Snap Shot A 26-year-old G1P0 diabetic woman is delivering at 42 weeks' gestation has a complicated vaginal delivery in which the shoulders do not deliver with ease. The birth weight is 4300 grams. The baby is noted postpartum to have difficulty moving the left arm. Introduction Impaction of the anterior shoulder into the pubic symphis during vaginal delivery Risk factors maternal obesity gestatoinal diabetes recall that insulin is a growth factor resulting in macrosomia fetal macrosomia prolonged second stage of labor vacuum or forceps-assisted delivery Evaluation Intrapartum assessment difficulty with external rotation of the head retraction of the head back into vaginal introitus also known as the "turtle sign" Treatment Non-manipulative maneuvers suprapubic pressure flexion of maternal hips (McRoberts maneuver) Manipulative maneuvers rotation of fetal shoulders 180 degrees (Wood's corkscrew) delivery of posterior arm Emergent cesarean section pushing the fetal head back into the vaginal canal with immediate transport to cesarean section (Zavanelli maneuver) Prognosis, Prevention, and Complications Fetal hypoxia secondary to stalled delivery with the fetal head outside the vagina and the fetal body inside the vagina Fetal brachial plexis damage secondary to severe traction of the neck away from the anterior shoulder classically presents as Erb-Duchenne palsy