STOP all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia

What should you do after primary maneuvers fail?

Try to deliver the posterior arm. Although the order of maneuvers in the proposed algorithm may vary, a recent study using a database of more than 130,000 deliveries suggests that use of posterior arm delivery after failure of primary maneuvers, such as McRoberts or suprapubic pressure, may more likely result in resolution.⁵

Start from the beginning, and try again. If the first set of maneuvers does not resolve the problem, running through them again usually leads to success. Although the risk of fetal hypoxia increases the longer it takes to resolve the dystocia, it may actually facilitate delivery because fetal tone may also decrease.

Zavanelli maneuver. In general, use of the Zavanelli maneuver with replacement of the fetal head accompanied by cesarean section is a last resort; there is a lack of data to support its use earlier in the process or more frequently. This maneuver requires reversing the cardinal movements related to head descent in order to successfully complete replacement.

Shoulder dystocia in obese patients proves more difficult

In my own experience with obese patients, suprapubic pressure is often ineffective due to the presence of a large fat pad or pannus. Use of an anterior Rubin’s maneuver to rotate the shoulders about 30° to the oblique often facilitates delivery.

Liberal use of episiotomy to facilitate posterior arm delivery or rotational maneuvers is often necessary with obese patients.

Documentation is key

Documentation of the dystocia event in the patient’s permanent record should not occur until after the care team has discussed the case. This will ensure that the maneuvers utilized and the related timing of events are recorded accurately. This is critically important should a lawsuit occur, since discrepancies or errors in charting will hamper defense of the case. A checklist, such as the one provided by the American College of Obstetricians and Gynecologists, lists key points that should be recorded and outlines important steps related to the event.⁶

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