Examkin

Question

Difficulty: EasyObstetric Complications

A 30-year-old woman, gravida 3, para 2, at 41 weeks gestation is in the second stage of labor. The fetal head is delivered but immediately retracts tightly against the maternal perineum (turtle sign). The anterior shoulder does not deliver with gentle downward traction. Arrange the following management steps in the most appropriate standard sequential order.

  1. 1Instruct the patient to stop pushing and sharply flex her hips against her abdomen (McRoberts maneuver).
  2. 2Apply firm, downward suprapubic pressure to dislodge the anterior shoulder.
  3. 3Perform internal rotation maneuvers or delivery of the posterior fetal arm.
  4. 4Replace the fetal head into the pelvis (Zavanelli maneuver) and proceed to emergency cesarean delivery.

Answer

The standard sequence begins with the McRoberts maneuver, follows with suprapubic pressure, proceeds to internal vaginal maneuvers if needed, and reserves the Zavanelli maneuver as a last resort.
The correct sequence follows the standard stepwise algorithm for shoulder dystocia, progressing safely from the least invasive external maneuvers (McRoberts, suprapubic pressure) to more invasive internal maneuvers (delivery of posterior arm, rotational maneuvers), and finally to last-resort catastrophic measures (Zavanelli maneuver followed by cesarean).

Step-by-Step Solution

1
Recognize shoulder dystocia and instruct the patient to halt pushing.
The maternal expulsive efforts are stopped to prevent further impaction.
Continuing to push worsens the impaction of the anterior shoulder against the pubic symphysis.
2
Perform the McRoberts maneuver.
The maternal pelvis anterior-posterior diameter is maximized.
Hyperflexion of the maternal hips is the first-line and least invasive maneuver, resolving a large portion of cases.
3
Apply suprapubic pressure.
The anterior shoulder is manually dislodged from behind the pubic symphysis.
This provides direct mechanical force to collapse the fetal shoulder diameter and slip it under the symphysis.
4
Execute internal maneuvers (e.g., posterior arm delivery, Woods corkscrew).
The fetal biacromial diameter is reduced or the fetus is rotated to a favorable angle.
Internal access is required when external forces are insufficient to resolve the impaction.
5
Perform the Zavanelli maneuver.
The fetal head is replaced into the vaginal canal to allow for a cesarean section.
This catastrophic measure is only used when all other vaginal delivery techniques have definitively failed.

Key Concept

Management of shoulder dystocia (HELPERR algorithm / sequential escalation)
Rate this question

Topics

Obstetric Complications

More questions from this topic