Shoulder dystocia — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response — say it in this order, out loud: ^[1][5]

• "This is a shoulder dystocia. I am declaring it and noting the time of delivery of the head now."
• "I would call for help by name: the obstetric consultant, the senior midwife, the anaesthetist and the neonatal resuscitation team. I want a scribe and a timekeeper, and I will call out each manoeuvre as I do it."
• "I would ask the mother to stop pushing, flatten the bed and bring her buttocks to the edge."
• "Two assistants, one leg each, into McRoberts. Then suprapubic pressure from the side of the fetal back, downward and oblique. Routine axial traction with the next contraction."^[1]

Examiner is listening for: the words said out loud, the time noted, named roles, and the mother instructed to stop pushing before any manoeuvre. ^[5]

Probe 1 — "The student midwife starts to push on the fundus. What do you do?"

• Stop it immediately and out loud, without humiliating her: "Thank you — no fundal pressure please. Move to her left leg and hold it in hyperflexion for me."^[1]
• Justify it: "Fundal pressure drives the impacted shoulder harder onto the symphysis. It has been associated with uterine rupture, and in a prospective series it significantly increased severe perineal laceration, with an odds ratio of 2.71 and a synergistic effect alongside vacuum and episiotomy."^[6]
• This is a rapport-and-respect domain probe as much as a knowledge probe. Correct the action, keep the person. ^[5]

Probe 2 — "McRoberts and suprapubic pressure have not worked. Ninety seconds have passed."

• "I would evaluate for an episiotomy — not to relieve the impaction, which is bony, but to make room for my hand."^[1]
• "I would go internal, entering posteriorly into the sacral hollow. Rubin II first: two fingers behind the anterior shoulder, pushing it toward the fetal chest to adduct the girdle. Then Woods screw: fingers in front of the posterior shoulder, rotating in a corkscrew arc, combining the two in the same direction."^[1][2]
• "If rotation fails I would deliver the posterior arm: follow the humerus to the antecubital fossa, flex the elbow, sweep the forearm across the chest and out. In the Consortium on Safe Labor data that had the highest resolution rate of any manoeuvre at 84.4%, and I accept the risk of a humeral fracture because an arm heals."^[2]

Probe 3 — "Why not just try McRoberts again? It is the least invasive thing you can do."

• "Because repeating a failed manoeuvre spends time without changing the mechanics. In the Consortium on Safe Labor analysis the total number of manoeuvres performed correlated significantly with neonatal injury, so the safe strategy is to change manoeuvre rather than repeat one."^[2]
• "And the interval matters. Cord arterial pH falls about 0.011 units per minute. Under five minutes, severe acidosis and encephalopathy each occurred in 0.5%; at five minutes or more those were 5.9% and 23.5%."^[3]
• "But I would not turn that into 'pull harder to beat the clock'. In Lerner's series every uncomplicated dystocia had delivered by four minutes — a well-run sequence gets there without force."^[4]

Probe 4 — "The baby is delivered at four minutes with a flail right arm. The mother is crying and asks if her baby is paralysed."

This is scored under rapport, respect and communication. Demonstrate it out loud. ^[1]

• Hand the baby to the neonatal team, then go to the mother's eye level and use her name. Do not conduct this conversation over your shoulder.
• "Your baby's shoulder was stuck and we had to use several manoeuvres to free him. The nerves that work his right arm have been stretched, which is why the arm is floppy right now."
• "Most babies with this recover completely. The physiotherapists will see him before you go home. If the arm has not recovered by about three months we refer to a specialist nerve service — but the majority never need that."
• "I am going to write all of this down now, and I will come back later today to go through it again properly with you both."^[1][5]

Probe 5 — "What must your record contain?"

• Time of delivery of the head, time of delivery of the body, and the interval.
• Which shoulder was anterior — the fact everyone forgets and every expert report asks for.
• Every manoeuvre in order, with the time and the operator for each.
• The traction described in words: routine axial traction applied with contractions.
• Who was present and when they arrived; whether an episiotomy was performed.
• Paired cord gases, Apgar scores, birth weight, the paediatric examination.
• Maternal genital tract inspection and quantitative blood loss.
• The explanation given to the parents and the time it was given, plus the incident report and unit proforma.^[1][5]

Probe 6 — "She asks about her next pregnancy."

• "Your risk of it happening again is higher than average — about 7 in 100, roughly three times the background risk after adjustment. But most women who have had a shoulder dystocia go on to have a normal vaginal birth; in the largest register cohort 78% of them did."^[7]
• "What we can influence: your blood sugars if you develop gestational diabetes, keeping an eye on the baby's growth, and having a senior clinician at the birth with a plan already written down."^[7]
• "If this arm does not recover, that changes the conversation and a planned caesarean becomes a reasonable choice. We will make that decision together, with the numbers in front of us."^[1][7]