During a vaginal delivery, the fetal head delivers but the shoulders fail to restitute. The McRoberts maneuver and suprapubic pressure fail to release the anterior shoulder after 60 seconds. What is the most appropriate NEXT step in managing this shoulder dystocia?

• A Rubin II maneuver — pressure on the posterior aspect of the anterior shoulder to adduct and rotate it under the symphysis
• B Woods screw maneuver — pressure on the anterior surface of the posterior shoulder to abduct it
• C Zavanelli maneuver — cephalic replacement followed by emergency cesarean
• D Delivery of the posterior arm by sweeping it across the chest ✓

Explanation

Following failure of McRoberts + suprapubic pressure (first-line), internal rotational maneuvers are attempted: Rubin II (adduction of anterior shoulder), Woods screw (abduction of posterior shoulder), or Rubin II + Woods 'screw' together. If these fail, delivery of the posterior arm directly — identified by locating the fetal arm in the hollow of the sacrum, sweeping it across the chest and delivering the hand — has the highest success rate of all 'rescue' internal maneuvers and is associated with the least fetal injury compared to Zavanelli. Zavanelli (cephalic replacement) is a last resort associated with high maternal and fetal morbidity.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.