It is an obstetric emergency and should be handled by an experienced obstetrician. Timely management of shoulder dystocia requires prompt recognition. Head to body delivery interval should be within 5 minutes to reduce hypoxic-ischaemic encephalopathy. Features that may be noted include

• Difficulty delivering face and chin
• The head remaining tightly applied to vulva (turtleneck sign)
• Failure of restitution of fetal head
• Failure of the shoulders to descend

The management of shoulder dystocia can be aided with the use of the HELPERR mnemonic

Most cases of shoulder dystocia (up to 90%) will be successfully managed with the McRobert’s maneuver. However other maneuvers that may be required include Rubin 1 and 2 maneuvers, woodscrew maneuver, reverse wood screw maneuver and all four maneuver. In any situation, do not apply fundal pressure as it can complicate the condition.

Symphysiotomy and Cleidotomy may be considered when above listed maneuvers are not successful

The Zavanelli maneuver can also be considered to return the fetal head into uterus and perform a Caesarean delivery.

• Maternal Complications include postpartum hemorrhage, obstetric lacerations e.g. perineal, vaginal and cervical tear, 3rd- and 4th-degree perineal lacerations with resulting urinary and fecal incontinence, femoral and lateral femoral cutaneous neuropathies from prolonged use of the McRobert’s position secondary to nerve compression underneath the inguinal ligament, symphyseal separation secondary to hyperflexion of maternal legs, urethral, bladder and uterine rupture.
• Neonatal Complications associated with shoulder dystocia include brachial plexus injuries, clavicle and humeral fractures, fetal distress, birth asphyxia, cerebral palsy and neonatal death.

• Anticipation by Identification of women at risk
• Early identification and prompt initiation of measures to aid delivery
• Management of maternal and fetal complications that may arise from the condition.
• Elective Caesarean Delivery should be considered in women with gestational diabetes mellitus irrespective of control if estimated fetal weight is >4.5kg
• Though routine induction of labor does not prevent shoulder dystocia in non-diabetic women with suspected fetal macrosomia, but it reduces incidence in GDM after 38 completed weeks.