From the Guidelines
The best next step in managing a patient with a retained anterior shoulder and a tight nuchal cord during delivery is to perform the McRoberts maneuver, as recommended by the most recent guidelines 1. This involves sharply flexing the mother's thighs against her abdomen to flatten the sacrum and rotate the symphysis pubis, which can help dislodge the impacted shoulder. While performing this maneuver, an assistant should apply suprapubic pressure to help push the anterior shoulder under the pubic symphysis. The tight nuchal cord should be reduced if possible or clamped and cut if necessary, but only after addressing the shoulder dystocia. Key considerations in this scenario include:
- The patient's prolonged labor and failed spontaneous delivery of the shoulder, which increase the risk of fetal hypoxia and brachial plexus injury
- The importance of promptly resolving the shoulder dystocia to prevent serious complications, as emphasized in recent guidelines 1
- The potential need for additional maneuvers, such as internal rotation or delivery of the posterior arm, if the McRoberts maneuver is unsuccessful. It is crucial to prioritize the McRoberts maneuver as the first-line intervention, given its effectiveness and relatively low invasiveness, as supported by the latest evidence 1.
From the Research
Managing Retained Anterior Shoulder and Tight Nuchal Cord
In the event of a retained anterior shoulder and a tight nuchal cord during delivery, following a prolonged labor and failed spontaneous delivery of the shoulder, the best next step is to employ specific maneuvers to facilitate a safe delivery.
- The McRoberts maneuver, with or without suprapubic pressure, is recommended as the initial procedure for shoulder release in case of shoulder dystocia 2, 3, 4, 5.
- If the McRoberts maneuver fails, other obstetric procedures such as Woods' maneuver or delivery of the posterior arm should be considered 3, 4, 5.
- It is essential to avoid excessive traction on the fetal head, fundal pressure, and inverse rotation of the fetal head, as these actions can increase the risk of complications 4, 5, 6.
- A pediatrician should be immediately informed of the situation, and the initial clinical examination should check for complications such as brachial plexus injury or clavicle fracture 4, 5.
- Practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal injury and is highly recommended 4, 5.
Key Considerations
- Shoulder dystocia is an unpredictable obstetric emergency that requires prompt recognition and management to minimize the risk of complications 2, 3, 4, 5.
- The risk factors for shoulder dystocia include fetal macrosomia, previous shoulder dystocia, and gestational diabetes mellitus, among others 2, 3, 4, 5.
- A calm and thoughtful approach to managing shoulder dystocia is crucial to ensure the best possible outcome for both the mother and the baby 2, 4, 5.