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ob.shoulder-dystocia.v1

Shoulder Dystocia

obstetricsacuteadultpregnancy
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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.

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EFW + risk factor profile + setting tagged

Patient inputs (24)

Tachypnea > 22 — maternal stress / pain / hypovolemia

Hypoxemia raises suspicion for amniotic fluid embolism (mimic — sudden hypoxia + hypotension + DIC at delivery)

Diabetes is a major risk factor (disproportionate truncal growth); changes EFW cesarean threshold from 5000 g to 4500 g

Recurrence ~ 12%; cesarean recommended for prior severe dystocia / BPI / macrosomia recurrence (ACOG PB 178 2017)

Term ≥ 37 wk most common; ≥ 41 wk post-term elevated risk; preterm dystocia rare

EFW ≥ 4500 g (diabetic) OR ≥ 5000 g (non-diabetic) is the anticipatory cesarean threshold; EFW elevation drives team huddle + simulation readiness

Baseline hemoglobin + serial trend if PPH cascade (dystocia → atony + laceration PPH is common)

Type & screen on admission; crossmatch ≥ 2 units PRBC if active PPH after delivery; MTP activation if EBL > 1500 mL (Pacheco SMFM 47 2019)

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

Apgar at 1, 5, 10 min; 10-min Apgar ≤ 5 is a therapeutic hypothermia criterion

Hemodynamic baseline — dystocia → PPH cascade is common; hypotension is a hemorrhagic-shock flag

Tachycardia > 110 disproportionate to bleed is a concealed-PPH or maternal stress flag

Critical medicolegal atom; head-to-body interval clock starts at head delivery; HIE risk rises sharply > 5 min

Critical medicolegal atom; documents which shoulder was impacted; informs BPI side prediction

XR if palpable crepitus or asymmetric arm position concerning for clavicle / humerus fracture; not routine

Pre-dystocia FHR baseline; during dystocia FHR not accessible; post-delivery neonatal HR per NRP

Compare prior birthweights to current EFW — recurrence risk highest when current EFW ≥ prior dystocia EFW

BMI ≥ 30 is independent risk factor ~ 1.5-2x baseline

Short maternal stature is a small independent risk factor; pelvic dimensions correlate

Prolonged 2nd stage of labor with head descent but no further progress is a risk factor

Forceps / vacuum ~ 1.5-2x baseline dystocia risk; informs team readiness

PROM ± chorio is antecedent risk factor; routes to ob.chorioamnionitis.v1 if fever + secondary criteria emerge

DIC surveillance if PPH cascade or AFE mimic; fibrinogen target ≥ 200 mg/dL

Confirm EFW antepartum + during admission if not recently estimated; informs anticipatory planning + cesarean threshold

