Shoulder dystocia is encountered after delivery of the fetal head. The McRoberts manoeuvre and suprapubic pressure fail after 30 seconds. Which is the CORRECT sequence of next internal manoeuvres according to the HELPERR mnemonic?

• A Delivery of posterior arm first → Rubin II → Episiotomy
• B Rubin II → Wood screw → Reverse Wood screw → delivery of posterior arm ✓
• C Fundal pressure → Rubin II → Zavanelli manoeuvre
• D Gaskin all-fours position (Roll) → Rubin II → Wood screw → posterior arm delivery

Explanation

After failed McRoberts + suprapubic pressure, HELPERR dictates: H – Call for Help; E – Evaluate for Episiotomy; L – Legs (McRoberts); P – Suprapubic Pressure; E – Enter (internal manoeuvres): Rubin II (pressure on anterior shoulder's posterior surface to adduct and rotate), then Wood screw (pressure on posterior shoulder's anterior surface, rotating opposite direction), then Reverse Wood screw (Rubin II on posterior shoulder); R – Remove the posterior arm; R – Roll to all-fours (Gaskin). Fundal pressure must NEVER be applied (worsens impaction). Zavanelli (cephalic replacement + caesarean) is a last resort.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.