What is the most appropriate maneuver to help prevent shoulder dystocia during delivery in a pregnant woman with diabetes mellitus (DM) and obesity?

Management of Shoulder Dystocia in Pregnant Women with Diabetes and Obesity

The McRoberts maneuver (hyperflexion of maternal thighs onto abdomen) combined with suprapubic pressure should be the initial approach to prevent and manage shoulder dystocia in this high-risk patient. 1

Understanding the Clinical Context

This patient has two major risk factors for shoulder dystocia:

• Diabetes mellitus increases fetal macrosomia risk, which directly correlates with shoulder dystocia 2, 1
• Maternal obesity compounds this risk through increased birth weight and difficult delivery mechanics 3

Treatment of gestational diabetes with nutrition therapy, blood glucose monitoring, and insulin reduces serious perinatal complications including shoulder dystocia 3

Initial Maneuver Selection: McRoberts Position

The McRoberts maneuver (also called Gaskin maneuver when performed on all-fours) is recommended as the first-line procedure for shoulder release when shoulder dystocia occurs. 2, 1

Why McRoberts First:

• Less invasive than internal maneuvers 4
• Success rate of 47.7% after spontaneous vaginal delivery 4
• Can be performed immediately without additional equipment 1
• Reduces need for more aggressive interventions 2

Sequential Approach When McRoberts Fails

If McRoberts maneuver is unsuccessful, the evidence-based sequence is:

1. Add suprapubic pressure (Rubin maneuver) - applies downward pressure above the pubic symphysis to dislodge the anterior shoulder 2, 1, 5

2. Internal rotational maneuvers (Woods' screw maneuver) - if suprapubic pressure fails 2, 1

3. Posterior arm delivery - extraction of the posterior arm 2, 1, 5

4. All-fours position (Gaskin maneuver as repositioning) - if other maneuvers unsuccessful 2, 6

Critical Pitfalls to Avoid

Never apply fundal pressure (Kristeller maneuver) - this is a risk factor for shoulder dystocia, not a treatment, and can worsen impaction 2

The Zavanelli maneuver (cephalic replacement) is a last-resort procedure requiring return of the fetal head to the uterus followed by cesarean delivery - only when all other maneuvers fail 2, 1

Success Rate Considerations:

• Combined McRoberts and suprapubic pressure succeeds in only 25.8% of all shoulder dystocia cases 4
• After instrumental delivery, success drops to 15% 4
• 74.2% of cases require rotational or posterior arm maneuvers 4

Prevention Strategy

Optimal glycemic control during pregnancy is essential - insulin is the preferred agent for diabetes management in pregnancy 3

Target weight gain for obese women is 10-20 pounds during pregnancy 3

Low-dose aspirin 100-150 mg daily starting at 12-16 weeks reduces preeclampsia risk (another complication in diabetic pregnancies) 3

Team Preparation Requirements

All labor and delivery teams must be prepared to recognize and treat shoulder dystocia as most cases occur without warning 1

Training and simulation exercises improve physician and team performance when shoulder dystocia occurs 1

Key team actions include:

• Unequivocally announcing the dystocia 1
• Summoning extra assistance immediately 1
• Tracking time from head delivery to full delivery 1
• Performing gross lateral episiotomy to facilitate maneuvers 2

Answer: B. Suprapubic pressure - when combined with McRoberts maneuver as the initial approach, though McRoberts positioning itself is the true first step 2, 1, 4, 5