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningshoulder_dystocia_at_recognition
    Shoulder dystocia at recognition — turtle sign + failed axial-traction delivery of anterior shoulder — life-threatening obstetric emergency; immediate call for help + start clock + HELPERR sequence (Help / Episiotomy-for-room / Legs-McRoberts / Pressure-suprapubic / Enter-rotational / Remove-posterior-arm / Roll-Gaskin); each maneuver ~ 30 s without progress → escalate; do NOT perseverate on failed maneuvers; clock-time documentation mandatory for medicolegal
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningprolonged_head_to_body_interval_5min
    Head-to-body interval > 5 min — life-threatening; HIE risk rises sharply as cord pH falls ~ 0.04 per min after head delivery; all HELPERR + posterior arm + Gaskin failed → expedite delivery via Zavanelli (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only); emergent peds team for neonatal resuscitation; therapeutic hypothermia evaluation if HIE criteria met
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningzavanelli_or_symphysiotomy_last_resort
    Zavanelli maneuver (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only) — life-threatening last resort; all HELPERR + posterior arm + Gaskin maneuvers have failed + head-to-body interval approaching or exceeding 5 min; very high complication rate; case-series data only; symphysiotomy used only in LMIC where cesarean unavailable (significant maternal morbidity); cleidotomy (intentional fetal clavicle fracture) reserved for fetal demise
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghypoxic_ischemic_encephalopathy_post_delivery
    Neonatal hypoxic-ischemic encephalopathy (HIE) post-shoulder dystocia — life-threatening; criteria ≥ 36 wk GA + (cord pH ≤ 7.0 OR base excess ≤ -16 OR 10-min Apgar ≤ 5 OR sentinel hypoxic event including prolonged dystocia > 5 min head-to-body) + moderate-severe encephalopathy on Sarnat staging → therapeutic hypothermia within 6 h (whole-body cooling to 33.5°C × 72 h then controlled rewarming); reduces death + major neurodevelopmental disability NNT ~ 9; NICU + neuroprotection sub-engine; continuous EEG + neuroimaging at completion; developmental tracking through 18-22 mo
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneonatal_brachial_plexus_injury
    Neonatal brachial plexus injury (BPI) — Erb's palsy C5-C6 (most common; arm internally rotated + adducted + elbow extended + wrist flexed) vs Klumpke C8-T1 (intrinsic hand weakness + claw hand) vs complete plexus injury (flail arm) — severe; immediate post-delivery neurologic exam mandatory (arm symmetry + Moro + grasp + spontaneous movement); pediatric neurology + orthopedic consult; PT engagement starting at 2-3 wks; ~ 90% resolve by 1 year; ~ 10% persistent → surgical exploration / repair consideration at 3-6 mo if no recovery; subsequent pregnancy cesarean recommended
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_shoulder_dystocia_next_pregnancy
    Prior shoulder dystocia in prior pregnancy — severe future-pregnancy risk; recurrence ~ 12% (range 6-25%); ACOG PB 178 2017 + RCOG GTG 42 2012 recommend cesarean for prior severe dystocia / BPI in prior delivery / suspected macrosomic recurrence (EFW ≥ 5000 g non-diabetic OR EFW ≥ 4500 g diabetic); preconception MFM counseling + serial growth US + glycemic optimisation if diabetic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_hemorrhage_after_shoulder_dystocia
    Postpartum hemorrhage after shoulder dystocia — severe; dystocia is a known atony + laceration PPH antecedent (~ 11-19% incidence); uterotonic ladder (oxytocin → carboprost if no asthma → methylergonovine if no HTN → misoprostol) + TXA within 3 h + laceration repair; if EBL > 1500 mL OR DIC features → MTP 1:1:1 PRBC:FFP:platelets + cryoprecipitate (Pacheco SMFM 47 2019); B-Lynch / uterine artery ligation / hysterectomy if uncontrolled; routes to ob.postpartum-hemorrhage.core.v1 with dystocia carryover
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateneonatal_clavicle_or_humerus_fracture
    Neonatal clavicle fracture (~ 1-10%) or humerus fracture (< 1%) — moderate; palpate clavicles for crepitus + asymmetric position; XR if concern; usually heals without intervention; immobilisation (e.g., pinning sleeve to shirt for arm) for humerus fracture; clavicle fracture: gentle handling + clavicle pad; pediatric orthopedic followup
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildgdm_or_macrosomia_anticipatory_planning
    GDM / DM2 + EFW ≥ 4500 g OR EFW ≥ 5000 g (non-diabetic) at admission — mild (anticipatory tier; not yet emergent); antepartum risk stratification + multidisciplinary team huddle + simulation-trained team readiness check; consider elective cesarean per ACOG PB 178 2017 EFW thresholds; serial growth US + glycemic control if diabetic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsimulation_training_team_readiness
    Multidisciplinary simulation training + drills + PROMPT or ALSO curriculum — mild (system-level quality improvement; not patient-level emergent); ACOG PB 178 2017 strong recommendation + RCOG GTG 42 2012 mandate q6 mo drills for L&D teams; multidisciplinary simulation reduces incidence + improves outcomes including BPI rates; system audit + team feedback loop
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute shoulder dystocia — HELPERR sequence + post-delivery PPH surveillance + neonatal neuroprotection (ACOG PB 178 2017 + RCOG GTG 42 2012 + Shankaran NEJM 2005 + Pacheco SMFM 47 2019)
axis: shoulder_dystocia_acute_managementstep helperr_sequence_initiation - HELPERR sequence initiation — Help + Episiotomy-for-room + Legs-McRoberts + Pressure-suprapubic (ACOG PB 178 2017)
Selected step "HELPERR sequence initiation — Help + Episiotomy-for-room + Legs-McRoberts + Pressure-suprapubic (ACOG PB 178 2017)" — Turtle sign + failed axial-traction delivery of anterior shoulder

outpatient playbook — drug actions (5)

