Search

A precipitous delivery can be among the most stressful events an emergency physician encounters. The physician must assess 2 patients (mother and fetus) and be prepared to manage a variety of complications that may arise during delivery. A majority of precipitous deliveries result in good outcomes for both mother and baby, but emergency physicians must be prepared to manage feared complications, such as tight nuchal cords, shoulder dystocia, and breech presentation. An understanding of the labor process as well as advanced planning can help decrease the stress and chaos inherent to any precipitous delivery.

Shoulder dystocia is an obstetric emergency which is unpredictable and complicates approximately 0.5-1% of vaginal births. This article discusses the risk factors and the associated fetal and maternal complications, while it is also an overview of techniques and algorithms to handle shoulder dystocia.

Objective Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia. Study design We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required. Results We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia. Conclusion In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery.

Precipitous or emergency department (ED) delivery is a stressful event that requires preparation to comfortably approach and safely manage—often including development of ED delivery checklists or kits and appropriate expedited consultant notification (i.e., paging lists). Complications are rare but include shoulder dystocia, prolapsed umbilical cord, and breech presentation. If a shoulder dystocia is encountered, an algorithm of maneuvers can be employed and should start with McRoberts maneuver and application of suprapubic pressure and proceed to include rotational or internal maneuvers. Management of a prolapsed umbilical cord should start with elevation of the presenting fetal part to alleviate pressure on the umbilical cord and expedited obstetric assistance for emergent cesarean section. Breech delivery is best managed by allowing the mother to deliver the fetus with no assistance in delivery until the umbilicus is visualized.

Shoulder dystocia (SD) is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. It complicates 0.5-1% of vaginal deliveries. Risks of brachial plexus birth injury (level of evidence [LE]3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) increase with SD. Its main risk factors are previous SD and macrosomia, but both are poorly predictive; 50-70% of SD cases occur in their absence, and most deliveries when they are present do not result in SD. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of SD. Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for SD (Grade C). In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (Grade A). Women with gestational diabetes require diabetes care (diabetic diet, glucose monitoring, insulin if needed) (Grade A) because it reduces the risk of macrosomia and SD (LE1). Only two measures are proposed for avoiding SD and its complications. First, induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more (professional consensus). Second, cesarean delivery is recommended before labor in three situations and during labor in one: (i) estimated fetal weight (EFW) >4500g if associated with maternal diabetes (Grade C), (ii) EFW >5000g in women without diabetes (Grade C), (iii) history of SD associated with severe neonatal or maternal complications (professional consensus), and finally during labor, (iv) in case of fetal macrosomia and failure to progress in the second stage, when the fetal head station is above +2 (Grade C). In cases of SD, it is recommended to avoid the following actions: excessive traction on the fetal head (Grade C), fundal pressure (Grade C), and inverse rotation of the fetal head (professional consensus). The McRoberts maneuver, with or without suprapubic pressure, is recommended first (Grade C). If it fails and the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, it is preferable to attempt to deliver the posterior arm next (professional consensus). It appears necessary to know at least two maneuvers to perform should the McRoberts maneuver fail (professional consensus). A pediatrician should be immediately informed of SD. The initial clinical examination should check for complications, such as brachial plexus injury or clavicle fracture (professional consensus). If no complications are observed, neonatal monitoring need not be modified (professional consensus). The implementation of practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury. SD remains an unpredictable obstetric emergency. All physicians and midwives should know and perform obstetric maneuvers if needed, quickly but calmly.

Any delivery in the emergency department is considered a precipitous birth and is an anxiety-producing event. Many deliveries proceed without incident. However, the emergency physician must be prepared for several dreaded scenarios, such as nuchal cord, shoulder dystocia, and breech birth. This article reviews the basics, complications, and management of such deliveries.

This article reviews one of the less common but most dreaded complications of labor and delivery, shoulder dystocia, an infrequent but potentially devastating event that results from impaction of the fetal shoulders in the maternal pelvis. Shoulder dystocia occurs most commonly in patients without identified risk factors, and can result in both maternal and fetal morbidity. Because the vast majority of cases of shoulder dystocia are unpredictable, obstetric care providers must be prepared to recognize dystocia and respond appropriately in every delivery. Detailed documentation is essential after any delivery complicated by shoulder dystocia.

