Which Maneuvers Work Best for Acute Management of Shoulder Dystocia?

Shoulder dystocia can result in maternal and neonatal injuries, including brachial plexus palsies, fractures of the clavicle and humerus, and hypoxic-ischemic encephalopathy in babies as well as postpartum hemorrhage and fourth-degree lacerations in mothers. Although its incidence remains relatively low (reported between 0.6% and 1.4%), it continues to be a clinical challenge for birth attendants and is among the 4 largest causes of monetary awards in obstetric tort cases. Recognizing this problem, Dr Matthew K. Hoffman and colleagues sought to determine the efficacy of various obstetric maneuvers used to resolve shoulder dystocia and their impact on neonatal injury.

Hoffman and colleagues used an electronic database with 206,969 deliveries from 12 centers of the Consortium on Safe Labor. Using the database as well as the medical records of those found to have shoulder dystocia, the researchers identified the cases in which there was successful use of a maneuver leading to delivery of the neonate as well as those cases in which the development of a neonatal injury was attributable to the management of the shoulder dystocia. In this study, the researchers limited their definition of neonatal injury to brachial plexus injury (Erb palsy or Klumpke palsy), nonintentional fracture of the clavicle or humerus diagnosed by radiography, hypoxic-ischemic encephalopathy, or neonatal death. Maneuvers were classified into one of the following groups: McRoberts maneuver, suprapubic pressure, Rubin maneuver, delivery of the posterior shoulder, Woods corkscrew maneuver, Gaskin maneuver (delivery in the maternal knee-chest position), Zavanelli maneuver, and fundal pressure.

Of the births in the registry, there were 2018 cases of shoulder dystocia, with 101 neonates (5.2%) incurring injury. Ten of the fetuses incurred multiple injuries. The most common injury was Erb palsy, which occurred in 59.4% of the cases (Figure 1). Hoffman and colleagues also found that dystocia occurred more often in younger women, African American women, and non-Hispanic women as well as in those women who were less parous. In addition, the mean weight of the neonates who experience dystocia was higher than those who did not.

Figure 1. Incidence of neonatal injury by type.

Interestingly, there were no significant differences found based on who primarily managed the shoulder dystocia (ie, resident physicians compared with midwives or attending physicians). Hoffman and colleagues noted that neonatal injury was more likely to incur after operative vacuum delivery (22.8%) as compared to those cases in which the head was delivered spontaneously (14.5%); they did not find similar outcomes for forceps use.

On average, 1.86 maneuvers were needed in each case to relieve the dystocia; in total, 3751 maneuvers were performed. Hoffman and colleagues noted that 84.4% of deliveries had successful resolution of the shoulder dystocia when delivery of the posterior shoulder was attempted. Success rates ranged from 24.3% for the McRoberts maneuver to 72.0% for the Woods corkscrew.

As expected, the percentage of neonatal injuries increased as the number of maneuvers used increased. McRoberts and suprapubic pressure methods were associated with the lowest rates of neonatals with injuries. Odds ratios for the various methods can be found in Figure 2.

Figure 2. Odds ratios for neonatal injury based on maneuver type.

“We were able to clearly demonstrate that delivery of the posterior shoulder was superior to other maneuvers in the acute management of shoulder dystocia with a comparable rate of neonatal injury,” Hoffman and colleagues concluded. “Based on our data, we strongly encourage the early use of maneuvers to deliver the posterior shoulder when a shoulder dystocia is encountered.”

More Information

AAFP: Shoulder DystociaRCOG: A Difficult Birth: What Is Shoulder Dystocia?
 

Related Content

Obstetrics Case Report: Shoulder DystociaEducational Tutorial: Shoulder Dystocia: Evidence-Based View
 

Maneuvers for Managing Shoulder Dystocia

McRoberts maneuver

Suprapubic pressure

Rubin II Maneuver
 

Delivery of the posterior shoulder

Woods Corkscrew Maneuver

Zavanelli Maneuver

References:

Reference
Hoffman MK, Bailit JL, Branch DW, et al. A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol. 2011 Jun;117(6):1272-1278.