Question 1 · Paediatrics & Obstetrics · Easy
The head has delivered but the shoulders fail to deliver with the next contraction. What is the first manoeuvre?
- AStrong continuous traction on the head to free the anterior shoulder
- BAll-fours position, then gentle traction on the posterior shoulder
- CMcRoberts manoeuvre, then suprapubic pressure from an assistant
- DDeliver the posterior arm with the elbow flexed across the chest
- EUrgent transfer in the left lateral position to an obstetric unit
Show answer
Answer: C
McRoberts manoeuvre, then suprapubic pressure from an assistant
Shoulder dystocia is impaction of the anterior shoulder behind the symphysis pubis. After calling for expert help, the first manoeuvre is McRoberts: lie the mother flat, remove any pillows and hyperflex her legs against her abdomen, then assess with routine traction; if that fails, an assistant applies suprapubic pressure just above the symphysis from the side of the fetal back. The ABC reports success rates as high as 90% for McRoberts, and up to 90% for McRoberts combined with suprapubic pressure, so most cases resolve with these first two manoeuvres. Only if both fail is the mother moved onto all fours for attempted delivery of the posterior shoulder, and the Oxford Handbook lists delivery of the posterior arm as a further option. Urgent transfer in the left lateral position to the nearest obstetric unit is triggered by failure at that later stage, not used in place of the first-line manoeuvres. Strong continuous traction on the head can cause brachial plexus injury and must be avoided.
Where this comes from
- ABC of Prehospital Emergency Medicine
- Ch. 28 Care of Special Groups: The Obstetric Patient · Shoulder dystocia: McRoberts manoeuvre · p. 154“McRoberts manoeuvre (Figure 28.7) has reported success rates as high as 90%.”
- Ch. 28 Care of Special Groups: The Obstetric Patient · Shoulder dystocia: traction on the head · p. 154“can result in brachial plexus injury and must be avoided”
- Ch. 28 Care of Special Groups: The Obstetric Patient · Shoulder dystocia: all-fours position after the first two manoeuvres fail · p. 154“the mother should be asked to assume the ‘all fours’ position”
- Ch. 28 Care of Special Groups: The Obstetric Patient · Shoulder dystocia: transfer after failure · p. 154“Failure of delivery at this stage should trigger urgent transfer”
- Ch. 28 Care of Special Groups: The Obstetric Patient · Key points · p. 158“McRobert’s manoeuvre combined with suprapubic pressure has up to a 90% success rate”
- Oxford Handbook of Pre-Hospital Care
- Ch. 12 Emergency obstetrics, gynaecology, and care of the newborn · Abnormal labour: shoulder dystocia · p. 690“Flex the mother’s legs up to her abdomen and try again.”
- Ch. 12 Emergency obstetrics, gynaecology, and care of the newborn · Abnormal labour: shoulder dystocia, posterior arm · p. 690“Deliver the posterior arm.”