A generous episiotomy may be desired at this time to aford room posteriorly.
3.
Suprapubic pressure is used initially by most practitioners because it has the advantage of simplicity. Only one assistant is needed to provide suprapubic pressure, while normal downward traction is applied to the fetal head.
4.
The McRoberts maneuver requires two assistants. Each assistant grasps a leg and sharply lexes the maternal thigh toward the abdomen.
These maneuvers will resolve most cases of shoulder dystocia. If the above listed steps fail, the following steps may be attempted, and any of the maneuvers may be repeated: 5.
Delivery of the posterior arm is attempted. With a fully extended arm, however, this is usually diicult to accomplish.
6.
Woods screw maneuver is applied.
7.
Rubin maneuver is attempted.
The American College of Obstetricians and Gynecologists (2017c) has concluded that no one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. Performance of the McRoberts maneuver, however, is deemed a reasonable initial approach. In one review of more than 2000 cases, Hofman and colleagues (2011) noted an 84-percent success rate with posterior shoulder delivery and comparable rates of neonatal injury compared with other standard methods. This contrasts with a review of 205 cases, in which posterior shoulder delivery yielded greater neonatal injury rates than rotational methods (Leung, 201i1b). Spain and associates (2015) found that duration rather than a speciic maneuver increased neonatal injury.
Importantly, progression from one maneuver to the next should be organized and methodical. As noted, the urgency to relieve the dystocia should be balanced against potentially lnJurious traction forces and manipulations. Lerner and coworkers (201l) in their evaluation of 127 shoulder dystocia cases reported that all neonates without sequelae from shoulder dystocia were born by 4 minutes. Conversely, most depressed neonates-57 percent-had head-to-body delivery intervals >4 minutes. The percentage of depressed neonates rose sharply after 3 minutes.
Shoulder dystocia training and protocols using simulationbased education and drills has evidence-based support. These tools improve performance and retention of drill steps (Buerkle, 2012; Crofts, 2008; Grobman, 201l). Their use has translated into improved neonatal outcome in some, but not all, investigations (Crofts, 2016; Fransen, 2017; Kim, 2016; Walsh, 201l). The American College of Obstetricians and Gynecologists (2012) also has created a Patient Safety Checklist to guide the documentation process with shoulder dystocia.
In 2014, 0.7 percent of deliveries in the United States were planned home births and 0.2 percent were unplanned (MacDorman, 2016). Of unplanned births in a 15-year epoch in Norway, 69 of 6027 or 1.1 percent resulted in fetal or neonatal death. This high rate was attributable to infection, prematurity, and placental abruption (Gunnarsson, 2017). Multiparity and distance from the hospital were ascribed risks (Gunnarsson, 2014). In the United States, youth, lack of prenatal care, minority race, and lower educational attainment were associated risks for unplanned home birth (Declercq, 2010).