal evaluation complete + PT/ortho/neuro followup arranged if injury
  12. 12FOLLOWUP
    6-wk postpartum visit + dystocia-specific anticipatory guidance: recurrence ~ 12% (cesarean for prior severe / BPI / macrosomia recurrence — EFW ≥ 5000 g non-diabetic OR ≥ 4500 g diabetic); mental health screen (EPDS for PPD; PCL-5 for peripartum PTSD — dystocia is a known PTSD trigger); contraception counseling; immunization review. If BPI: PT continued; ortho/neuro followup at 1 + 3 + 6 mo; surgical exploration / repair consideration at 3-6 mo if no recovery; ~ 90% resolve by 1 year. If clavicle/humerus fx: pediatric ortho; usually heals without intervention. If HIE: pediatric neurology + developmental tracking; therapeutic hypothermia outcomes assessment at 18-22 mo per Shankaran NEJM 2005. Preconception MFM consultation for next pregnancy (timing + delivery mode planning). Simulation team feedback loop closed.
    advance: Postpartum visit complete; future-pregnancy counseling delivered; PT/ortho/neuro/developmental followups in place; mental health screened