Int J Gynecol Obstet,
129
1991, 35: 129-131
International Federation of Gynecology and Obstetrics
McRoberts J.A. O’Leary Department
maneuver for shoulder dystocia: a survey and N.B. Pollack
of Obstetrics
and Gynecology,
Jersey City Medical Center, Jersey City, New Jersey (USA)
(Received November 24th, 1989) (Revised and accepted March 3rd, 1990)
Abstract A survey of 108 major teaching institutions in the United States regarding the utilization of the McRoberts maneuver for shoulder dystocia was conducted. Only 40% taught the procedure but 64% reported being familiar with its use. Among users, on/y 32% used it as the initial step. Surprisingly, only 40% thought it reduced fetal trauma.
Keywords:
Shoulder
Dystocia;
McRoberts
maneuver. Introduction
Shoulder dystocia will always remain a dreaded complication of obstetrics. With current trends towards the liberal use of abdominal delivery for patients with multiple risk factors, hopefully its incidence will decline [6,7]. However, the fact remains that anyone who practices obstetrics is responsible for dealing with even the most difficult shoulder dystocia. Recent interest in alternative maneuvers in shoulder dystocia has brought attention to the reverse knee-chest position or McRobert’s maneuver as a less traumatic but effective method of delivering impacted shoulders [ 1,2,4]. Because it is an unusual occurrence, clinicians will continue to have little chance to develop expertise and confidence, thus continuing evaluation of available techniques is of value. 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Currently most respected references offer management plans that employ relatively traumatic techniques involving fetal manipulation to effect delivery of impacted shoulders [3,5,8]. Maternal manipulation, the McRobert’s maneuver, involves firmly flexing the knees to the maternal chest thus rotating the symphysis pubis cephalad and straightening the sacrum relative to the lumbar spine. Although it is commonly recognized that this does not change the dimensions of the true pelvis, it does change the angle of inclination of the pelvic inlet. This opening of the pelvic inlet may free the anterior shoulder from the symphysis effecting an atraumatic delivery. The purpose of this study was to ascertain the familiarity with the McRobert’s maneuver, its frequency of use, and experience or success with its utilization in a large group of teaching institutions. Materials and methods
To assess the national experience and current status with the McRobert’s maneuver a questionnaire was distributed to program directors at one hundred and eight major academic centers in the United States having over 1500 deliveries per year and with approved residency training program in obstetrics and gynecology. The questionnaire assessed familiarity with the maneuver, whether or not it is taught at the institution, and whether it is advocated as a first line approach. In addition the number of times the maneuver was Clinical and Clinical Research
130
O’Leary and Pollack
employed, its success or failure and an opinion as to whether it was felt to decrease fetal manipulation and trauma were also ascertained.
first time. Two noted the possibility of medicolegal significance in the future if it were not,employed while one individual commented that it was too exotic.
Results
Comment Of 108 questionnaires, 74 (69%) were returned. Sixty-four percent of the institutions were familiar with the maneuver, and 40.0% taught the maneuver to housestaff. Of the institutions familiar with the maneuver, 32.0% advocated it as a first line approach, while 53.0% would only use it as a secondary procedure before more traumatic fetal manipulations. The remaining institutions (15%) used it rarely, or as a last resort. The number of times the maneuver was attempted in a l-year period at these institutions ranged from 0 to 50. Fourteen institutions attempted it greater than 5 times in one year. Five attempted it more than 20 times in the last year, and one center used it on 49 occasions. There was no specific identifiable geographic distribution for use of this technique, and there was no correlation with the size of the service and the preference for the McRoberts maneuver. Approximate success rates when the maneuver was attempted were as follows: 20% experienced a success rate of less than 25%; 20% experienced a success rate of 25-50%; 20% experienced a success rate of 50-75%; 40% experienced a 75% success rate or greater. In response to the inquiry regarding decreased fetal manipulation and infant trauma with this maneuver, 40% thought it did, 12% thought it did not and 44% were unsure. The most common response to drawbacks of the procedure was none. The three major limitations noted were the need for two assistants, lifting the legs from the stirrups requiring extra time, and difficulty with moving the very obese patient. Duration of use was described as many years by several individuals while a small number observed that the maneuver recently became known and thus experience was very limited. Many cornmentors were personally very anxious to attempt the maneuver for the Int J Gynecol Obstet 35
An overview of these results with the McRoberts maneuver for the management of shoulder dystocia in 74 teaching hospitals reveals the national opinion can be divided basically breaks into three groups each representing a third. One third of the country is not familiar with the McRobert’s maneuver and have no experience with it. One-third knows of the maneuver and feels it has a role, but lacks experience with it. Finally, a third of the institutions are well aware of the maneuver and have used it a significant number of times with an overall success rate of approximately 50%. Those who use it as an initial technique are very enthusiastic. The optimum method for treating shoulder dystocia remains debatable. Many methods have been described and the question of superiority is clouded by the undeniable fact that no clinic .has had enough patients to statistically validate a given approach. The McRoberts maneuver continues to gain acceptability and may become the most popular and effective current technique. The greatest current emphasis must be on prevention, identification of risk factors and anticipation. During the 1930s and 194Os, before ultrasound was available, obstetricians occasionally obtained X-rays of the lower back and pelvis to evaluate for possible disproportion. A consummate obstetrician named Richardson called this reviewer’s attention to an anatomical confirmation of the female skeleton which he entitled “increased pelvic inclination.” A line extended down from the lumbar spine and parallel to it tended to be anterior to the symphysis pubis. One might call it an exaggerated lordosis. In such patients, this obstetrician utilized a position for delivery which is described in this paper as the McRobert’s maneuver.
