Management of Shoulder Dystocia
The McRoberts maneuver combined with suprapubic pressure should be performed immediately as first-line intervention for shoulder dystocia, as this approach is simple, effective, and associated with low morbidity. 1, 2
Immediate First-Line Management
Position the mother in McRoberts position by hyperflexing her legs tightly to her abdomen while she is supine, which lowers the fetal head in the umbilical-coccygeal axis and straightens the sacrum 1, 2
Apply suprapubic pressure simultaneously with the McRoberts maneuver to dislodge the anterior shoulder from behind the pubic symphysis 1, 2
Avoid fundal pressure, excessive traction on the fetal head, or inverse rotation of the fetal head, as these maneuvers increase morbidity without improving outcomes 3
Do not perform routine episiotomy solely for shoulder dystocia management, as it does not systematically reduce the risk of anal sphincter injury 1, 3
The McRoberts maneuver with suprapubic pressure resolves 88-90% of shoulder dystocia cases when used as first-line intervention 4. However, success rates drop significantly to only 15% when shoulder dystocia occurs after instrumental delivery compared to 47.7% after spontaneous vaginal delivery 5.
Secondary Maneuvers (When McRoberts Fails)
If McRoberts and suprapubic pressure fail, proceed immediately to direct fetal manipulation maneuvers:
Woods' screw maneuver should be performed preferentially if the posterior shoulder is engaged, involving manual rotation of the fetal shoulders 4, 3
Delivery of the posterior arm should be performed preferentially if the posterior shoulder is not engaged, by introducing a hand into the vagina and sweeping the posterior arm across the fetal chest 4, 3
Manual vaginal disimpaction (vaginal push method) involves introducing a hand into the vagina to move the fetal head upward, though care must be taken to avoid further deflexion which could compound impaction 1
The evidence does not demonstrate superiority of one second-line maneuver over another 3. Direct fetal manipulation techniques are not associated with increased rates of bone fracture (16.5% vs 11.4%) or brachial plexus injury (21.3% vs 13.3%) compared to cases resolved with McRoberts alone 6.
Critical Pitfalls to Avoid
Using only 1-2 fingers for suprapubic pressure is inadequate and less effective; proper technique requires sufficient force application 1
After instrumental delivery, anticipate an 85% failure rate of McRoberts maneuver, so operators performing instrumental deliveries must be proficient in all secondary maneuvers 5
Call for help immediately and ensure a third person is available to assist with the McRoberts maneuver 3
Post-Resolution Management
Administer 5-10 IU of oxytocin via slow IV or intramuscular infusion immediately after successful resolution to reduce postpartum hemorrhage risk 1
Consider 1 g of tranexamic acid IV within 1-3 hours if postpartum hemorrhage develops 1
Training Requirements
All delivery room personnel should undergo simulation-based training on shoulder dystocia management, as this improves recognition, proper execution of maneuvers, and team communication 1, 2
Operators must know at least two secondary maneuvers beyond McRoberts to perform quickly but without precipitation 3