Management of Shoulder Dystocia in Newborns
The McRoberts maneuver should be used as first-line intervention for shoulder dystocia, involving hyperflexion of the mother's legs tightly to her abdomen, with simultaneous suprapubic pressure to help dislodge the anterior shoulder from behind the pubic symphysis. 1
Initial Management
- Position the patient in a supine position compatible with the McRoberts maneuver to ensure optimal effectiveness 1
- Apply suprapubic pressure simultaneously with the McRoberts maneuver to help dislodge the anterior shoulder from behind the pubic symphysis 1
- This combination of maneuvers resolves approximately 58% of shoulder dystocia cases 2
- Avoid excessive traction on the fetal head as this may increase the risk of brachial plexus injury 1
Secondary Maneuvers (if initial approach fails)
- Proceed to manual vaginal disimpaction (vaginal push method) as a secondary maneuver, involving introduction of a hand into the vagina to move the fetal head upward 1
- Consider the Woods screw maneuver (rotating the posterior shoulder) and/or delivery of the posterior arm for refractory cases 2
- The all-fours maneuver (moving the laboring patient to her hands and knees) has shown success in 83% of cases without additional maneuvers and can be considered as an alternative approach 3
- The shoulder shrug technique (shrugging the posterior shoulder and rotating the head-shoulder unit 180 degrees) may be attempted in persistent cases 4
Risk Factors and Prevention
- Although several risk factors are associated with shoulder dystocia, it remains largely unpredictable in individual cases 5
- The American Academy of Family Physicians recommends considering prophylactic cesarean delivery for suspected fetal macrosomia with estimated fetal weights >5,000g in women without diabetes and >4,500g in women with diabetes 1
- Labor induction for suspected fetal macrosomia is not recommended as it doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia 1
Post-Delivery Management
- Administer 5-10 IU of oxytocin via slow IV or intramuscular infusion to reduce the risk of postpartum hemorrhage after successful resolution of shoulder dystocia 1
- Consider intravenous administration of 1g of tranexamic acid within 1-3 hours after bleeding onset if postpartum hemorrhage occurs 1
- Evaluate the newborn for potential injuries, particularly brachial plexus injuries and fractures, which increase with the number of maneuvers required 2
Training Recommendations
- Simulation-based training programs on shoulder dystocia management are strongly recommended for emergency medicine teams to improve skills and reduce maternal and fetal morbidity 1
- Multidisciplinary team training should focus on recognition of risk factors, proper execution of maneuvers, and effective communication during this obstetric emergency 1