Effectiveness of combined obstetric maneuvers and instrumental assist techniques in the management of shoulder dystocia: a systematic review of maternal-fetal outcomes and associated complications
DOI:
https://doi.org/10.56183/iberojhr.v5i2.821Palavras-chave:
Shoulder dystocia, Obstetric maneuvers, Instrumental delivery, Maternal outcomes, Neonatal outcomes, Brachial plexus injury.Resumo
Shoulder dystocia is a rare but serious obstetric emergency associated with significant maternal and neonatal morbidity. Although various maneuvers such as the McRoberts position, suprapubic pressure, and rotational techniques are established first-line interventions, recent studies suggest that combined maneuvers and instrumental assist techniques may improve outcomes. However, their effectiveness and associated complications remain debated. This review aims to evaluate the effectiveness of combined obstetric maneuvers and instrumental assist techniques in the management of shoulder dystocia, with a focus on maternal-fetal outcomes and complications. A narrative review is conducted using recent literature from PubMed, ScienceDirect, Google Scholar, and the Cochrane Library. Studies assessing maternal and neonatal outcomes following combined maneuvers (e.g., McRoberts with suprapubic pressure, posterior arm delivery with rotational techniques) and instrumental assists (vacuum extraction, forceps) were included. Key outcomes analyzed were delivery success, maternal morbidity, neonatal injury, and complication rates. Evidence shows McRoberts with or without suprapubic pressure resolves only 25.8% of shoulder dystocia cases, highlighting limited standalone efficacy. Posterior arm delivery demonstrates the highest success rate (86.1%), surpassing rotational maneuvers (62.4%) and external methods (56%), with computational models confirming reduced brachial plexus strain. Instrumental assists carry trade-offs: vacuum increases shoulder dystocia risk (OR ~2.9), while forceps achieve higher success but with greater maternal trauma (33.8% severe lacerations). Sequential vacuum–forceps use markedly elevates neonatal morbidity (RR 3.9 intracranial hemorrhage). Newer strategies like posterior axilla sling traction (success 18/19 cases) and safety bundles significantly reduce neonatal trauma and NICU admissions. Combined obstetric maneuvers are generally safe and effective in resolving shoulder dystocia, reducing both delivery time and neonatal hypoxia. Instrumental assists should be reserved for refractory cases due to their higher complication rates. Standardized protocols and multicenter prospective studies are needed to optimize decision-making, minimize risks, and improve maternal-fetal outcomes in shoulder dystocia management.
Referências
Alves, Á. L. L., Nozaki, A. M., Polido, C. B. A., & Knobel, R. (2022). Management of shoulder dystocia. Revista Brasileira de Ginecologia e Obstetricia, 44(7), 723–735. https://doi.org/10.1055/s-0042-1755446
Anderson, J., Hampton, R. M., & Lugo, J. (2017). Postoperative care of symphysiotomy performed for severe shoulder dystocia with fetal demise. Case Reports in Women’s Health, 14, 6–7. https://doi.org/10.1016/j.crwh.2017.03.001
Ashley Hill, D., Lense, J., Orlando Hospital, A., & Fay Roepcke, F. (2020). Shoulder Dystocia: Managing an Obstetric Emergency. American Family Physician, 102(2), 84–90. https://www.aafp.org/pubs/afp/issues/2020/0715/p84.html
Bailit, J. L., Grobman, W. A., Rice, M. M., Wapner, R. J., Reddy, U. M., Varner, M. W., Thorp, J. M., Caritis, S. N., Iams, J. D., Saade, G., Rouse, D. J., & Tolosa, J. E. (2016). Evaluation of delivery options for second-stage events. American Journal of Obstetrics and Gynecology, 214(5), 638.e1-638.e10. https://doi.org/10.1016/j.ajog.2015.11.007