We report on 2 primigravidae developing pneumomediastinum and subcutaneous emphysema associated with the second stage of labor. Both of the newborns had a comparatively high birth-weight (3,855 g and 4,245 g, respectively). In the first case, the patient felt a sudden chest pain during expulsion followed by dyspnea and swelling of the face. The birth was terminated by vacuum extraction. In the second case, a mild shoulder dystocia occurred, which could be resolved by McRoberts maneuver. The patient exhibited a swollen face and shortness of breath on the first postpartum day. Physical examination revealed crackly skin over the lower face, both sides of the neck and the front of the chest. In both cases, CT scan of the chest revealed pneumomediastinum and a subcutaneous emphysema of the upper thorax, however without showing a pneumothorax. The first patient underwent bronchoscopy and esophagogastroduodenoscopy; there were no abnormalities detected. The pneumomediastinum and subcutaneous emphysema gradually diminished spontaneously in both cases. Appropriate pain management and empirical antibiotics were applied. Pneumomediastinum during labor and birth, typically with subcutaneous emphysema in the face and neck, is a rare condition, but there are reported cases in the literature. Based on the limited available evidence, it seems to have a benign, self-limiting course. A conservative management appears -appropriate and sufficient.

Objective In an effort to reduce shoulder dystocia incidence and morbidity, some obstetricians use prophylactic maternal hip hyperflexion (McRoberts maneuver), with the hope of facilitating delivery and decreasing the traction needed for delivery. The objective of this study was to evaluate whether the delivery force is reduced with the prophylactic McRoberts maneuver in a prospective, objective manner. Study design Between April 2002 and July 2003, we randomly assigned multiparous women with term, cephalic singleton gestations to delivery in the lithotomy or McRoberts position. A single physician used a force-measuring system that consisted of a custom glove with force sensors to record the amount of force that was exerted on the fetal head. The primary outcomes of the study were peak force (pounds; highest force needed to accomplish entire delivery), peak force for delivery of anterior shoulder (pounds), and peak force rate (pounds per second; the duration required to reach the peak force). Results The peak force was not different between the patients in the lithotomy position (n=13) versus the McRoberts position (n=14; 7.2 ± 0.8 lbs vs 8.0 ± 0.7 lbs; P =.5). The peak force for delivery of the anterior shoulder (6.7 ± 0.8 lbs vs 7.1 ± 0.7 lbs; P =.7) and peak force rate (32.3 ± 7.0 lbs/sec vs 29.1 ± 3.5 lbs/sec; P =.7) were not different between the patients in the lithotomy position versus the McRoberts position, respectively. There was no difference between the groups for gestational age, birth weight, incidence of diabetes mellitus, or operative vaginal delivery. The subjective degree of difficulty of the delivery correlated with the peak force ( R 2 =0.53; P =.001). Conclusion The use of the McRoberts maneuver before clinical diagnosis of shoulder dystocia provides no reduction in the force that is used in traction on the fetal head during vaginal delivery in multiparous patients. The acceptance of this maneuver to be used prophylactically requires re-evaluation.

Objective The purpose was to study the impact of maternal endogenous and clinician-applied exogenous delivery forces on brachial plexus stretching during a shoulder dystocia event. Study design A computer software crash dummy model (MADYMO, version 5.4, TNO Automotive, Delft, The Netherlands) was modified on the basis of established maternal pelvis and fetal anatomic specifications. The brachial plexus was modeled as a spring, with mechanical properties that were based on previously reported experimental data. Increasing amounts of endogenous or exogenous loading forces were applied until delivery of the anterior fetal shoulder occurred. Brachial plexus deformation was assessed as percent stretch in the nerve (Change in length/Original length×100). Results With lithotomy positioning, both maternal endogenous and clinician-applied exogenous delivery forces were associated with brachial plexus stretching (15.7% vs 14.0%, respectively). McRoberts positioning reduced needed loading forces for delivery and resulted in 53% less brachial plexus stretch (6.6%). Downward lateral displacement of the fetal head was associated with a 30% increase in brachial plexus stretch (18.2%) compared with axial positioning of the head (14.0%). Conclusion Brachial plexus stretch varied as a result of the load required for delivery, the source of the applied force, pelvic orientation, and fetal head positioning. Maternally derived and clinician-applied delivery forces can both lead to brachial plexus deformation when shoulder dystocia is encountered. The McRoberts maneuver can reduce brachial plexus stretching. Management of fetal head position may also be important in reducing unnecessary brachial plexus stretch.