McRoberts maneuver for shoulder dystocia
References 1
2 3 4 5
Gonik B, Stringer C, Held B: An alternate maneuver for the management of shoulder dystocia. Am J Obstet Gynecol 145: 882, 1983. Harris BH Jr: Shoulder dystocia. Clin Obstet Gynecol27: 106, 1984. Hibbard LT: Shoulder dystocia. Clin Obstet Gynecol 34: 424, 1969. McRoberts W: Maneuvers for shoulder dystocia. Contemp Obstet Gynecol 24: 17, 1984. O’Leary J, Gunn D: Cephalic replacement for shoulder dystocia. Contemp Obstet Gynecol 27: 157, 1986.
6 7 8
131
O’Leary J: Shoulder dystocia - an ounce of Prevention. Contemp Obstet Gynecol 27: 78, 1986. O’Leary J, Leonetti H: Shoulder dystocia. Prevention and treatment. Am J Obstet Gynecol, in press. Resnik R: Management of shoulder girdle dystocia. Obstet Gynecol 23: 559, 1980.
Clin
Address for reprints: J.A. O’Leary 801 Ostrum Street Bethlehem PA 18015, USA
Clinical and Clinical Research
129
1991, 35: 129-131
International Federation of Gynecology and Obstetrics
McRoberts J.A. O’Leary Department
maneuver for shoulder dystocia: a survey and N.B. Pollack
of Obstetrics
and Gynecology,
Jersey City Medical Center, Jersey City, New Jersey (USA)
(Received November 24th, 1989) (Revised and accepted March 3rd, 1990)
Abstract A survey of 108 major teaching institutions in the United States regarding the utilization of the McRoberts maneuver for shoulder dystocia was conducted. Only 40% taught the procedure but 64% reported being familiar with its use. Among users, on/y 32% used it as the initial step. Surprisingly, only 40% thought it reduced fetal trauma.
Keywords:
Shoulder
Dystocia;
McRoberts
maneuver. Introduction
Shoulder dystocia will always remain a dreaded complication of obstetrics. With current trends towards the liberal use of abdominal delivery for patients with multiple risk factors, hopefully its incidence will decline [6,7]. However, the fact remains that anyone who practices obstetrics is responsible for dealing with even the most difficult shoulder dystocia. Recent interest in alternative maneuvers in shoulder dystocia has brought attention to the reverse knee-chest position or McRobert’s maneuver as a less traumatic but effective method of delivering impacted shoulders [ 1,2,4]. Because it is an unusual occurrence, clinicians will continue to have little chance to develop expertise and confidence, thus continuing evaluation of available techniques is of value. 0020-7292/91/$03.50 0 1991 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Currently most respected references offer management plans that employ relatively traumatic techniques involving fetal manipulation to effect delivery of impacted shoulders [3,5,8]. Maternal manipulation, the McRobert’s maneuver, involves firmly flexing the knees to the maternal chest thus rotating the symphysis pubis cephalad and straightening the sacrum relative to the lumbar spine. Although it is commonly recognized that this does not change the dimensions of the true pelvis, it does change the angle of inclination of the pelvic inlet. This opening of the pelvic inlet may free the anterior shoulder from the symphysis effecting an atraumatic delivery. The purpose of this study was to ascertain the familiarity with the McRobert’s maneuver, its frequency of use, and experience or success with its utilization in a large group of teaching institutions. Materials and methods
To assess the national experience and current status with the McRobert’s maneuver a questionnaire was distributed to program directors at one hundred and eight major academic centers in the United States having over 1500 deliveries per year and with approved residency training program in obstetrics and gynecology. The questionnaire assessed familiarity with the maneuver, whether or not it is taught at the institution, and whether it is advocated as a first line approach. In addition the number of times the maneuver was Clinical and Clinical Research
130
O’Leary and Pollack
employed, its success or failure and an opinion as to whether it was felt to decrease fetal manipulation and trauma were also ascertained.
first time. Two noted the possibility of medicolegal significance in the future if it were not,employed while one individual commented that it was too exotic.
