A term patient in active labor reaches complete cervical dilation and begins the pushing phase. After several contractions, the fetal head emerges but then abruptly retracts against the vulva, and the fetal cheeks begin to bulge. Standard gentle downward traction does not yield delivery of the body. Arrange the following interventions in the correct sequential order for managing this clinical scenario, from initial response to maneuvers of last resort.
- 1Instruct the patient to cease pushing and recruit additional clinical staff
- 2Hyperflex the maternal legs against the abdomen and apply suprapubic pressure
- 3Perform internal vaginal maneuvers, such as delivering the posterior fetal arm
- 4Push the fetal head back into the vaginal canal and proceed to emergent cesarean delivery
Answer
The correct sequence begins with stopping maternal pushing and calling for help, followed by the McRoberts maneuver with suprapubic pressure, then internal vaginal maneuvers, and finally cephalic replacement (Zavanelli maneuver) as a last resort.
Shoulder dystocia is managed using a standardized, escalating algorithm designed to minimize fetal hypoxic injury and maternal trauma. The sequence prioritizes recruiting multidisciplinary help and halting maternal pushing first. The McRoberts maneuver combined with suprapubic pressure serves as the primary mechanical intervention. If these external techniques fail, internal rotational maneuvers or delivery of the posterior arm are utilized. The Zavanelli maneuver is exclusively a last-resort procedure due to its high associated maternal and fetal morbidity.
Step-by-Step Solution
Key Concept
The management of shoulder dystocia progresses sequentially from the least invasive external maneuvers (McRoberts and suprapubic pressure) to more invasive internal maneuvers, reserving surgical replacement as a last resort.