A primigravida delivers the fetal head but the shoulders fail to deliver despite routine traction. What is the first step in management?

1. A

   McRoberts maneuver with suprapubic pressure

2. B

   Wood's corkscrew maneuver

3. C

   Rubin maneuver

4. D

   Zavanelli maneuver

Appeared in: NORCET 1 - 2020

Explanation

Listen in Hindi

• The McRoberts maneuver is the recommended first-line intervention for shoulder dystocia because it is non-invasive and highly effective.
• This maneuver involves hyperflexing the mother's thighs against her abdomen, which alters the pelvic angle by flattening the sacral promontory and rotating the symphysis pubis superiorly.
• This change in pelvic geometry can often dislodge the impacted anterior shoulder without requiring internal manipulation.
• Suprapubic pressure is applied simultaneously by an assistant to help push the anterior shoulder into a more favorable oblique diameter and under the pubic symphysis.

Why Other Options Were Wrong

• Option B: The Wood's corkscrew maneuver is an internal rotational maneuver, which is considered a secondary intervention, not the first step. It is performed only if the McRoberts maneuver and suprapubic pressure fail to resolve the dystocia.
• Option C: The Rubin maneuver is another type of internal rotational maneuver. Like the Wood's maneuver, it is a secondary step in the management algorithm, attempted after the failure of the McRoberts maneuver.
• Option D: The Zavanelli maneuver is a procedure of last resort. It involves pushing the fetal head back into the uterus (cephalic replacement) followed by an emergency Cesarean section. It is only considered after all other standard maneuvers have failed and carries significant maternal and fetal risks.

Related Visual

• Visual 1: Diagram - A diagram illustrating the McRoberts maneuver, showing the change in pelvic angle as the mother's thighs are flexed
• towards her abdomen.
• Visual 2: Flowchart - A flowchart depicting the HELPERR mnemonic, showing the sequential steps for managing shoulder dystocia, starting with calling for help and the McRoberts maneuver.

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Management of Shoulder Dystocia as background academic context rather than a clinical decision trigger.
• Shoulder dystocia is an unpredictable obstetric emergency that requires a rapid, coordinated, and systematic response from the entire delivery team to minimize the risk of severe complications.
• The primary risks to the fetus include birth asphyxia (lack of oxygen), which can lead to brain damage or death, and brachial plexus injury (Erb's palsy), which can cause permanent arm weakness or paralysis.
• Maternal risks include severe postpartum hemorrhage, perineal tears, and uterine rupture.

How to Approach the Question

• First, identify the clinical situation described in the question stem. The delivery of the fetal head followed by the failure of the shoulders to deliver is the classic definition of shoulder dystocia.
• Recognize that shoulder dystocia is an obstetric emergency requiring a specific, ordered sequence of interventions.
• Recall the standard management protocol for shoulder dystocia, often summarized by the HELPERR mnemonic.
• The question asks for the 'first step' in management. According to the protocol, the initial physical maneuver is the McRoberts maneuver (Legs), often performed with suprapubic pressure (Pressure).
• Evaluate the options provided. Option A directly corresponds to the initial steps of the standard protocol.
• Eliminate the other options by placing them correctly in the sequence: Wood's and Rubin maneuvers are secondary (internal) maneuvers, and the Zavanelli maneuver is a last-resort procedure.

Concept Tested & Keywords

• Concept Tested: Management of Shoulder Dystocia
• Stem keywords: primigravida, fetal head, shoulders fail to deliver, routine traction
• Lead-in keywords: first step
• Clinical cues: The scenario describes a classic case of shoulder dystocia, an obstetric emergency.

Question ID

QYMDnGZ8dVkXEWdtZUemc9

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