Results
Comment Of 108 questionnaires, 74 (69%) were returned. Sixty-four percent of the institutions were familiar with the maneuver, and 40.0% taught the maneuver to housestaff. Of the institutions familiar with the maneuver, 32.0% advocated it as a first line approach, while 53.0% would only use it as a secondary procedure before more traumatic fetal manipulations. The remaining institutions (15%) used it rarely, or as a last resort. The number of times the maneuver was attempted in a l-year period at these institutions ranged from 0 to 50. Fourteen institutions attempted it greater than 5 times in one year. Five attempted it more than 20 times in the last year, and one center used it on 49 occasions. There was no specific identifiable geographic distribution for use of this technique, and there was no correlation with the size of the service and the preference for the McRoberts maneuver. Approximate success rates when the maneuver was attempted were as follows: 20% experienced a success rate of less than 25%; 20% experienced a success rate of 25-50%; 20% experienced a success rate of 50-75%; 40% experienced a 75% success rate or greater. In response to the inquiry regarding decreased fetal manipulation and infant trauma with this maneuver, 40% thought it did, 12% thought it did not and 44% were unsure. The most common response to drawbacks of the procedure was none. The three major limitations noted were the need for two assistants, lifting the legs from the stirrups requiring extra time, and difficulty with moving the very obese patient. Duration of use was described as many years by several individuals while a small number observed that the maneuver recently became known and thus experience was very limited. Many cornmentors were personally very anxious to attempt the maneuver for the Int J Gynecol Obstet 35
An overview of these results with the McRoberts maneuver for the management of shoulder dystocia in 74 teaching hospitals reveals the national opinion can be divided basically breaks into three groups each representing a third. One third of the country is not familiar with the McRobert’s maneuver and have no experience with it. One-third knows of the maneuver and feels it has a role, but lacks experience with it. Finally, a third of the institutions are well aware of the maneuver and have used it a significant number of times with an overall success rate of approximately 50%. Those who use it as an initial technique are very enthusiastic. The optimum method for treating shoulder dystocia remains debatable. Many methods have been described and the question of superiority is clouded by the undeniable fact that no clinic .has had enough patients to statistically validate a given approach. The McRoberts maneuver continues to gain acceptability and may become the most popular and effective current technique. The greatest current emphasis must be on prevention, identification of risk factors and anticipation. During the 1930s and 194Os, before ultrasound was available, obstetricians occasionally obtained X-rays of the lower back and pelvis to evaluate for possible disproportion. A consummate obstetrician named Richardson called this reviewer’s attention to an anatomical confirmation of the female skeleton which he entitled “increased pelvic inclination.” A line extended down from the lumbar spine and parallel to it tended to be anterior to the symphysis pubis. One might call it an exaggerated lordosis. In such patients, this obstetrician utilized a position for delivery which is described in this paper as the McRobert’s maneuver.
McRoberts maneuver for shoulder dystocia
References 1
2 3 4 5
Gonik B, Stringer C, Held B: An alternate maneuver for the management of shoulder dystocia. Am J Obstet Gynecol 145: 882, 1983. Harris BH Jr: Shoulder dystocia. Clin Obstet Gynecol27: 106, 1984. Hibbard LT: Shoulder dystocia. Clin Obstet Gynecol 34: 424, 1969. McRoberts W: Maneuvers for shoulder dystocia. Contemp Obstet Gynecol 24: 17, 1984. O’Leary J, Gunn D: Cephalic replacement for shoulder dystocia. Contemp Obstet Gynecol 27: 157, 1986.
6 7 8
131
O’Leary J: Shoulder dystocia - an ounce of Prevention. Contemp Obstet Gynecol 27: 78, 1986. O’Leary J, Leonetti H: Shoulder dystocia. Prevention and treatment. Am J Obstet Gynecol, in press. Resnik R: Management of shoulder girdle dystocia. Obstet Gynecol 23: 559, 1980.
Clin
Address for reprints: J.A. O’Leary 801 Ostrum Street Bethlehem PA 18015, USA
Clinical and Clinical Research
