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?

Shoulder Dystocia Prevention in High-Risk Obstetric Patients

Suprapubic pressure (Option B) is the most appropriate maneuver to help prevent shoulder dystocia during delivery in a pregnant woman with diabetes mellitus and obesity, as it can be applied prophylactically when shoulder dystocia is anticipated in high-risk patients.

Understanding the Question Context

This question asks about prevention of shoulder dystocia, not treatment after it occurs. The distinction is critical:

• Rubin maneuver (Option A) is a therapeutic rotational technique used after shoulder dystocia has occurred 1
• Suprapubic pressure (Option B) can be used both prophylactically and therapeutically 2
• Gaskin maneuver (Option C, also called McRoberts position or all-fours position) is primarily therapeutic 1, 3
• Zavanelli maneuver (Option D) is a last-resort cephalic replacement technique for failed shoulder dystocia management 1

Risk Factors Present in This Patient

This patient has multiple significant risk factors for shoulder dystocia:

• Diabetes mellitus increases risk of fetal macrosomia and shoulder dystocia 4.3-fold for type 1 diabetes and 3.2-fold for type 2 diabetes 4
• Obesity independently increases risk of macrosomia (OR = 7.7 for type 1 diabetes, 3.8 for type 2 diabetes) 4
• The combination creates particularly high risk for shoulder dystocia 5, 3

Evidence for Prophylactic Maneuvers

Prophylactic suprapubic pressure combined with McRoberts positioning showed promising results in one randomized trial of 185 women at risk for delivering large babies. The prophylactic group had 5 cases of shoulder dystocia compared to 15 in the control group (RR 0.44,95% CI 0.17 to 1.14), and required significantly fewer therapeutic maneuvers after head delivery (3 versus 13 cases, RR 0.31,95% CI 0.09 to 1.02) 2.

When cesarean sections performed in the prophylactic group were included in analysis, there were significantly fewer instances of shoulder dystocia (RR 0.33,95% CI 0.12 to 0.86) 2.

Clinical Application Algorithm

For high-risk patients (diabetes + obesity):

1. Anticipate shoulder dystocia before delivery of the fetal head 3
2. Position patient in McRoberts position (knees to chest) as delivery approaches 3, 2
3. Apply suprapubic pressure prophylactically during delivery of the anterior shoulder 2
4. Avoid fundal pressure (Kristeller maneuver), which is contraindicated as it worsens impaction 1

Important Caveats

• Most shoulder dystocia cases occur without warning - more than 50% occur in patients without identifiable risk factors 5
• All delivery personnel must be trained in shoulder dystocia management regardless of prophylactic measures 3
• Simulation exercises improve outcomes when shoulder dystocia occurs 3
• Prophylactic maneuvers may increase cesarean section rates in some studies 2

Alternative Consideration

For diabetic patients with estimated fetal weight >4250g, elective cesarean section should be considered to avoid shoulder dystocia entirely, as this represents the highest risk category 5.

However, among the listed maneuver options for vaginal delivery, suprapubic pressure is the only technique with evidence supporting prophylactic use to prevent shoulder dystocia before it occurs 2.