  1. 1. iron repletion if postpartum anemia
    rxcui 24947
    Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant • PO/IV • TID PO or per infusion protocol
    trigger: Postpartum Hgb < 11 g/dL after dystocia-related PPH
    Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance)
  2. 2. contraception
    Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.) • PO/IM/implant/IUD • per agent
    trigger: Patient request + medical eligibility
    Avoid short interpregnancy interval; ACOG MEC
  3. 3. antidiabetic optimisation if diabetic
    Per endocrine team — metformin, insulin per glycemic targets • PO/SC • per agent
    trigger: Persistent diabetes postpartum (DM2 conversion from GDM or pre-existing)
    Glycemic control reduces macrosomia + dystocia recurrence in next pregnancy
  4. 4. influenza + COVID + Tdap vaccines per ACIP
    Per ACIP • IM • per schedule
    trigger: Postpartum
    Standard ACIP recommendations
  5. 5. acetaminophen / NSAIDs for pain
    rxcui 161
    Acetaminophen 650-1000 mg PO q6h PRN OR ibuprofen 400-600 mg PO q6h PRN • PO • q6h PRN
    trigger: Persistent perineal / pelvic pain
    NSAIDs acceptable postpartum (vs antepartum where avoided)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Turtle sign at vaginal delivery — fetal head retracts against perineum after crowning; defining feature of shoulder dystocia (ACOG PB 178 2017); Failure of normal axial-traction delivery of the anterior shoulder after the head has emerged — defining feature of shoulder dystocia (ACOG PB 178 2017); Estimated fetal weight ≥ 4500 g (diabetic) OR ≥ 5000 g (non-diabetic) at delivery — anticipatory cesarean indication per ACOG PB 178 2017.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Shoulder Dystocia** (ob.shoulder-dystocia.v1).
Phenotype framing: 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).
Scope: 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.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute shoulder dystocia — HELPERR sequence + post-delivery PPH surveillance + neonatal neuroprotection (ACOG PB 178 2017 + RCOG GTG 42 2012 + Shankaran NEJM 2005 + Pacheco SMFM 47 2019)** — step "HELPERR sequence initiation — Help + Episiotomy-for-room + Legs-McRoberts + Pressure-suprapubic (ACOG PB 178 2017)".

Setting playbook (outpatient) — Routine 6-wk postpartum visit + dystocia-specific anticipatory guidance: recurrence ~ 12%; cesarean for prior severe / BPI / macrosomia recurrence in next pregnancy; BPI followup with PT + ortho/neuro; mental health screen (peripartum PTSD); preconception counseling. Neonate: developmental tracking if HIE / BPI; ortho/neuro followups
1. iron repletion if postpartum anemia Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant PO/IV TID PO or per infusion protocol — Postpartum Hgb < 11 g/dL after dystocia-related PPH (Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance))
2. contraception Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.) PO/IM/implant/IUD per agent — Patient request + medical eligibility (Avoid short interpregnancy interval; ACOG MEC)
3. antidiabetic optimisation if diabetic Per endocrine team — metformin, insulin per glycemic targets PO/SC per agent — Persistent diabetes postpartum (DM2 conversion from GDM or pre-existing) (Glycemic control reduces macrosomia + dystocia recurrence in next pregnancy)
4. influenza + COVID + Tdap vaccines per ACIP Per ACIP IM per schedule — Postpartum (Standard ACIP recommendations)
5. acetaminophen / NSAIDs for pain Acetaminophen 650-1000 mg PO q6h PRN OR ibuprofen 400-600 mg PO q6h PRN PO q6h PRN — Persistent perineal / pelvic pain (NSAIDs acceptable postpartum (vs antepartum where avoided))

Non-pharmacologic actions:
- Mental health counseling / therapy if EPDS ≥ 10 or PCL-5 elevated (dystocia is known peripartum PTSD trigger)
- PT continued for BPI (engagement starting 2-3 wks); home exercises + ROM
- Lactation continued support if breastfeeding (compatible with all dystocia-related medications per LactMed)
- Postpartum exercise progression per ACOG
- Future-pregnancy preconception counseling — 18+ mo interpregnancy interval; optimise glycemic control if diabetic; serial growth US + cesarean criteria review
- Pediatric follow-up coordination for high-risk newborn — 24-48 h post-discharge peds visit, then 1 wk + 1 mo developmental + immunization tracking
- BPI-specific peds neuro + ortho followup; surgical exploration consideration at 3-6 mo if no recovery
- HIE-specific developmental tracking through 18-22 mo per Shankaran NEJM 2005 framework
- Empathic family support + psychological care after catastrophic events

