From the Guidelines
The primary technique for facilitating head to body delivery in cases of shoulder dystocia is the McRoberts maneuver, which should be attempted first, whether associated or not with suprapubic pressure, as first-line intervention. This technique involves sharply flexing the mother's thighs against her abdomen to flatten the sacrum and rotate the symphysis pubis upward, helping to dislodge the anterior shoulder 1. The McRoberts maneuver can be combined with suprapubic pressure applied by an assistant in a downward and lateral direction to push the fetal shoulder under the pubic symphysis.
Some key points to consider when performing the McRoberts maneuver include:
- Sharply flexing the mother's thighs against her abdomen to maximize the effect of the maneuver
- Applying suprapubic pressure in a downward and lateral direction to help dislodge the anterior shoulder
- Avoiding excessive traction on the fetal head and neck to prevent brachial plexus injury
If the initial maneuvers fail, other techniques such as internal rotational maneuvers (e.g. Woods' screw technique or Rubin maneuver) or delivery of the posterior arm may be attempted 1. However, the McRoberts maneuver remains the first-line intervention for shoulder dystocia due to its simplicity and effectiveness. It's also important to note that training and management algorithms with a sequential, structured, and flexible approach are crucial for improving outcomes in cases of shoulder dystocia, and high-fidelity simulation and implementation of standardized care pathways can be beneficial for training healthcare professionals 1.
In terms of neonatal outcome, the goal of these techniques is to safely deliver the baby while minimizing the risk of injury to the baby and the mother. By prioritizing the McRoberts maneuver and other evidence-based techniques, healthcare professionals can help improve outcomes for both mothers and babies in cases of shoulder dystocia.
From the Research
Head to Body Delivery in Shoulder Dystocia
The primary techniques for facilitating head to body delivery in cases of shoulder dystocia include:
- McRoberts' maneuver, which is often the first line of treatment 2, 3, 4, 5
- Suprapubic pressure, which can be used in conjunction with McRoberts' maneuver 2, 3, 4, 5
- Woods' maneuver, which can be performed after McRoberts' maneuver and suprapubic pressure if necessary 2, 4, 5
- Delivery of the posterior arm, which can be used if the above maneuvers are unsuccessful 2, 4, 5
Techniques and Success Rates
The success rates of these techniques vary, with McRoberts' maneuver and suprapubic pressure being successful in 58% of cases in one study 4, and 25.8% of cases in another study 3. The addition of Woods' maneuver and/or delivery of the posterior arm can increase the success rate, but may also increase the risk of neonatal and maternal complications 4.
Recommendations for Practice
The available evidence recommends that McRoberts' maneuver and suprapubic pressure be used as the first line of treatment for shoulder dystocia, with Woods' maneuver and delivery of the posterior arm being reserved for refractory cases 5. It is also recommended that healthcare providers be trained in the use of simulation to manage shoulder dystocia, and that pediatricians be immediately informed in case of shoulder dystocia 5, 6.