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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Shoulder Dystocia
Sponsored by The Indian Health Service Clinical Support Center
7. Maneuvers - internal
So, what if you’ve got that “one in five” SD that doesn’t respond (Ramsey) to the above simple maneuvers? Probably the next best maneuver is called the “Wood screw maneuver”
(Sorry about all the eponyms; you needn’t necessarily remember them, but they have become standard terminology, and you will hear them frequently.)
The “Wood screw” involves another attempt to disimpact the anterior shoulder, this time by trying to move the fetus into the oblique, so that the upper, impacted, shoulder will drop beneath the pubic arch. So let’s say the fetus has delivered ROA (it’s “looking” towards the maternal left). Its left, upper, shoulder is anterior, and is the impacted one. Your mission is to push the posterior, right, shoulder upwardly, while your assistant exerts suprapubic pressure down and to the left to push the anterior shoulder out from behind the pubis. (Vice-versa if it’s LOA…)
In order to do this you must introduce your fingers. This is hard because the fetal head is retracted back against the perineum in a “turtle sign”, and you usually cannot get your fingers in anteriorly. This is the time you may need an episiotomy in order to have some room posteriorly to insert two fingers to push up on the posterior shoulder. (Again, if the fetus is in ROA, the posterior shoulder is the right shoulder, and vice-versa for LOA.) If that doesn’t work, the next, very similar, maneuver is the Rubin maneuver. It’s just the reverse. This time you introduce two fingers posteriorly and try to work them up anteriorly until you encounter the anterior shoulder. You then try to gently, but firmly, pull down that impacted anterior shoulder from behind as your assistant exerts downward suprapubic pressure. The expectation is that, between the two of you, you will move the fetus into a more oblique position and disimpact the shoulder.
Here is an interesting twist (no pun intended):
Consider this
Birth Simulator for Shoulder Dystocia - Rubin's maneuver requires the least traction
Without expeditious and appropriate management, both mother and fetus are at risk for injury, even death. Up to 27% of shoulder dystocia deliveries are associated with brachial plexus palsy, of which 10% are permanent. A novel birth simulator designed by biomedical engineers at Johns Hopkins University in Baltimore, Maryland, helps identify the least traumatic delivery procedure for shoulder dystocia and other problem deliveries and assists in physician training. Conclusion: In a laboratory model of initial maneuvers for shoulder dystocia, anterior Rubin's maneuver requires the least traction for delivery and produces the least amount of brachial plexus tension. Further study is needed to validate these results clinically.
Gurewitsch ED et al Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: An objective evaluation. Am J Obstet Gynecol. 2005 Jan;192(1):153-60.
