A. Shoulder dystocia is a medical and possibly surgical emergency. Two assistants should be called for if not already present, as well as an anesthesiologist and pediatrician. A generous episiotomy should be cut. The following sequence is suggested:

1. McRoberts maneuver: The legs are removed from the lithotomy position and flexed at the hips, with flexion of the knees against the abdomen. Two assistants are required. This maneuver may be performed prophylactically in anticipation of a difficult delivery.

2. Suprapubic pressure: An assistant is requested to apply pressure downward, above the symphysis pubis. This can be done in a lateral direction to help dislodge the anterior shoulder from behind the pubic symphysis. It can also be performed in anticipation of a difficult delivery. Fundal pressure may increase the likelihood of uterine rupture and is contraindicated.

3. Rotational maneuvers: The Woods' corkscrew maneuver consists of placing two fingers against the anterior aspect of the posterior shoulder. Gentle upward rotational pressure is applied so that the posterior shoulder girdle rotates anteriorly, allowing it to be delivered first. The Rubin maneuver is the reverse of Woods's maneuver. Two fingers are placed against the posterior aspect of the posterior (or anterior) shoulder and forward pressure applied. This results in adduction of the shoulders and displacement of the anterior shoulder from behind the symphysis pubis.

4. Posterior arm release: The operator places a hand into the posterior vagina along the infant's back. The posterior arm is identified and followed to the elbow. The elbow is then swept across the chest, keeping the elbow flexed. The fetal forearm or hand is then grasped and the posterior arm delivered, followed by the anterior shoulder. If the fetus still remains undelivered, vaginal delivery should be abandoned and the Zavanelli maneuver performed followed by cesarean delivery.

5. Zavanelli maneuver: The fetal head is replaced into the womb. Tocolysis is recommended to produce uterine relaxation. The maneuver consists of rotation of the head to occiput anterior. The head is then flexed and pushed back into the vagina, followed abdominal delivery. Immediate preparations should be made for cesarean delivery.

6. If cephalic replacement fails, an emergency symphysiotomy should be performed. The urethra should be laterally displaced to minimize the risk of lower urinary tract injury.

B. The McRoberts maneuver alone will successfully alleviate the shoulder dystocia in 42% to 79% of cases. For those requiring additional maneuvers, vaginal delivery can be expected in more than 90%. Finally, favorable results have been reported for the Zavanelli maneuver in up to 90%.

References: See page 184.

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