EBM Consult

Rubin I & II Maneuvers

    • Rubin I (suprapubic pressure): attempts to dislodge the anterior shoulder from behind the pubic symphysis
    • Rubin II: manual anterior rotation of fetal shoulder to decrease shoulder diameter
    • Shoulder dystocia
      • "Turtle sign" = retraction of the fetal head against the maternal perineum
      • Difficulty or failure to accomplish external rotation of the head after it has passed the perineum
      • Resistance to the delivery of the anterior shoulder with the usual amount of traction applied to the fetal head
    Risk Factors Associated with Shoulder Dystocia
    • Abnormal pelvic anatomy
    • Excessive weight gain
    • Fetal macrosomia (suspected)
    • Gestational/pre-gestational diabetes
    • Multiparity
    • Obesity (>200 lbs.)
    • Operative vaginal delivery
    • Post-term gestation
    • Precipitous delivery
    • Previous history of shoulder dystocia
    • Previous large infant (> 4000 grams)
    • Prolonged second state of labor
    • Protracted active phase of labor
    • Short stature (< 5" tall) 

    Technique (Rubin I):

    1. Have an assistant at the mothers side place their hands on the suprapubic region of the mothers abdomen
      1. Position is similar to that of CPR with assistant above the woman
        1. May need a step stool to attain correct position
      2. Mother should be lying on back with legs hyperflexed and knees to chest (McRobert's position)
    2. With the heel of the hand (or fist) and arms straight, apply moderate pressure obliquely (downward and laterally) to fetal anterior shoulder
    3. If continuous pressure does not dislodge the shoulder use a rocking motion (compression/relaxation)

    Technique (Rubin II):

    1. Place fingers/hand on the most easily accessible fetal shoulder
      1. May require episiotomy 
    2. Push the shoulder toward the anterior surface of the fetal chest
      1. May result in abduction of both fetal shoulders and decrease the shoulder to shoulder dimension, freeing the impacted anterior shoulder  
    • Do not perform fundal pressure or encourage continued maternal pushing  
    Editors & Reviewers


    • Anthony J. Busti, MD, PharmD, FNLA, FAHA

    Last Reviewed:  September 2016

    1. Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician. 2004;69(7):1707-14.
    2. Beckman CRB et al. Obstetrics and Gynecology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2014;112.
    3. Preparing for clinical emergencies in obstetrics and gynecology. Committee Opinion No. 487. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1032-4.
    4. Sokol RJ, Blackwell SC, for the American College of Obstetricians and Gynecologists. Committee on Practice Bulletins-Gynecology. ACOG practice bulletin no. 40: shoulder dystocia.  2002. (Replaces practice pattern number 7, October 1997).Int J Gynaecol Obstet. 2003;80:87-92.