Question

What is the correct order of maneuvers in shoulder dystocia?

• A. McRoberts $\rightarrow$ Rubin $\rightarrow$ Gaskin $\rightarrow$ Zavanelli
• B. Zavanelli $\rightarrow$ McRoberts $\rightarrow$ Gaskin $\rightarrow$ Rubin
• C. Rubin $\rightarrow$ Gaskin $\rightarrow$ McRoberts $\rightarrow$ Zavanelli
• D. McRoberts $\rightarrow$ Suprapubic pressure $\rightarrow$ Rubin $\rightarrow$ Zavanelli

Hint:

In shoulder dystocia, remember: McRoberts first, Zavanelli last.

Answer 1

The Correct Option is A

Step 1: Understanding the Question:
Shoulder dystocia is an emergency where the fetal head is delivered but the anterior shoulder is impacted behind the maternal symphysis pubis. Rapid, systematic maneuvers are required to release the shoulder.
Step 2: Detailed Explanation:

McRoberts Maneuver: This is the first-line external maneuver involving hyperflexion of the maternal hips. It flattens the sacrum and rotates the symphysis pubis cephalad, facilitating disimpaction.

Rubin II Maneuver: If external maneuvers (including suprapubic pressure) fail, internal maneuvers are used. Rubin II involves reaching into the vagina and applying pressure to the posterior aspect of the anterior shoulder to adduct it.

Gaskin Maneuver: Also known as the "all-fours" position. This change in maternal position can increase pelvic diameters and use gravity to help the shoulder slip past the pubic bone.

Zavanelli Maneuver: This is a terminal, highly invasive rescue maneuver. It involves flexing the fetal head and pushing it back into the uterus, followed by an immediate emergency Cesarean section. It is associated with high maternal and fetal morbidity.

Logical Progression: The management moves from non-invasive (McRoberts) to invasive internal rotation (Rubin) to maternal positioning (Gaskin) and finally to extreme surgical measures (Zavanelli).

Step 3: Final Answer:
The correct clinical sequence for escalating interventions in shoulder dystocia is McRoberts followed by Rubin, Gaskin, and finally Zavanelli.