Shoulder Dystocia Management

Aka: Shoulder Dystocia Management, Wood-Screw maneuver, Rubin Maneuver, Zavanelli Maneuver

1. Definitions
   1. Suprapubic Pressure
      1. Apply pressure over Bladder (never over fundus)
      2. Oblique downward and anterior pressure
         1. Initial attempt: Apply pressure for 30 to 60 sec
         2. Later: Rocking motion similar to CPR
      3. Effect: Decreases fetal Shoulder breadth
   2. McRoberts Position
      1. Efficacy
         1. Resolves >40% of dystocias
         2. Resolves 50% when used with suprapubic pressure
      2. Technique
         1. Flex thighs
         2. Patient pulls knees toward ears
      3. Effect: Expands size of maternal Pelvis
         1. Flattens lumbar lordosis
         2. Symphysis rotates superiorly
   3. Episiotomy
      1. Cut a generous episiotomy
      2. May be delayed until after pressure and McRoberts
      3. Effect
         1. Does not effect Bony Pelvis obstruction
         2. Increases room to work for rotational maneuvers
   4. Rotational Maneuvers
      1. Perform maneuvers while maintaining downward traction
      2. Maneuvers described for left occiput position
      3. Rubin II Maneuver
         1. Two fingers placed behind anterior Shoulder
         2. Apply downward pressure around arc of rotation
         3. Rotate presenting part clockwise for 30-60s
      4. Wood-Screw maneuver
         1. Two fingers placed in front of posterior Shoulder
         2. Apply upward pressure around arc of rotation
         3. Rotate presenting part clockwise for 30-60 sec
      5. Rubin II Maneuver with Wood-Screw maneuver
         1. Maximizes torque for rotation
         2. Difficult due to limited vaginal space for maneuver
      6. Reverse Wood-Screw
         1. Reverse direction of rotation (counter-clockwise)
   5. Posterior arm delivery
      1. Flex elbow and sweep Forearm across chest
      2. Avoid grasping upper arm (humerus Fracture risk)
   6. Gaskin Maneuver or all-fours position
      1. Patient rolls onto hands and knees
      2. Apply downward traction to deliver posterior Shoulder
      3. Above rotational maneuvers may be repeated if needed
      4. Effect: Increases pelvic diameters (TOC, Sagittal)
   7. Maneuvers of last resort
      1. Deliberate Clavicle Fracture
      2. Zavanelli Maneuver
         1. Cesarean section with cephalic replacement
      3. Symphysiotomy
      4. Abdominal surgery with hysterotomy
2. Management Mnemonic: PERSPIRE
   1. Preparation
      1. Delivery Room
      2. Nurses on steps
   2. Episiotomy
   3. (Mc)Roberts Position (See Above)
   4. Suprapubic Pressure
   5. Posterior arm delivery
   6. Internal Rotation
      1. Wood-Screw maneuver (rotate face towards floor)
      2. Try with patient positioned on all 4 extremities
   7. Emergency
      1. Fracture Clavicle
      2. Zavanelli Maneuver (See above)
3. Management Mnemonic: HELPER (ALSO course)
   1. Help
      1. Call for Help
   2. Episiotomy
   3. Legs
      1. Position with McRoberts Maneuver for 30-60 seconds
      2. See Description above
   4. Pressure at suprapubic area
   5. Enter
      1. Position hands in position
         1. Two fingers by anterior Shoulder
         2. Two fingers by posterior Shoulder
      2. Rubin Maneuver: Rotate counter-clockwise for 30-60s
      3. Wood-Screw maneuver: Rotate clockwise for 30-60 sec
   6. Remove the posterior arm
      1. Roll the patients to hands and knees
      2. Repeat the above procedure
   7. Replace fetal head (Zavanelli Maneuver)
4. Avoid harmful maneuvers
   1. Fundal pressure
   2. Excessive traction on fetal head or neck
   3. Twisting or bending neck
5. References
   1. Gherman (1998) Am J Obstet Gynecol 178:1126-30
   2. Baxley (2004) Am Fam Physician 69:1707-14