What is the management of shoulder dystocia during childbirth?

Management of Shoulder Dystocia During Childbirth

In the event of proven shoulder dystocia during childbirth, the McRoberts maneuver is recommended as first-line intervention, whether associated or not with suprapubic pressure. 1

Initial Management

• The McRoberts maneuver should be performed immediately upon recognition of shoulder dystocia, involving hyperflexion of the mother's legs tightly to her abdomen with the possibility of lowering the fetal head in the umbilical-coccygian axis 1
• Suprapubic pressure may be applied simultaneously with the McRoberts maneuver to help dislodge the anterior shoulder from behind the pubic symphysis 1
• Position the patient in a supine position compatible with the McRoberts maneuver to ensure optimal effectiveness 1

Secondary Maneuvers (if McRoberts fails)

Manual Vaginal Disimpaction

• If the McRoberts maneuver is unsuccessful, manual vaginal disimpaction (vaginal push method) may be attempted, involving introduction of a hand into the vagina to move the fetal head upward 1
• Care must be taken to apply pressure correctly to avoid further deflexion of the fetal head which could compound impaction behind the pubic symphysis 1

All-Fours Maneuver

• Moving the laboring patient to her hands and knees position (all-fours maneuver) has shown success in resolving shoulder dystocia with minimal morbidity 2
• This technique has demonstrated effectiveness with a reported success rate of 83% without need for additional maneuvers 2

Additional Techniques

• For persistent shoulder dystocia, consider internal rotation maneuvers such as Woods' screw or Rubin maneuver 3
• Delivery of the posterior arm may be attempted if other maneuvers fail 3

Special Considerations

• Episiotomy is not systematically recommended outside of specialized structures for the sole purpose of reducing the risk of anal sphincter injury during shoulder dystocia management 1
• Prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes 1
• Labor induction is not recommended for suspected fetal macrosomia as it doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia 1

Post-Delivery Management

• After successful resolution of shoulder dystocia, administer 5 to 10 IU of oxytocin via slow IV or intramuscular infusion to reduce the incidence of postpartum hemorrhage 1
• In case of post-partum hemorrhage, consider intravenous administration of 1 g of tranexamic acid within 1 to 3 hours after bleeding onset 1
• Carefully document all maneuvers used and their sequence, as shoulder dystocia is frequently underreported and associated with increased risk of neonatal injury 4

Training Recommendations

• Simulation-based training programs on mechanical dystocia (shoulder dystocia) are strongly recommended for emergency medicine teams to improve management skills and reduce maternal and fetal morbidity and mortality 1
• Multidisciplinary team training should focus on recognition of risk factors, proper execution of maneuvers, and effective communication during this obstetric emergency 1

Common Pitfalls and Caveats

• Shoulder dystocia is largely unpredictable, occurring in approximately 0.5-0.62% of vaginal deliveries 4, 3
• Despite known risk factors (macrosomia, maternal diabetes, obesity), most cases occur without warning, necessitating immediate recognition and appropriate management 5
• Attempting to deliver the fetal head during a uterine contraction can exacerbate problems with elevating the head 1
• Excessive traction on the fetal head should be avoided as it increases the risk of brachial plexus injury 6
• Midpelvic operative vaginal delivery should be avoided in cases of suspected fetal macrosomia except in extreme emergencies 1