What are the steps for performing Pinnard's (also known as supra-pubic pressure) maneuver to manage shoulder dystocia during delivery?

Pinnard's Maneuver (Suprapubic Pressure) for Shoulder Dystocia

Suprapubic pressure should be applied as the first-line intervention for shoulder dystocia in combination with the McRoberts maneuver, using firm downward and lateral pressure just above the pubic symphysis to dislodge the impacted anterior shoulder. 1

Step-by-Step Technique

Initial Positioning and Preparation

• Call for help immediately and note the time when shoulder dystocia is diagnosed, as duration correlates with neonatal morbidity 2
• Simultaneously initiate McRoberts maneuver (maternal thigh hyperflexion tightly to abdomen) while preparing for suprapubic pressure 3, 1
• Never apply fundal pressure, as this is associated with up to 77% fetal injury rate including severe spinal cord injuries 4

Suprapubic Pressure Application (Pinnard's Maneuver)

• Position your hands just above the maternal pubic symphysis on the side of the fetal back (where the anterior shoulder is impacted) 5
• Apply firm, continuous downward pressure using a closed fist or the heel of your hand, directing force posteriorly and laterally toward the fetal chest 5
• The goal is to adduct the anterior shoulder and reduce its bisacromial diameter, allowing it to slip beneath the pubic symphysis 5
• Maintain pressure for 30-60 seconds while gentle downward traction is applied to the fetal head 5

Alternative Suprapubic Pressure Technique

• If continuous pressure fails, use rocking motion by applying intermittent pressure coordinated with gentle head traction between contractions 3
• Avoid attempting delivery during contractions, as this exacerbates difficulty with elevating the head and increases trauma risk 3, 6

Critical Pitfalls to Avoid

• Never use fundal pressure - this catastrophic error causes severe injuries including lower thoracic spinal cord damage with permanent neurological deficits 4
• Do not apply excessive downward traction on the fetal head alone without suprapubic pressure, as this increases brachial plexus injury risk 5
• Avoid delays in escalating to additional maneuvers if McRoberts plus suprapubic pressure fails within 30-60 seconds 2

If Initial Maneuvers Fail

• Proceed immediately to Rubin maneuver (rotating anterior shoulder to oblique position) or Woods screw maneuver (rotating posterior shoulder) 2, 5
• Consider delivery of posterior arm if rotational maneuvers are unsuccessful 2, 5
• The all-fours maneuver (moving patient to hands and knees) achieves 83% success rate with mean delivery time of 2.3 minutes and minimal morbidity 7
• Duration of dystocia is the key predictor of morbidity, not the specific maneuver used, so clinicians should utilize whichever technique is most likely to achieve rapid delivery 2

Special Consideration for Occiput-Posterior Position

• If the fetal head is occiput-posterior, the shoulders may be transverse rather than anteroposterior 8
• In this rare scenario, manually rotate the shoulders to an oblique position before applying standard maneuvers, and consider episiotomy to facilitate manipulation 8