O&G SAQs · Intrapartum care — obstetric emergencies
Shoulder dystocia — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on shoulder dystocia: the first 60 seconds, the manoeuvre ladder with technique, the two contraindicated actions, and the medico-legal record after a brachial plexus injury. Per-sub-part marking rubric included.
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Prompt
You are the on-call registrar. A 33-year-old G2P1 with diet-controlled gestational diabetes has a spontaneous vaginal birth at 40+3 weeks after a 9-hour labour augmented with oxytocin. The head delivers at 04:12, retracts against the perineum and does not restitute. Gentle axial traction with the next contraction fails to deliver the shoulders. Her first baby weighed 4.1 kg and was delivered by vacuum. (a) Outline your management in the first 60 seconds, giving the reasoning for each step. (5 marks) (b) The shoulders remain impacted. Describe, with technique, the manoeuvres you would perform next and the order in which you would perform them. (5 marks) (c) State two actions that are contraindicated and justify each. (2 marks) (d) The baby is delivered at 04:16 with a flail right arm. List what your contemporaneous record must contain. (3 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. Marks come from specifics: the named manoeuvre, the direction of the hand, the reason, the time. Write labelled points, not prose. Answer the sub-part you were asked. [1]
Reveal model answer and mark schemeShowHide
(a) The first 60 seconds (5 marks)
One mark per point with its reasoning, maximum five. [1][3]
- Declare it and note the time. Say "shoulder dystocia" out loud and record 04:12 as the time of delivery of the head. The interval is the clock everything else is judged against.[1][4]
- Call for help by name and role — senior obstetrician, senior midwife, anaesthetist, neonatal resuscitation team — and allocate a scribe and a timekeeper. Trained teams with recorded manoeuvres have lower injury rates.[3]
- Stop maternal pushing and lie her flat with the buttocks to the edge of the bed. Continued expulsive effort drives the anterior shoulder harder onto the symphysis, and you cannot perform McRoberts on a propped-up woman.[1]
- McRoberts — an assistant on each leg, thighs hyperflexed onto the abdomen. This rotates the symphysis cephalad and straightens the sacrum; it does not enlarge the pelvis.[1]
- Suprapubic pressure from the side of the fetal back, heel of the hand just above the symphysis, directed downwards and obliquely toward the fetal chest — continuous, then rocking. This adducts the shoulder girdle into the oblique diameter.[1][5]
Reasoning marks are awarded for explaining the mechanism, not just naming the step. A mark is also available for noting that her previous 4.1 kg vacuum birth and gestational diabetes made this a predictable but unpreventable event. [7]
(b) The next manoeuvres, with technique (5 marks)
One mark each for episiotomy assessment, internal rotation, posterior arm, all-fours, and an explicit statement about escalation and last-resort manoeuvres. [1][2]
| Step | Technique | Why |
|---|---|---|
| Evaluate for episiotomy | Cut or extend only if you need room for your hand | It does not move bone; it makes space for internal manoeuvres |
| Rubin II | Two fingers behind the anterior shoulder, push it toward the fetal chest | Adducts the girdle, narrows the bisacromial diameter, rotates into the oblique |
| Woods screw | Fingers in front of the posterior shoulder, rotate in a corkscrew arc; combine with Rubin II in the same direction | Rotates the shoulders out of the anteroposterior plane |
| Delivery of the posterior arm | Follow the posterior humerus to the antecubital fossa, flex the elbow, sweep the forearm across the chest and out | Highest resolution rate of any manoeuvre (84.4%); humeral fracture is an acceptable trade |
| All-fours (Gaskin) | Roll her onto hands and knees, then repeat rotation or posterior arm | Changes sacral position and frees the now-uppermost posterior shoulder |
- Escalate rather than repeat. Each additional manoeuvre correlates with a higher injury rate, so change manoeuvre instead of repeating a failed one.[2]
- Name the last-resort options for the final mark: posterior axilla sling traction, cleidotomy, Zavanelli cephalic replacement with tocolysis and immediate caesarean, abdominal rescue, symphysiotomy. State that these are senior-led and carry major morbidity.[1]
- Enter posteriorly, into the sacral hollow — the only space the pelvis lends you.[2]
(c) Two contraindicated actions (2 marks)
One mark each. Both must carry a justification. [1][6]
- Fundal pressure. It drives the impacted shoulder harder against the symphysis, has been associated with uterine rupture, and significantly increased severe perineal laceration in a prospective series (odds ratio 2.71), with synergistic harm alongside vacuum and episiotomy.[6]
- Lateral traction that flexes the fetal neck, or rotating the head to rotate the body. This is the mechanism of brachial plexus injury. Traction must be axial, along the line of the fetal spine, applied with a contraction.[1][3]
(d) The contemporaneous record (3 marks)
One mark per group of three items, maximum three. Marks are lost for a record without times. [1][3]
- Times: time of delivery of the head (04:12), time of delivery of the body (04:16), the calculated head-to-body interval, and the time each staff member arrived.
- Mechanism: which shoulder was anterior, every manoeuvre in order with its own time and the person who performed it, and a description in words of the traction used (routine axial traction, applied with contractions).
- Outcome and aftercare: episiotomy performed or not, paired cord gases, Apgar scores, birth weight, the paediatric examination findings for the flail arm, maternal genital tract inspection and quantitative blood loss, and the explanation given to the parents with the time it was given.[1][4]
A bonus-credit answer adds: complete the unit shoulder dystocia proforma, submit an incident report, and book the follow-up appointment. [3]
References7ShowHide
- [1]American College of Obstetricians and Gynecologists Practice Bulletin No 178: Shoulder Dystocia Obstet Gynecol, 2017.PMID 28426618
- [2]Hoffman MK, Bailit JL, Branch DW, et al. A comparison of obstetric maneuvers for the acute management of shoulder dystocia Obstet Gynecol, 2011.PMID 21555962
- [3]Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training Obstet Gynecol, 2008.PMID 18591302
- [4]Leung TY, Stuart O, Sahota DS, et al. Head-to-body delivery interval and risk of fetal acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a retrospective review BJOG, 2011.PMID 21199293
- [5]Lok ZL, Cheng YK, Leung TY, et al. Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study BMC Pregnancy Childbirth, 2016.PMID 27793109
- [6]Matsuo K, Shiki Y, Yamasaki M, et al. Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration Arch Gynecol Obstet, 2009.PMID 19263062
- [7]Jeppegaard M, Larsen MH, Thams AB, et al. Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study Acta Obstet Gynecol Scand, 2024.PMID 38409800