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Difficulty: EasyObstetric Complications

A 28-year-old G2P1 at 40 weeks gestation is in the second stage of labor. After delivery of the fetal head, it retracts tightly against the maternal perineum (turtle sign). Gentle downward traction fails to deliver the anterior shoulder. Arrange the following management steps for this complication in the correct sequential order from first to last.

  1. 1Call for additional assistance and instruct the patient to stop pushing
  2. 2Perform the McRoberts maneuver and apply suprapubic pressure
  3. 3Attempt delivery of the posterior arm or perform internal rotational maneuvers
  4. 4Perform the Zavanelli maneuver followed by emergent cesarean delivery

Answer

The correct sequence is: Call for assistance -> McRoberts maneuver with suprapubic pressure -> Internal rotational maneuvers / delivery of posterior arm -> Zavanelli maneuver.
The management of shoulder dystocia follows a standardized, escalating sequence to minimize fetal asphyxia and trauma. It begins with calling for help and stopping maternal pushing to prevent further impaction. First-line external maneuvers (McRoberts and suprapubic pressure) alter maternal pelvic geometry and dislodge the shoulder. If these fail, secondary internal maneuvers (delivering the posterior arm or rotational maneuvers) are used to manipulate the fetus. Maneuvers of last resort, such as the Zavanelli maneuver (cephalic replacement) and symphysiotomy, are reserved for cases completely refractory to all other interventions.

Step-by-Step Solution

1
Recognize the clinical presentation as shoulder dystocia
Diagnosis of an acute obstetric emergency requiring a structured algorithm
The 'turtle sign' and failure of gentle downward traction confirm shoulder dystocia.
2
Identify the immediate initial response
Call for help and stop maternal pushing
Additional personnel are required for subsequent maneuvers and fetal resuscitation, while pushing worsens the bony impaction.
3
Select the first-line physical interventions
McRoberts maneuver and suprapubic pressure
These are non-invasive external maneuvers that resolve the majority of shoulder dystocia cases and carry the lowest risk of maternal or fetal trauma.
4
Identify secondary and last-resort interventions
Internal maneuvers followed by Zavanelli maneuver if needed
Invasive internal maneuvers are attempted only when external maneuvers fail. Cephalic replacement is strictly a last resort due to high morbidity.

Key Concept

Sequential management of shoulder dystocia (HELPERR mnemonic framework)
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Topics

Obstetric Complications

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