Background: The protocol for shoulder dystocia assumes an anterior shoulder entrapped above the pubic symphysis. If the shoulders lie in a different position, a different strategy is required. Such a situation can occur in shoulder dystocia with an occipito-posterior position.
Case: An operative vaginal delivery in a nulliparous woman resulted in a shoulder dystocia with the head in the occipito-posterior position, and the usual maneuvers were unsuccessful. The shoulders were transverse and after being manipulated into the oblique plane, an atraumatic vaginal delivery resulted.
Conclusion: In the rare situation of an occipito-posterior shoulder dystocia, the shoulders may be in the transverse position. This situation can be addressed by manipulating the shoulders and by making an episiotomy to facilitate the maneuver. If unsuccessful, cephalic replacement may be an option.