What is the proper way to apply suprapubic pressure in a shoulder dystocia?

Proper Application of Suprapubic Pressure in Shoulder Dystocia

Suprapubic pressure should be applied simultaneously with the McRoberts maneuver, with pressure directed posteriorly against the anterior shoulder in a downward and lateral direction to help dislodge the anterior shoulder from behind the pubic symphysis. 1

Correct Technique for Suprapubic Pressure

• Position the patient in a supine position compatible with the McRoberts maneuver (hyperflexion of the mother's legs tightly to her abdomen) to ensure optimal effectiveness of both maneuvers 1
• An assistant should apply pressure with the palm of the hand directly above the pubic symphysis 1
• The pressure should be directed posteriorly (toward the mother's back) and laterally (from the fetal back toward the fetal chest) to rotate the anterior shoulder into the wider oblique diameter of the pelvis 1
• Apply firm, steady pressure rather than intermittent pressure for better effectiveness 1
• Avoid applying pressure incorrectly, which could cause further deflexion of the fetal head and compound impaction behind the pubic symphysis 1

Sequence and Timing

• Suprapubic pressure is recommended as a first-line intervention along with the McRoberts maneuver 1, 2
• These two maneuvers together resolve approximately 58% of shoulder dystocia cases 2
• If the initial maneuvers fail after appropriate attempts, proceed to secondary maneuvers such as Woods' screw maneuver or delivery of the posterior arm 2, 3

Common Pitfalls to Avoid

• Do not apply fundal pressure (uterine expression), as this can worsen the impaction of the anterior shoulder 4
• Avoid excessive traction on the fetal head, which can increase the risk of brachial plexus injury 4
• Do not attempt inverse rotation of the fetal head as this can cause further complications 4
• Avoid using only 1-2 fingers for suprapubic pressure, as this approach is less effective and may increase the risk of fetal injury 5
• Be aware that the success rate of McRoberts maneuver with suprapubic pressure is significantly lower after instrumental delivery (15%) compared to spontaneous vaginal delivery (47.7%) 6

Training Considerations

• Simulation-based training is strongly recommended for all delivery room personnel to improve management skills for shoulder dystocia 5, 1
• Multidisciplinary team training should focus on proper execution of maneuvers and effective communication during this obstetric emergency 1
• All operators performing instrumental delivery should be proficient in all maneuvers to relieve shoulder dystocia, as McRoberts with suprapubic pressure has a higher failure rate in these cases 6

Effectiveness and Outcomes

• The number of maneuvers required to resolve shoulder dystocia correlates with the severity of neonatal and maternal complications 2
• A systematic approach of McRoberts maneuver, suprapubic pressure, and axillary traction has been suggested as an effective protocol for managing shoulder dystocia 7
• The success of suprapubic pressure depends on proper technique and timing, with immediate application upon recognition of shoulder dystocia being crucial 3