If changing the woman's position, and suprapubic pressure, does not work, the caregiver may start to internally manipulate the baby's position to help deliver the shoulders.
These can include:
Rotating the shoulders. The caregiver may try to rotate the baby's anterior shoulder, by placing their hand into the woman's vagina in front of, (or behind) the baby's top shoulder. When the next contraction starts, the shoulder is rotated to one side, to help it slip under the woman's pubic bone. Once this is done, suprapubic pressure may also be used by another caregiver, to help deliver the baby. Alternatively, the baby's posterior shoulder can be rotated around to the front, 180
o. This can facilitate the release of the anterior shoulder, allowing the baby to be born. (This is called the 'Wood's screw manoeuvre'.)
Delivering the posterior arm. While it is ideal to deliver the anterior shoulder first, if this cannot be done the caregiver will try and deliver the baby's posterior arm and shoulder instead. The caregiver places their hand into the woman's vagina towards their bottom, over their perineum and along the hollow of her sacral bone. The posterior arm is swept across the baby's chest and delivered first, allowing the anterior shoulder to follow.
The 'Zavanelli Manoeuvre'
The Zavanelli manoeuvre is rarely used, and would only be attempted in extremely difficult circumstances, where everything else has failed. It is attempted if the baby appears to be well, and the caregiver believes there is time to perform a Caesarean operation. The 'Zavanelli Manoeuvre' involves the caregiver flexing the baby's head and replacing it back inside the woman's vagina (yes you read that correctly!).
The woman is then taken to the operating theatre and a Caesarean is performed, usually with a
general anaesthetic, because it is quicker. The baby's head may need to be held in place by one of the caregivers, until the operation is performed.
Episiotomy