Objective: To document radiographically the changes in pelvic dimensions created by McRoberts’ maneuver. Methods: Women at least 37 weeks’ pregnant who presented to labor and delivery were eligible for study entry. Anterior-posterior and lateral x-rays were taken with women in the dorsal lithotomy position and after application of McRoberts’ maneuver, in which the maternal legs were hyperflexed 45 degrees onto the maternal abdomen. A two-tailed paired t test was used to assess the changes in the pelvic diameters, with P < .05 considered statistically significant. Results: Thirty-six subjects were enrolled in the study and 34 x-rays were suitable for analysis. McRoberts’ maneuver was associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory (51.53 ± 2.03 versus 38.07 ± 1.96 degrees, P < .001). There was a 24% decrease in the angle created by drawing a line bisecting the symphysis pubis relative to the horizontal (P < .001). With McRoberts’ maneuver the angle created by a line bisecting the longitudinal axis of the fifth lumbar vertebra and the longitudinal axis of the upper sacrum also increased (133.75 ± 2.25 to 140.14 ± 2.12 degrees, P = .04). Conclusion: Ours are the first systematic observations of pelvic changes associated with McRoberts’ maneuver, confirming the traditional thinking that the maneuver causes a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum.

OBJECTIVE: Our purpose was to determine the rate of success of the McRoberts' maneuver as the initial treatment for shoulder dystocia and to compare the rate of maternal and neonatal morbidity with those cases of shoulder dystocia requiring additional obstetric maneuvers. A secondary goal was to assess those factors associated with successful McRoberts' maneuvers. STUDY DESIGN: A retrospective review of shoulder dystocia cases occurring between 1991 and 1994 was performed. The identified cases were divided into two groups on the basis of the maneuvers used to relieve the shoulder dystocia. The first group comprised cases in which the McRoberts' maneuver was used as the sole treatment and the second group consisted of cases in which additional maneuvers were subsequently used. Exclusion criteria included lack of documentation concerning the maneuvers used or cases in which the McRoberts' maneuver was not the initial technique used. The two groups were compared with respect to various antepartum, intrapartum, and neonatal characteristics. RESULTS: During the study period we identified 250 cases of shoulder dystocia among 44,072 vaginal deliveries, for an incidence of 0.57%. Of these, 236 cases (94%) fulfilled entry criteria. The McRoberts' position alone successfully alleviated the shoulder dystocia in 98 cases (42%). In the group of cases where the McRoberts' maneuver was the sole maneuver used, there were significantly lower mean birth weights (p = 0.008), shorter durations of the active phase of labor (p = 0.009), and shorter second stages (p < 0.0001). In the group of cases that required additional maneuvers to relieve the shoulder dystocia, there was a trend toward an increased incidence of postpartum hemorrhage and brachial plexus injury (p = 0.07). CONCLUSIONS: These data suggest that the McRoberts' maneuver is associated with a significant degree of success in relieving shoulder dystocia and may be associated with decreased morbidity compared with other maneuvers. On the basis of these findings, we recommend the McRoberts' maneuver as the initial technique for disimpaction of the anterior shoulder.(Am J Obstet Gynecol 1997;176:656-61.)

Objectives: To ascertain the type and order of maneuvers that should be used for the treatment of shoulder dystocia; and to attempt to quantify the severity of shoulder dystocia, and to determine its correlation with perinatal outcome. Methods: We reviewed all consecutive cases of shoulder dystocia from January 1986 to August 1994 in our institution to obtain the type, order and number of maneuvers used for delivery. Patients were stratified by the number of maneuvers required for delivery. Outcome parameters included cord pH, Apgar score, neonatal trauma (Erb's palsy and fracture), and maternal trauma. Results: The incidence of shoulder dystocia was 0.7% (39 280 total vaginal deliveries). Use of only two maneuvers, McRoberts and suprapubic pressure, resulted in resolution in 58% of cases. The addition of the Woods screw maneuver and/or delivery of the posterior arm was sufficient in all remaining cases. The rates of neonatal palsy and fracture, and maternal fourth-degree laceration, increased with the number of maneuvers. Conclusions: The McRoberts maneuver and suprapubic pressure should be first-line treatment for shoulder dystocia. More difficult and damaging maneuvers such as Woods screw and delivery of the posterior arm may be reserved for refractory cases. Additional maneuvers are rarely necessary for delivery. The number of maneuvers may serve as a measure of the severity of the shoulder dystocia.

Objective To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. Methods We conducted a 10-year (1980–1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. Results There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. Conclusion Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forceps delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.

Background The most common neonatal complications associated with shoulder dystocia include transient brachial plexus palsy, clavicular fracture, and humeral fracture. Fracture of the fetal radius has not been previously reported. Case We encountered a shoulder dystocia with the fetal head in the right occiput anterior position that necessitated the McRoberts maneuver, suprapubic pressure, the Wood and Rubin maneuvers, and extraction of the posterior fetal arm to effect delivery. The 4610-g infant experienced a spiral fracture of the right (anterior) radius and a fracture of the left (posterior) midhumeral shaft. Conclusion Neonatal radial fracture can result from shoulder dystocia or the maneuvers employed for the alleviation of the shoulder dystocia. (Obstet Gynecol 2003;102:36–8.)

