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Difficulty: MediumLabor, Delivery, and Puerperium

A 29-year-old multiparous patient at 40 weeks gestation is in the second stage of labor. Following the 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 steps in the most appropriate sequence of escalation for managing this obstetric emergency according to standard protocols.

  1. 1Call for additional obstetric, neonatal, and anesthesia assistance while instructing the patient to stop pushing
  2. 2Hyperflex the maternal thighs against her abdomen and apply firm suprapubic pressure
  3. 3Execute internal rotational maneuvers (e.g., Woods corkscrew or Rubin maneuver)
  4. 4Identify and manually deliver the posterior fetal arm
  5. 5Perform cephalic replacement followed by emergent cesarean delivery

Answer

The correct sequence is: Call for assistance, perform the McRoberts maneuver with suprapubic pressure, execute internal rotational maneuvers, manually deliver the posterior arm, and finally perform cephalic replacement if all other maneuvers fail.
Shoulder dystocia is an obstetric emergency requiring a systematic escalation of maneuvers. The initial response must be to stop maternal pushing and call for specialized assistance. The first-line clinical maneuvers are the McRoberts maneuver (maternal hip hyperflexion) and suprapubic pressure, which together relieve up to 40-60% of cases. If these fail, internal rotational maneuvers (like the Woods corkscrew or Rubin maneuver) are attempted to rotate the shoulders into an oblique plane. If still unresolved, manual delivery of the posterior arm is performed to effectively reduce the bisacromial diameter. Maneuvers of last resort, such as cephalic replacement (Zavanelli maneuver), are strictly reserved for catastrophic cases where all other non-surgical maneuvers have failed.

Step-by-Step Solution

1
Recognize shoulder dystocia (turtle sign) and immediately call for help.
Additional personnel (obstetrics, anesthesia, pediatrics) arrive to assist.
Managing shoulder dystocia requires a coordinated team approach; maternal pushing must also be stopped to prevent further impaction of the fetal shoulder.
2
Perform the McRoberts maneuver and apply suprapubic pressure.
The maternal pelvis flattens, the symphysis pubis rotates cephalad, and the anterior shoulder is often dislodged.
These are the first-line clinical maneuvers because they are non-invasive, rapid to perform, and resolve a large majority of cases.
3
Proceed to internal rotational maneuvers (e.g., Rubin or Woods corkscrew).
The bisacromial diameter of the fetus is rotated into the oblique diameter of the maternal pelvis.
If external maneuvers fail, internal manipulation is necessary to physically change the orientation of the fetal shoulders.
4
Manually deliver the posterior fetal arm.
The posterior shoulder drops into the hollow of the sacrum, decreasing the bisacromial diameter.
This is a reliable next step when rotational maneuvers alone do not relieve the impaction, allowing the anterior shoulder to slide under the symphysis pubis.
5
Perform the Zavanelli maneuver (cephalic replacement) and prepare for emergent cesarean delivery.
The fetal head is returned to the vagina, and delivery is accomplished abdominally.
This is a maneuver of last resort, used only when all other vaginal delivery maneuvers have been exhausted, due to high maternal and fetal morbidity risks.

Key Concept

Algorithm for the management of shoulder dystocia (HELPERR mnemonic)
Estimated Time:1m 0s
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Topics

Labor, Delivery, and Puerperium

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