AVOID / contraindication checks:
- No excessive lateral or downward traction on fetal head BPI risk (ACOG PB 178 2017 + RCOG GTG 42 2012)
- No fundal pressure worsens impaction (ACOG PB 178 2017 + RCOG GTG 42 2012)
- Routine episiotomy not recommended only for room during rotational maneuvers (ACOG PB 178 2017)
- Document time of head recognition maneuvers response body delivery anterior shoulder force cord gases Apgar neonatal exam (ACOG PB 178 2017 + RCOG GTG 42 2012; medicolegal anchor)
- Do NOT perseverate on failed maneuver escalate 30s windows (ACOG PB 178 2017)
- Carboprost contraindicated in asthma (ACOG PB 183 2017)
- Methylergonovine contraindicated in hypertension or preeclampsia (ACOG PB 183 2017)
- Tranexamic acid within 3 hours of birth only (WOMAN 2017 PMID 28456509)
- Massive transfusion 1to1to1 PRBC FFP platelets with cryo for fibrinogen lt 200 (Pacheco SMFM 47 2019 PMID 30447216 — NEEDS_SOURCE_REVIEW, unverified 2026 05 25)
- Therapeutic hypothermia initiate within 6h of birth if criteria met (Shankaran NEJM 2005 PMID 16221780)
- Elective cesarean EFW ge 5000g non diabetic or ge 4500g diabetic (ACOG PB 178 2017)
- Cesarean for prior severe shoulder dystocia or BPI or macrosomia recurrence (ACOG PB 178 2017)
- Simulate q6mo multidisciplinary drills PROMPT or ALSO curriculum (ACOG PB 178 2017 strong recommendation + RCOG GTG 42 2012)

Monitoring

Regimen monitoring:
- Time of head delivery + time of recognition + each maneuver attempt + response + time of body delivery (medicolegal atoms — mandatory)
- Anterior shoulder side (left or right) documented
- Force applied during maneuvers documented (avoid excessive lateral/downward traction)
- Umbilical cord gases (artery + vein) at delivery — pH + BE for HIE criteria
- Apgar scores at 1, 5, 10 min
- Immediate neonatal exam — arm symmetry + Moro + grasp + spontaneous movement (BPI screen)
- Palpate clavicles for crepitus; XR if concern
- Maternal vitals q15 min × 2 h then q1 h × 4 h then q4 h × 24 h
- Fundal tone q15 min × 2 h postpartum (atony surveillance — dystocia is known risk)
- Lochia + perineal exam + pain control
- Maternal CBC + coag q4-6 h if PPH cascade
- Newborn handoff: dystocia + maneuvers reached + injuries identified + cord gases + Apgar → peds/NICU
- If BPI: PT engagement at 2-3 wks; ortho/neuro followup at 1+3+6 mo
- If HIE: continuous core temperature 33.5°C × 72 h if therapeutic hypothermia in progress; EEG; neuroimaging at completion
- Maternal mental health screen at discharge + 6 wk (peripartum PTSD risk after dystocia)
- Multidisciplinary debrief within 24 h: documentation finalised + simulation feedback loop + empathic family disclosure + psychological support

Setting (outpatient) monitoring:
- 6-wk postpartum visit; additional visit at 1-2 wk if extended episiotomy / 3rd-/4th-degree laceration / cesarean wound concern
- Newborn outpatient peds at 24-48 h then 1 wk then 1 mo then per developmental schedule
- Maternal mental health re-screen at 6 wk + 3 mo + 6 mo (peripartum PTSD risk)
- BPI ped neuro + ortho followup at 1 + 3 + 6 mo + 1 yr
- HIE developmental tracking at 4, 12, 18-22 mo per Shankaran framework
- Future-pregnancy preconception visit when contemplated
- Glycemic optimisation followup if diabetic

Follow-up plan: 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.
- Close-out criterion: Postpartum visit complete; future-pregnancy counseling delivered; PT/ortho/neuro/developmental followups in place; mental health screened

Monitoring phase: 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.

Disposition

Current setting: outpatient — Routine 6-wk postpartum visit + dystocia-specific anticipatory guidance: recurrence ~ 12%; cesarean for prior severe / BPI / macrosomia recurrence in next pregnancy; BPI followup with PT + ortho/neuro; mental health screen (peripartum PTSD); preconception counseling. Neonate: developmental tracking if HIE / BPI; ortho/neuro followups

Disposition criteria:
- Resolution: 6-wk postpartum visit complete, mental health stable, contraception in place, immunizations up to date, BPI/HIE/fracture followups arranged, newborn developmental tracking ongoing → discharge from dystocia-specific surveillance back to routine primary care + preconception planning with MFM referral for next pregnancy

