The HELPERR protocol is a memory aid used in obstetric emergency training. It describes a structured response to shoulder dystocia, including calling for assistance, repositioning the mother, and using techniques to free the baby's shoulders. These maneuvers are designed to resolve the obstruction while limiting unnecessary force.
Why shoulder dystocia requires a coordinated response
Shoulder dystocia is recognized when the baby's head has delivered but the shoulders remain obstructed.
Normal gentle delivery efforts may not be enough to deliver the body.
The emergency requires a prompt, organized response from the medical team.
Clinicians must recognize the obstruction, communicate clearly, and select appropriate maneuvers.
Delays can increase the risk of complications.
However, excessive force can also cause injury.
The goal is to release the shoulder through controlled changes in position rather than pulling harder on the baby's head.
Understanding the HELPERR mnemonic
HELPERR represents several actions taught in shoulder dystocia training.
Letter | Action | Purpose |
|---|---|---|
H | Help | Call for additional medical assistance |
E | Evaluate episiotomy | Consider whether additional space is needed for internal maneuvers |
L | Legs | Perform the McRoberts maneuver |
P | Pressure | Apply suprapubic pressure |
E | Enter | Use internal rotational maneuvers |
R | Remove | Deliver the posterior arm when appropriate |
R | Roll | Consider moving the mother onto hands and knees |
The mnemonic is an educational framework rather than a rigid rule that every maneuver must be performed in exactly the same order.
Clinical circumstances determine which techniques are appropriate.
The McRoberts maneuver
The McRoberts maneuver involves sharply flexing the mother's thighs toward her abdomen.
This changes pelvic positioning and can help release the baby's impacted shoulder.
It is commonly used as an early response to shoulder dystocia.
The technique does not require pulling forcefully on the baby's neck.
McRoberts positioning may be especially useful when combined with suprapubic pressure.
However, it does not resolve every case.
Suprapubic pressure
Suprapubic pressure is applied above the mother's pubic bone.
The aim is to help move the baby's shoulder into a position that allows delivery.
The pressure may be directed in a way that helps rotate or dislodge the impacted shoulder.
It differs from fundal pressure.
Fundal pressure involves pushing on the upper uterus and is not recommended for resolving shoulder dystocia because it can worsen the obstruction.
Internal rotation maneuvers
When external techniques are unsuccessful, clinicians may use internal rotational maneuvers.
The Rubin maneuver involves applying pressure to help rotate the baby's shoulders.
The Woods screw maneuver also aims to rotate the shoulders into a more favorable position.
These procedures require clinical skill and careful judgment.
The purpose is to change the relationship between the shoulders and the maternal pelvis.
Posterior arm delivery and maternal repositioning
Another option is delivering the baby's posterior arm.
This may reduce the width of the shoulders and help free the obstruction.
The Gaskin maneuver involves moving the mother onto her hands and knees.
Changing maternal position may alter pelvic dimensions and help complete delivery.
The choice of maneuver depends on the mother's condition, available assistance, and the specific obstruction.
Why avoiding excessive traction matters
The brachial plexus nerves travel from the neck into the shoulder and arm.
Excessive traction can stretch these nerves and contribute to injury.
However, brachial plexus injuries can also occur without improper traction.
A safe response involves appropriate maneuvers, careful communication, and timely escalation.
Common questions around the HELPERR protocol
What is the first action during shoulder dystocia?
Recognizing the emergency and calling for appropriate assistance are essential early steps.
Does the McRoberts maneuver always work?
No. Additional maneuvers may be necessary.
Is an episiotomy enough to release a trapped shoulder?
No. An episiotomy may create space for internal maneuvers but does not remove the bony obstruction itself.
To learn more, visit: https://birthinjuryadvocate.com/birth-injuries/shoulder-dystocia/
