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

1. A

   A. McRoberts maneuver with suprapubic pressure

2. B

   B. Wood's corkscrew maneuver

3. C

   C. Rubin maneuver

4. D

   D. Zavanelli maneuver

Appeared in: INI-CET EXAM -2026

Explanation

• Shoulder dystocia is an obstetric emergency where the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after the head is delivered.
• The initial and least invasive management is the McRoberts maneuver, which involves hyperflexing the mother's thighs sharply against her abdomen.
• This maneuver flattens the sacrum and rotates the symphysis pubis cephalad, which often resolves the obstruction without requiring more invasive procedures.
• Suprapubic pressure is applied concurrently by an assistant to help adduct the fetal shoulders and rotate them into a more favorable pelvic diameter.
• This combination is the universally recommended first step in management protocols for shoulder dystocia due to its effectiveness and relative safety.

Why Other Options Were Wrong

• Option B: The Wood's corkscrew maneuver is an internal rotational maneuver, not the first step. It involves applying pressure to the posterior shoulder to rotate the fetus 180 degrees.
• Option C: The Rubin maneuver is another internal maneuver where the provider attempts to adduct the fetal shoulders by pushing the most accessible shoulder toward the fetal chest.
• Option D: The Zavanelli maneuver is a procedure of last resort and is never the first step. It involves pushing the fetal head back into the uterus (cephalic replacement) followed by an emergency cesarean section.

Related Visual

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 a time-critical emergency. The umbilical cord is compressed between the fetal body and the maternal pelvis, which can lead to fetal hypoxia, acidosis, brain injury, or death if delivery is delayed.
• The nurse's role is critical: immediately call for help (obstetrician, anesthesia, pediatrics), assist the mother into the McRoberts position, apply suprapubic pressure as directed by the provider, and meticulously document the time of head delivery, the maneuvers performed, and the time of body delivery.
• What if the McRoberts maneuver and suprapubic pressure fail? The provider will proceed to second-line internal maneuvers, such as delivering the posterior arm or performing the Rubin or Wood's corkscrew maneuvers. The nurse's role is to continue assisting, communicating with the team, and preparing for potential neonatal resuscitation.

How to Approach the Question

• First, identify the clinical scenario presented in the question. The delivery of the fetal head followed by the failure of the shoulders to deliver despite traction is the classic definition of shoulder dystocia.
• Recognize that this is an obstetric emergency requiring a specific sequence of actions.
• The question asks for the 'first step' in management. This requires you to recall the prioritized algorithm for shoulder dystocia.
• Evaluate the options based on invasiveness and standard protocols. Management typically proceeds from the least invasive to the most invasive maneuvers.
• Recall or apply a mnemonic like HELPERR. The 'L' for Legs (McRoberts) and 'P' for Pressure (Suprapubic) are the initial maneuvers.
• Eliminate the other options: Wood's and Rubin maneuvers are internal (more invasive) and performed later. The Zavanelli maneuver is a last-resort surgical intervention.

Concept Tested & Keywords

• Concept Tested: Management of Shoulder Dystocia
• Stem keywords: primigravida, fetal head, shoulders fail to deliver, routine traction, shoulder dystocia
• Lead-in keywords: first step
• Clinical cues: The clinical presentation of the fetal head delivering but the shoulders failing to follow with routine traction is the classic sign of shoulder dystocia, an obstetric emergency.

Question ID

QmO4_k_1nf_TBl-hONc77k

Copy ID

Reference Book

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 17-25

E6 Obstetrics Williams p. 7-17