Shoulder dystocia persists despite McRoberts manoeuvre, suprapubic pressure, Rubin rotation and posterior arm delivery. The fetal head remains tightly retracted against the perineum and the fetus is still alive. As a last-resort measure before fetal demise, the operator performs cephalic replacement. This manoeuvre consists of:

• A Flexing the head, pushing it back into the vagina under tocolysis, and proceeding immediately to caesarean delivery ✓
• B Rotating the head 180 degrees to convert the impacted biacromial diameter to the oblique pelvic axis
• C Deliberate fracture of the fetal clavicle followed by vaginal delivery of the trunk
• D Rapid fundal pressure while an assistant performs an episiotomy extension

Explanation

The Zavanelli manoeuvre involves returning the fetal head to the vagina in flexion with continuous reverse pressure, administering a tocolytic such as terbutaline to relax the uterus, maintaining flexion, and delivering by caesarean section. It is reserved for failed standard manoeuvres. Rotating the shoulders describes Wood screw-type moves, clavicular fracture is a separate salvage manoeuvre performed vaginally, and fundal pressure is contraindicated in shoulder dystocia because it worsens impaction.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.