Black, M., & Murphy, D. J. (2019). Forceps delivery for non-rotational and rotational operative vaginal delivery. Best Practice and Research: Clinical Obstetrics and Gynaecology, 56, 55–68. https://doi.org/10.1016/j.bpobgyn.2019.02.002
Cluver, C. A., & Hofmeyr, G. J. (2015a). Posterior axilla sling traction for shoulder dystocia: Case review and a new method of shoulder rotation with the sling. American Journal of Obstetrics and Gynecology, 212(6), 784.e1-784.e7. https://doi.org/10.1016/J.AJOG.2015.02.025
Cluver, C. A., & Hofmeyr, G. J. (2015b). Posterior axilla sling traction for shoulder dystocia: Case review and a new method of shoulder rotation with the sling. American Journal of Obstetrics and Gynecology, 212(6), 784.e1-784.e7. https://doi.org/10.1016/j.ajog.2015.02.025
Dall’Asta, A., Ghi, T., Pedrazzi, G., & Frusca, T. (2016). Does vacuum delivery carry a higher risk of shoulder dystocia? Review and meta-analysis of the literature. European Journal of Obstetrics and Gynecology and Reproductive Biology, 204, 62–68. https://doi.org/10.1016/j.ejogrb.2016.07.506
Davis, D. D., Roshan, A., & Varacallo, M. A. (2023). Shoulder Dystocia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470427/
Doty, M. S., Chauhan, S. P., Chang, K. W. C., Al-Hafez, L., McGovern, C., Yang, L. J. S., & Blackwell, S. C. (2020). Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia. AJP Reports, 10(1), e42. https://doi.org/10.1055/S-0040-1705140
Fong, A., Wu, E., Pan, D., Chung, J. H., & Ogunyemi, D. A. (2014). Temporal trends and morbidities of vacuum, forceps, and combined use of both. Journal of Maternal-Fetal and Neonatal Medicine, 27(18), 1886–1891. https://doi.org/10.3109/14767058.2014.904282,
Gardella, C., Taylor, M., Benedetti, T., Hitti, J., & Critchlow, C. (2001). The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes. American Journal of Obstetrics and Gynecology, 185(4), 896–902. https://doi.org/10.1067/mob.2001.117309
Gesner, T., Toncar, A., Jenkins, S. M., & Robert P. Griggs, J. (2024). McRoberts Maneuver. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK537280/
Giouleka, S., Tsakiridis, I., Ralli, E., Mamopoulos, A., Kalogiannidis, I., Athanasiadis, A., & Dagklis, T. (2024). Diagnosis and Management of Macrosomia and Shoulder Dystocia: A Comprehensive Review of Major Guidelines. Obstetrical and Gynecological Survey, 79(4), 233–241. https://doi.org/10.1097/OGX.0000000000001253,
Iaconianni, J. A., Balasubramanian, S., Grimm, M. J., Gonik, B., & Singh, A. (2024). Studying the Effects of Shoulder Dystocia and Neonate-Focused Delivery Maneuvers on Brachial Plexus Strain: A Computational Study. Journal of Biomechanical Engineering, 146(2), 021009. https://doi.org/10.1115/1.4064313
Jangö, H., Langhoff-Roos, J., Rosthøj, S., & Sakse, A. (2014). Modifiable risk factors of obstetric anal sphincter injury in primiparous women: A population-based cohort study. American Journal of Obstetrics and Gynecology, 210(1), 59.e1-59.e6. https://doi.org/10.1016/j.ajog.2013.08.043
Lau, S. L., Sin, W. T. A., Wong, L., Lee, N. M. W., Hui, S. Y. A., & Leung, T. Y. (2024). A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia. American Journal of Obstetrics and Gynecology, 230(3), S1027–S1043. https://doi.org/10.1016/J.AJOG.2023.01.016
Lok, Z. L. Z., Cheng, Y. K. Y., & Leung, T. Y. (2016). Predictive factors for the success of McRoberts’ manoeuvre and suprapubic pressure in relieving shoulder dystocia: A cross-sectional study. BMC Pregnancy and Childbirth, 16(1). https://doi.org/10.1186/S12884-016-1125-3
