What is the most appropriate maneuver to help prevent shoulder dystocia during delivery in a high-risk patient, such as a pregnant woman with diabetes mellitus (DM) and obesity?

Management of Shoulder Dystocia Prevention in High-Risk Obstetric Patients

The most appropriate maneuver to help prevent shoulder dystocia during delivery is suprapubic pressure (Option B), as treatment of gestational diabetes mellitus with glycemic control significantly reduces the incidence of shoulder dystocia by 58-62% compared to untreated patients. 1

Understanding the Question Context

This question appears to conflate prevention (which occurs through antepartum glycemic management) with treatment maneuvers (which are applied when shoulder dystocia has already occurred). The answer choices listed are all treatment maneuvers, not preventive strategies. However, among the options provided, suprapubic pressure is the most evidence-based initial intervention when shoulder dystocia occurs.

Primary Prevention: Glycemic Control

The single most effective strategy to prevent shoulder dystocia in pregnant women with diabetes and obesity is optimal glycemic control throughout pregnancy. 1

• Treatment of gestational diabetes mellitus reduces shoulder dystocia risk by 58% (RR 0.42,95% CI 0.23-0.77) in randomized controlled trials 1
• Cohort studies demonstrate an even greater reduction of 62% (RR 0.38,95% CI 0.19-0.78) 1
• This prevention occurs through reduction of fetal macrosomia, which decreases by 50% with treatment (RR 0.50,95% CI 0.35-0.71) 1

Glycemic targets during pregnancy for diabetes prevention of complications: 1

• Fasting glucose <95 mg/dL (5.3 mmol/L)
• One-hour postprandial <140 mg/dL (7.8 mmol/L)
• Two-hour postprandial <120 mg/dL (6.7 mmol/L)

Management Algorithm When Shoulder Dystocia Occurs

If shoulder dystocia occurs despite preventive measures, the evidence-based sequence is: 2, 3

First-Line Maneuvers (The "ABC" Approach)

1. McRoberts maneuver - Hyperflexion of maternal thighs onto abdomen, successful in 88% of cases 3
2. Suprapubic pressure (Option B) - Applied immediately after McRoberts, used in combination in most successful deliveries 2, 4, 3
3. Woods' screw maneuver (rotational) - If first two fail 3
4. Posterior arm delivery - Next step if rotation unsuccessful 4, 3

Why Suprapubic Pressure is the Correct Answer

Suprapubic pressure is the most appropriate choice among the listed options because: 2, 4

• It is applied as part of the initial response sequence, immediately following McRoberts positioning 3
• It directly addresses the mechanical problem by dislodging the impacted anterior shoulder from behind the pubic symphysis 4
• It is used in combination with McRoberts in the vast majority (>90%) of successfully managed cases 3
• The other options (Rubin, Gaskin, Zavanelli) are second-line or rescue maneuvers reserved for refractory cases 2

Critical Distinction: The Other Maneuvers

The remaining answer choices are not first-line preventive or initial treatment options: 2

• Rubin maneuver - A rotational technique used after initial maneuvers fail
• Gaskin maneuver (all-fours position) - Alternative positioning, not first-line 5
• Zavanelli maneuver - Cephalic replacement, a last-resort rescue procedure when all other maneuvers fail 2

Risk Stratification in This Patient

This patient with diabetes mellitus and obesity has significantly elevated risk: 6

• Maternal diabetes increases shoulder dystocia risk substantially, especially with fetal weights >4250g 6
• The combination of diabetes and obesity compounds macrosomia risk 1
• However, more than 50% of shoulder dystocia cases occur without identifiable risk factors, requiring universal preparedness 6, 2

Additional Preventive Considerations

Beyond glycemic control, consider: 1

• Low-dose aspirin 100-150 mg daily starting at 12-16 weeks gestation to reduce preeclampsia risk, which is elevated 4-6 fold in diabetic pregnancies 1
• Recommended weight gain of 10-20 lb for obese women during pregnancy 1
• Cesarean delivery may be considered for diabetic patients with estimated fetal weight >4250g, though prediction remains imperfect 6

Common Pitfalls to Avoid

Critical errors in shoulder dystocia management: 2

• Applying fundal pressure (absolutely contraindicated - worsens impaction)
• Excessive traction on fetal head (causes brachial plexus injury)
• Panic and disorganized approach rather than systematic maneuver sequence
• Failure to announce the emergency clearly and summon additional help immediately 2

All delivery teams caring for diabetic and obese pregnant women must maintain readiness through regular simulation training, as shoulder dystocia remains largely unpredictable despite risk factor identification. 6, 2