Shoulder dystotia is a rare but serious obstetric complication that can result in significant neonatal and maternal morbidity and in costly litigation. Conflict exists in the literature regarding definition, incidence, predictability and preventability, relationship to neonatal injury, and appropriate management models. Anticipatory clinical interventions for potential shoulder dystocia have included ultrasound assessment of macrosomia; elective induction of labor; elective caesarean section; altered place of birth; and generous episiotomy/episioproctotomy. The authors note that these interventions often conflict with client desires and nurse-midwifery philosophy of birth, generate significant risks and costs in themselves, and do not address the poor predictability of shoulder dystocia. In recent literature, the safety and efficacy of maternal position change maneuvers (such as McRoberts maneuver, hands-knees position, and squatting) have been presented as methods to resolve most cases of shoulder dystocia. Despite the success of these more benign, external maneuvers, the episiotomy mandate remains in nearly all obstetric and midwifery texts and handbooks (1–8) and journal references (9–19). A literature review of related professional disciplines was undertaken to study these conflicts and to identify support for applying a philosophy of minimal, appropriate intervention to the complex issue of shoulder dystocia.

BACKGROUND: The Zavanelli maneuver has typically been instituted when conventional maneuvers have failed to alleviate shoulder dystocia. Previously reported cases involving the Zavanelli maneuver have described cephalic replacement followed by immediate cesarean delivery. CASE: We encountered a case in which, despite the McRoberts maneuver, suprapubic pressure, Wood’s corkscrew manuever, and attempted extraction of the posterior fetal arm, the baby could not be delivered. The fetal vertex was partially reinserted into the vagina, and this dislodged the impacted shoulders. With expulsive efforts the mother was then able to achieve vaginal delivery of a 3870 g female infant. CONCLUSION: The modified Zavanelli maneuver may be used to successfully alleviate shoulder dystocia.

Lymphangiomas are rare hamartomatous malformations of skin lymphatics and subcutaneous tissues, and can occur anywhere in the body. Approximately 50% of lymphangiomas are present at birth and up to 90% are visible by the age of 2 years [1]. Approximately 70%–80% occur in theneck [2] and the remaining20%–30%occur in the axillary region [3]. Rare locations include the mediastinum, extremities, trunk, retroperitoneal area, abdominal viscera, pelvis, and chest wall [4]. In the present case, previously undetected fetal lymphangiomas were discovered during delivery at Bankura Sammilani Medical College, Bankura, India. A24-year-oldwoman, gravida2,was referred to thehospital's tertiary center at 39 weeks of pregnancy owing to nonprogress of labor. Her first infant had been delivered vaginally 2.5 years previously. On admission, vaginal examination revealed 4-cm cervical dilation, 80% effacement of cervix, vertex presentation, and 0 station. Oxytocin infusion was started. After 4 hours, the head of the fetus was delivered; however, delivery of the shoulders proved difficult and shoulder dystocia was diagnosed. The McRoberts, Woods, and Zavanelli maneuvers were unsuccessful. At laparotomy, the anterolateral uterine segment was ruptured. The dead fetus was delivered abdominally with assistance from below and the rupture was repaired. A 10×10-cm swelling was found on the right side of the anterior chest of the fetus (Fig. 1) and nonpitting edemawas found on the right upper limb. The fetus weighed 4.5 kg. Multiple fluid-filled spaces were found via ultrasonogram. The presence of lymphangioma and hemangioma was suspected; this was supported by computed tomography scan and confirmed via histopathology. Lymphangiomas are classified into 3 groups: lymphangioma simplex, consisting of capillary-sized channels; cavernous lymphangioma, consisting of dilated lymphatic channels; and cystic lymphangioma (hygroma), comprising multiple cysts of varying sizes [3]. Although the incidence of cystic lymphangioma is estimated to be 1 per 6000 pregnancies, it is a relatively common anomaly (1 per 875) in spontaneously aborted fetuses [2]. Based on the autopsy findings, the lesions in thepresent casewere considered to be cystic lymphangiomas. Lymphangiomas result from a defect in the connection between the lymphatic channels and the venous system, or from abnormal development of the lymphatic vessels [5]. Burke et al. [6] described a similar case in which cystic lymphangioma caused a difficult breech delivery. The shoulders and head of the dead fetus were delivered after multiple perforations of the lesion with a curette. Prenatal diagnosis of lymphangioma helps to plan the mode of delivery and intrapartum/postpartum care, and may decrease the morbidity of both mother and infant. Intrapartum ultrasound, if available, may be useful in cases of significant, unexpected shoulder dystocia caused by fetal lymphangioma.

