What is the best course of action for a patient experiencing shoulder dystocia (obstetric emergency) during delivery, considering their past medical history and current health status?

Management of Shoulder Dystocia

When shoulder dystocia occurs, immediately perform the McRoberts maneuver (hyperflexion of the mother's legs tightly to her abdomen) as first-line intervention, with simultaneous suprapubic pressure applied to dislodge the anterior shoulder from behind the pubic symphysis. 1

Immediate Recognition and Team Activation

• Call for help immediately and announce clearly that shoulder dystocia is occurring to activate the emergency response team 1, 2
• Position the patient supine to ensure the McRoberts maneuver can be performed optimally 1
• Begin tracking time from delivery of the head, as this is critical for documentation and decision-making 2

First-Line Maneuvers (Perform Simultaneously)

McRoberts Maneuver:

• Hyperflex both of the mother's legs tightly against her abdomen, which rotates the pelvis and lowers the fetal head in the umbilical-coccygeal axis 1
• This single maneuver resolves the majority of shoulder dystocia cases 1

Suprapubic Pressure:

• Apply firm downward and lateral pressure just above the pubic symphysis using the full hand (not just 1-2 fingers, as this is less effective and increases fetal injury risk) 1
• Direct pressure posteriorly to rotate the anterior shoulder into the oblique diameter 1

Secondary Maneuvers (If McRoberts Fails)

Manual Vaginal Disimpaction:

• Insert your hand into the vagina and push the fetal head upward to disengage the anterior shoulder from behind the pubic symphysis 1
• Critical pitfall: Apply pressure correctly to avoid further deflexion of the fetal head, which would worsen the impaction 1

Internal Rotational Maneuvers:

• Attempt to rotate the posterior shoulder anteriorly or deliver the posterior arm first 2
• These maneuvers require calm, deliberate technique to avoid brachial plexus injury 2

What NOT to Do

• Do not routinely perform episiotomy solely for shoulder dystocia, as it does not reduce anal sphincter injury risk and provides no additional room for the impacted shoulder 1
• Do not apply excessive traction on the fetal head, as this significantly increases the risk of brachial plexus injury 2
• Do not panic or rush—methodical execution of maneuvers is more effective than frantic attempts 2

Post-Delivery Management

Hemorrhage Prophylaxis:

• Administer oxytocin 5-10 IU via slow IV or IM injection immediately after delivery to prevent postpartum hemorrhage, which is more common after shoulder dystocia 1, 3
• If bleeding occurs despite oxytocin, give tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT = 276 to prevent one maternal death) 3

Neonatal Assessment:

• Immediately assess for brachial plexus injury, clavicular fracture, and hypoxia 2
• Document all maneuvers performed and their sequence for medicolegal purposes 2

Prevention Strategies

Antepartum Risk Assessment:

• Consider prophylactic cesarean delivery for estimated fetal weight >5,000 g in non-diabetic patients or >4,500 g in diabetic patients 1
• Do not induce labor for suspected macrosomia alone, as this doubles cesarean delivery risk without reducing shoulder dystocia incidence 1

Training Requirements

• All delivery room personnel must undergo simulation-based training for shoulder dystocia management, as this improves team performance and reduces maternal-fetal morbidity 1, 4
• Training should emphasize proper execution of maneuvers, recognition of risk factors, and effective communication during the emergency 1
• Regular drills ensure the team can execute maneuvers calmly and efficiently when real cases occur 4