Examkin

Question

Difficulty: HardLabor, Delivery, and Puerperium

A 3333-year-old G2P1 at 4040 weeks and 55 days gestation is pushing in the second stage of labor. The fetal head delivers but immediately retracts tightly against the maternal perineum. The attending physician applies gentle downward traction, but the anterior shoulder fails to deliver. The estimated fetal weight by third-trimester ultrasound was 45004500 g.

Arrange the following steps for the management of this obstetric emergency in the most appropriate sequential order, from the initial response to the maneuver of last resort.

  1. 1Instruct the patient to cease pushing and call for immediate obstetric, anesthetic, and pediatric assistance.
  2. 2Hyperflex the maternal hips against the abdomen and apply downward pressure just above the pubic symphysis.
  3. 3Insert a hand into the posterior vagina to sweep the fetal posterior arm across the chest and deliver the posterior hand.
  4. 4Administer uterine relaxants, perform cephalic replacement, and proceed to an emergent laparotomy.

Answer

The correct sequence for managing shoulder dystocia is: 1) Instruct the patient to cease pushing and call for help, 2) Hyperflex the maternal hips and apply suprapubic pressure, 3) Perform intravaginal maneuvers such as delivering the posterior arm, and 4) Perform cephalic replacement and emergent cesarean delivery as a last resort.
Shoulder dystocia is a critical obstetric emergency requiring a strict, algorithmic approach to minimize fetal asphyxia and brachial plexus injury. The first step is always preparation: recognizing the 'turtle sign', instructing the mother to stop pushing (which worsens impaction), and calling for multidisciplinary help. Next, providers must utilize first-line external maneuvers (McRoberts maneuver and suprapubic pressure) because they are rapid, non-invasive, and resolve the majority of dystocias. If these fail, secondary internal maneuvers (such as sweeping and delivering the posterior arm, or the Rubin/Woods corkscrew maneuvers) are utilized to manually reduce the fetal bisacromial diameter. Finally, if all standard maneuvers fail, rescue maneuvers of last resort—such as the Zavanelli maneuver (cephalic replacement followed by cesarean delivery) or symphysiotomy—are performed to save the fetus.

Step-by-Step Solution

1
Recognize shoulder dystocia (turtle sign) and immediately halt maternal pushing while calling for backup personnel.
Prevents further impaction of the fetal shoulder beneath the pubic symphysis and ensures pediatric/anesthetic teams are present.
Maternal pushing against an impacted shoulder exacerbates the dystocia and increases the risk of fetal injury.
2
Perform the McRoberts maneuver combined with suprapubic pressure.
Flattens the sacral promontory, increases the anteroposterior diameter of the pelvis, and manually pushes the anterior shoulder under the symphysis.
These are the safest, least invasive, and most rapidly deployable first-line maneuvers.
3
Proceed to internal (intravaginal) maneuvers, such as the delivery of the posterior arm or rotational maneuvers (e.g., Woods corkscrew).
Reduces the bisacromial diameter of the fetus by extracting the posterior arm, allowing the anterior shoulder to slide free.
Required when external manipulation is insufficient to dislodge the impaction.
4
Execute maneuvers of last resort, such as the Zavanelli maneuver (cephalic replacement).
The fetal head is pushed back into the vaginal canal to allow for an emergent cesarean delivery.
Reserved strictly for catastrophic cases to prevent fetal asphyxiation when all vaginal delivery maneuvers have failed.

Key Concept

Algorithmic stepwise management of shoulder dystocia
Rate this question

Topics

Labor, Delivery, and Puerperium

More questions from this topic