The McRoberts position, or maneuver, is a good first-line technique. If combined with more than gentle traction, a brachial plexus will occur. It usually requires additional strong suprapubic pressure.

Objective Much of our understanding and knowledge of shoulder dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is shoulder dystocia predictable? (2) Can shoulder dsytocia be prevented? (3) When shoulder dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of shoulder dystocia? Study design Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "shoulder dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion. Results There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of shoulder dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of shoulder-dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a shoulder dystocia event before any iatrogenic intervention may be associated with brachial plexus injury. Conclusion For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of shoulder dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by shoulder dystocia.

Objective To assess whether prophylactic use of the McRoberts maneuver and suprapubic pressure decreased the head-to-body time, as a proxy for shoulder dystocia, in at-risk patients. Methods Patients with estimated fetal weights over 3800 g were randomized to undergo the McRoberts maneuver and suprapubic pressure before delivery of the fetal head (prophylactic maneuvers) or to undergo maneuvers only after delivery of the head, if necessary (controls). A total of 185 patients were enrolled in the study. After exclusions (eg, abdominal delivery), there were 128 evaluable vaginal deliveries. The study had the power to detect a 30% difference in head-to-body time between groups. Results Head-to-body delivery times did not differ between the prophylactic and control patients (24 ± 18 seconds versus 27 ± 20 seconds, P = .38). In addition, the two groups did not differ in rates of admission of the infant to the special care nursery or in birth injuries. There was a significant increase in the risk of delivering by cesarean for patients randomized to the use of prophylactic maneuvers. Conclusion This study does not support the hypothesis that prophylactic use of the McRoberts maneuver and suprapubic pressure speeds delivery in a population of patients at increased risk for shoulder dystocia.

Background Delivery of the posterior arm, or the Barnum maneuver, is at times used late in shoulder dystocia management algorithms, and is not often a first- or second-line management protocol. Case A multiparous, diabetic patient, who was morbidly obese and had a residual obstetric brachial plexus injury, experienced a precipitous second stage of labor and severe shoulder dystocia. Attempts at the McRoberts maneuver with traction failed to deliver the fetus. In lieu of alternative maneuvers or continued attempts at traction, the posterior arm was delivered and the fetal trunk followed easily. Conclusion A geometric analysis reveals that using posterior arm delivery reduces the obstruction by more than a factor of two, relative to the McRoberts maneuver. We recommend earlier use of this maneuver during shoulder dystocia management.

Many authors have recommended the McRoberts' maneuver as the initial technique in the management of shoulder dystocia. There have been, however, no reported adverse maternal outcomes associated with this technique. We report a case of symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver. An overly exaggerated lithotomy position and thigh abduction stretches the articular surfaces of the symphysis pubis and places increased pressure on the femoral nerve by the overlying inguinal ligament.

S houlder dystocia occurs in 0.23%-2.09% of all vaginal deliveries and is a true obsketrical emergency (1). Risk factors include maternal obesity, diabetes mellitus, postdates pregnancy, fetal macrosomia, prolonged second stage of labor, oxytocin induction, and instrumental extraction (2,3). There are several maneuvers for the management of shoulder dystocia, which occurs during the second stage of labor or delivery. These include application of suprapubic pressure posteriorly (Mazzanti maneuver), flexing the legs onto the abdomen (McRoberts maneuver), rotational maneuver of the shoulder girdle (Wood’s screw rotational maneuver) (4,5), and cephalic replacement (Zavanelli maneuver) (6,7). Effective regional anesthesia will facilitate these maneuvers and enhance maternal cooperation. The Zavanelli maneuver involves manually replacing the feral head into the relaxed uterus followed by cesarean section. Recommendations to provide uterine relaxation include either deep general anesthesia or tocolysis with intravenous (IV) or subcutaneous terbutaline (1,8,9). We present a case in which the Zavanelli maneuver was performed under epidural anesthesia with uterine relaxation provided by amyl nitrite inhalation.

A case report of breech delivery complicated by entrapment of the aftercoming head is presented. McRoberts maneuver was applied to facilitate the release of the head. It is suggested that the same theoretical basis that stands behind the use of McRoberts maneuver in shoulder dystocia might make it applicable as one of the maneuvers to release the aftercoming head in breech delivery.

A survey of 108 major teaching institutions in the United States regarding the utilization of the McRoberts maneuver for shoulder dystocia was conducted. Only 40% taught the procedure but 64% reported being familiar with its use. Among users, only 32% used it as the initial step. Surprisingly, only 40% thought it reduced fetal trauma.