During a shoulder dystocia, McRoberts manoeuvre with suprapubic pressure, Rubin II, Wood's screw and removal of the posterior arm have all failed. The fetus is alive with a detectable heartbeat. What is the most appropriate next step?
- A Zavanelli manoeuvre followed by caesarean delivery ✓
- B Symphysiotomy
- C Deliberate clavicle fracture of the anterior shoulder
- D Fundal pressure to expel the shoulders
Correct answer: A. Zavanelli manoeuvre followed by caesarean delivery
Explanation
When all standard and secondary manoeuvres fail in a live fetus, the Zavanelli manoeuvre, flexing the head and replacing it into the vagina followed by caesarean delivery, is the accepted last-resort option, with tocolysis given to facilitate replacement. Fundal pressure is dangerous and never indicated in shoulder dystocia. Symphysiotomy and intentional clavicle fracture are salvage options considered mainly where caesarean capability is unavailable or replacement fails.
Reference: RCOG Green-top Guideline No. 42: Shoulder Dystocia, 2012 ed.
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Written and medically reviewed by the StethoPrep medical team.