SHOULDER DYSTOCIA: ROTATIONAL VS. NON-ROTATIONAL MANEUVERS

In this blog I’ll be reviewing the difference between rotational and non-rotational maneuvers in the management of a shoulder dystocia.  I’ll also discuss the efficacy in relieving the shoulder dystocia, and the risk of brachial plexus injury, comparing both types of maneuvers.   

Non-rotational maneuvers: pose the least risk on the degree of stretch on the brachial plexus nerve.  Examples include: McRoberts maneuver, suprapubic pressure, and delivery of the poster arm. 

According to ACOG, in cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia. Recent evidence has shown that delivery of the posterior arm has a high degree of success in accomplishing delivery.  In a computer-generated model, delivery of the posterior arm required the least amount of force to effect delivery and resulted in the lowest amount of brachial plexus stretch.  The use of the above maneuvers will relieve 95% of cases of shoulder dystocia within 4 minutes. 

Below Image (delivery of the posterior arm) requires the delivering provider to insert a hand into the vagina and deliver the posterior arm by sweeping it across the fetal chest

Rotational maneuvers: Examples include: The Rubin maneuver,  the Woods Screw maneuver

• The Rubin maneuver requires the delivering provider to insert a hand into the vagina and on the back surface of the posterior fetal shoulder.  The provider then rotates the fetal shoulder anteriorly towards the fetal face with his/her hand.
• The Woods Screw maneuver requires the delivering provider to rotate the fetus by exerting pressure on the anterior, collar bone region of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis (pubic bone).

Below Image (Rubin Maneuver)

References:

The American College of Obstetricians and Gynecologists. (2014). Neonatal brachial plexus palsy. ACOG Task Force on Brachial Plexus Palsy

The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]

 P.S. Comment and Share: What has been your experience in a brachial plexus case involving a shoulder dystocia?  How did the standards of care, specific to type of maneuvers, and type of traction employed, impact the outcome of the case?