What is the most recommended maneuver for preventing or managing shoulder dystocia in a pregnant woman with diabetes mellitus (DM) and obesity?

Management of Shoulder Dystocia in Pregnant Women with Diabetes and Obesity

The McRoberts maneuver, with or without suprapubic pressure, is the recommended first-line intervention for shoulder dystocia and should be performed immediately when dystocia is recognized. 1

First-Line Management: McRoberts Maneuver

The McRoberts maneuver is simple to perform, effective, and associated with low morbidity, making it the clear first choice for managing shoulder dystocia 1, 2. This involves:

• Hyperflexing the mother's legs tightly to her abdomen to flatten the sacral promontory and increase the pelvic outlet diameter 1
• Positioning the patient in a supine position compatible with rapid implementation of this maneuver 1
• Adding suprapubic pressure (not fundal pressure) to the McRoberts maneuver, which increases effectiveness without additional morbidity 1, 2

The guideline explicitly states that McRoberts maneuver is recommended as first-line intervention whether associated or not with suprapubic pressure 1. This approach successfully resolves the majority of shoulder dystocia cases 3, 2.

Critical Actions to Avoid

Do NOT perform the following, as they increase maternal and fetal morbidity:

• Excessive traction on the fetal head - this is not recommended and increases risk of brachial plexus injury 2
• Fundal (uterine) expression - this is contraindicated and can worsen the impaction 2
• Inverse rotation of the fetal head - this should not be performed 2
• Routine episiotomy - this is not recommended for shoulder dystocia management 1, 2

Second-Line Maneuvers

If McRoberts maneuver fails, the available data do not suggest superiority of one second-line maneuver over another 2. However, a logical algorithm based on clinical findings is:

If the posterior shoulder is engaged:

• Perform Wood's corkscrew maneuver (internal rotation) preferentially 2

If the posterior shoulder is NOT engaged:

• Deliver the posterior arm preferentially 2

The Rubin maneuver (adducting the fetal shoulders by applying pressure to the posterior aspect of the anterior shoulder) is also a recognized second-line option 3, 2.

Special Considerations for This Patient Population

Your patient with diabetes and obesity has significantly elevated risk for shoulder dystocia 3, 4, 5. The key preventive measure that should have been considered earlier in pregnancy:

• Cesarean delivery is recommended when estimated fetal weight exceeds 4500g in the presence of maternal diabetes 4
• This threshold is higher (>5000g) in non-diabetic women 4

Team Preparation and Communication

When shoulder dystocia occurs 3, 2:

• Unequivocally announce that dystocia is occurring to activate the team 3
• Call for additional help immediately, including an obstetrician if not already present 2
• Assign someone to track time from head delivery to complete delivery 3
• Maintain calm, clear communication with patient and team 3

Essential Knowledge Requirement

All physicians and midwives should know and be able to perform at least two maneuvers beyond McRoberts in case the first-line approach fails 2. Training and simulation exercises improve team performance when this emergency occurs 3.

The Gaskin maneuver (all-fours position) and Zavanelli maneuver (cephalic replacement) are described in the literature but are considered last-resort options when standard maneuvers fail 3. These are not first or second-line recommendations.