Escalation triggers (move to higher acuity):
- Postpartum bleeding / persistent uterine tenderness / foul lochia → endometritis or retained products workup (ED visit)
- New mental health crisis (PHQ-9 ≥ 15 or PCL-5 elevated with suicidal ideation) → urgent mental health referral
- BPI no recovery at 3-6 mo → surgical exploration consideration; ped neuro / ortho urgent visit
- HIE developmental concerns → urgent peds neurology evaluation
- Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns, asymmetric arm persistence) → urgent peds visit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Shoulder dystocia at recognition — turtle sign + failed axial-traction delivery of anterior shoulder — life-threatening obstetric emergency; immediate call for help + start clock + HELPERR sequence (Help / Episiotomy-for-room / Legs-McRoberts / Pressure-suprapubic / Enter-rotational / Remove-posterior-arm / Roll-Gaskin); each maneuver ~ 30 s without progress → escalate; do NOT perseverate on failed maneuvers; clock-time documentation mandatory for medicolegal
- [LIFE_THREATENING] Head-to-body interval > 5 min — life-threatening; HIE risk rises sharply as cord pH falls ~ 0.04 per min after head delivery; all HELPERR + posterior arm + Gaskin failed → expedite delivery via Zavanelli (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only); emergent peds team for neonatal resuscitation; therapeutic hypothermia evaluation if HIE criteria met
- [LIFE_THREATENING] Zavanelli maneuver (cephalic replacement + emergent cesarean) OR symphysiotomy (LMIC only) — life-threatening last resort; all HELPERR + posterior arm + Gaskin maneuvers have failed + head-to-body interval approaching or exceeding 5 min; very high complication rate; case-series data only; symphysiotomy used only in LMIC where cesarean unavailable (significant maternal morbidity); cleidotomy (intentional fetal clavicle fracture) reserved for fetal demise

Citations

- ACOG Practice Bulletin 178 (2017, reaffirmed 2024) — Shoulder Dystocia + RCOG Green-top Guideline 42 (2012, in-force reaffirmed) — Shoulder Dystocia + Gherman 1997 McRoberts methodology (PMID 9077624) + Bruner 1998 Gaskin all-fours maneuver (J Reprod Med 1998; 43(5): 439-443; PMID 9610468) + Gurewitsch AJOG 2006 Posterior arm delivery (PMID 17077244 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) + Shankaran NEJM 2005 Therapeutic hypothermia for HIE (PMID 16221780) + Pacheco LD et al SMFM Consult Series 47 (2019) Massive transfusion in pregnancy (PMID 30447216 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) — carryover for PPH-after-dystocia overlap + WOMAN trial Shakur 2017 (PMID 28456509) — TXA in PPH carryover + ACOG PB 183 2017 — PPH uterotonic ladder + ACOG PB 190 2018 — GDM anticipatory planning + WHO 2017 Managing complications in pregnancy and childbirth — symphysiotomy LMIC framework + Higgins 2016 (PMID 26855098) — chorio overlap carryover [PMID:9077624](https://pubmed.ncbi.nlm.nih.gov/9077624/)
- Cited evidence (PMID 9610468) [PMID:9610468](https://pubmed.ncbi.nlm.nih.gov/9610468/)
- Cited evidence (PMID 17077244) [PMID:17077244](https://pubmed.ncbi.nlm.nih.gov/17077244/)
- Cited evidence (PMID 16221780) [PMID:16221780](https://pubmed.ncbi.nlm.nih.gov/16221780/)
- Cited evidence (PMID 17012465) [PMID:17012465](https://pubmed.ncbi.nlm.nih.gov/17012465/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG Practice Bulletin 178 (2017, reaffirmed 2024) — Shoulder Dystocia + RCOG Green-top Guideline 42 (2012, in-force reaffirmed) — Shoulder Dystocia + Gherman 1997 McRoberts methodology (PMID 9077624) + Bruner 1998 Gaskin all-fours maneuver (J Reprod Med 1998; 43(5): 439-443; PMID 9610468) + Gurewitsch AJOG 2006 Posterior arm delivery (PMID 17077244 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) + Shankaran NEJM 2005 Therapeutic hypothermia for HIE (PMID 16221780) + Pacheco LD et al SMFM Consult Series 47 (2019) Massive transfusion in pregnancy (PMID 30447216 — NEEDS_SOURCE_REVIEW, unverified 2026-05-25) — carryover for PPH-after-dystocia overlap + WOMAN trial Shakur 2017 (PMID 28456509) — TXA in PPH carryover + ACOG PB 183 2017 — PPH uterotonic ladder + ACOG PB 190 2018 — GDM anticipatory planning + WHO 2017 Managing complications in pregnancy and childbirth — symphysiotomy LMIC framework + Higgins 2016 (PMID 26855098) — chorio overlap carryover — PMID:9077624
  • Cited evidence (PMID 9610468) — PMID:9610468
  • Cited evidence (PMID 17077244) — PMID:17077244
  • Cited evidence (PMID 16221780) — PMID:16221780
  • Cited evidence (PMID 17012465) — PMID:17012465