Menticoglou, S. (2018). Shoulder dystocia: Incidence, mechanisms, and management strategies. International Journal of Women’s Health, 10, 723–732. https://doi.org/10.2147/IJWH.S175088
Robinson, J. N., Norwitz, E. R., Cohen, A. P., McElrath, T. F., & Lieberman, E. S. (1999). Episiotomy, operative vaginal delivery, and significant perineal trauma in nulliparous women. American Journal of Obstetrics and Gynecology, 181(5 I), 1180–1184. https://doi.org/10.1016/S0002-9378(99)70104-3
Sentilhes, L., Senat, M. V., Boulogne, A. I., Deneux-Tharaux, C., Fuchs, F., Legendre, G., Le Ray, C., Lopez, E., Schmitz, T., & Lejeune-Saada, V. (2015). Shoulder dystocia: Guidelines for clinical practice-Short text. Journal de Gynecologie Obstetrique et Biologie de La Reproduction, 44(10), 1303–1310. https://doi.org/10.1016/j.jgyn.2015.09.053
Shoulder dystocia. (2017). Obstetrics and Gynecology, 129(5), e123–e133. https://doi.org/10.1097/AOG.0000000000002043
Skinner, S. M., Neil, P., Murray, N., Regan, J., Kumar, A., Mol, B. W., Hodges, R. J., & Rolnik, D. L. (2025). Clinical outcomes following implementation of an operative vaginal birth safety bundle: a prospective observational study and time-series analysis. American Journal of Obstetrics and Gynecology. https://doi.org/10.1016/j.ajog.2025.07.013
Spain, J. E., Frey, H. A., Tuuli, M. G., Colvin, R., MacOnes, G. A., & Cahill, A. G. (2015). Neonatal morbidity associated with shoulder dystocia maneuvers. American Journal of Obstetrics and Gynecology, 212(3), 353.e1-353.e5. https://doi.org/10.1016/j.ajog.2014.10.001
Stitely, M. L., & Gherman, R. B. (2014). Shoulder dystocia: Management and documentation. Seminars in Perinatology, 38(4), 194–200. https://doi.org/10.1053/J.SEMPERI.2014.04.004
Tsikouras, P., Kotanidou, S., Nikolettos, K., Kritsotaki, N., Bothou, A., Andreou, S., Nalmpanti, T., Chalkia, K., Spanakis, V., Peitsidis, P., Iatrakis, G., & Nikolettos, N. (2024). Shoulder Dystocia: A Comprehensive Literature Review on Diagnosis, Prevention, Complications, Prognosis, and Management. Journal of Personalized Medicine, 14(6). https://doi.org/10.3390/JPM14060586
Verma, G. L., Spalding, J. J., Wilkinson, M. D., Hofmeyr, G. J., Vannevel, V., & O’Mahony, F. (2021). Instruments for assisted vaginal birth. The Cochrane Database of Systematic Reviews, 9(9), CD005455. https://doi.org/10.1002/14651858.CD005455.pub3
Wang, Y., Niu, Y., Xu, Z., Yan, X., Li, J., & Xu, H. (2024). Association of the Kiwi OmniCup system with maternal and neonatal morbidity: A retrospective cohort study. International Journal of Gynecology and Obstetrics, 164(2), 699–707. https://doi.org/10.1002/IJGO.15037,
Woldegeorgis, B. Z., Gebrekidan, A. Y., Kassie, G. A., Azeze, G. A., Asgedom, Y. S., Alemu, H. B., & Obsa, M. S. (2024). Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis. PLoS ONE, 19(3 March). https://doi.org/10.1371/journal.pone.0298519
Xin, S., Wang, Z., Lai, H., Liu, L., Shen, T., Xu, F., Zeng, X., & Zheng, J. (2021). Clinical Effects of Form-Based Management of Forceps Delivery under Intelligent Medical Model. Journal of Healthcare Engineering, 2021. https://doi.org/10.1155/2021/9947255
Zhang, V. R. Y., Tan, E. L., Edison, P. E., & Kanagalingam, D. (2023). Operative vaginal delivery: practice patterns and outcomes at a tertiary general hospital. Singapore Medical Journal, 64(5), 313–318. https://doi.org/10.11622/SMEDJ.2022069
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Copyright (c) 2025 Luis Fabricio Correa Auqui, Augusto Cam Rojas, Elida Elizabeth Alvarado Cervantes, Dorel Guadalupe Arriaga Mata, Pablo Andres Lara Sanchez, María Isabel Mercado Herrera
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