Overview of McRoberts Maneuver
Shoulder dystocia happens when a baby’s shoulder gets stuck behind the mother’s pelvic bone during a normal vaginal birth. This problem can occur in up to 3% of all deliveries, even if there are no risk factors. When either the baby’s front or back shoulder get stuck, it can stop the baby from coming out even after the head has been delivered.
The chances of shoulder dystocia happening increase as the baby’s size increases. For instance, it happens in about 1% of babies who weigh less than 4,000 g (around 8.8 pounds). For babies who weigh between 4,000 g to 4,500 g (approximately 9 to 10 pounds), the rate jumps to about 5%. And for babies who weigh more than 4,500 g, the chance is between 9% to 10%.
Thankfully, there are some techniques doctors can use to resolve shoulder dystocia. One of the simplest procedures is called the McRoberts maneuver. The American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend using the McRoberts maneuver first, as it is easy, logical, quick, and effective. In fact, studies have shown that this simple technique can successfully dislodge the baby’s shoulder in up to 42% of cases.
Anatomy and Physiology of McRoberts Maneuver
Understanding the structure of the female pelvis is crucial in determining how shoulder dystocia (when a baby’s shoulder gets stuck during delivery) occurs and how it can be addressed using a specific technique known as the McRoberts maneuver.
The pelvic area is made up of 4 bones and 3 joints – the sacrum, the coccyx (tailbone), and two joined-up bones called the innominate bones. These innominate bones are made by combining the ilium, ischium, and pubic rami. The three joints are located where the sacrum and the ilium connect, and where the right and left pubic rami meet.
The pelvis, which has a bowl-like shape, is divided into two parts – the greater pelvis (the upper part) and the lesser pelvis (the lower part). The line dividing these two parts is a circular ridge called the pelvic brim. The space inside the lesser pelvis is called the pelvic inlet and it’s through this space that a baby descends during delivery, eventually emerging through another opening, the pelvic outlet.
We often measure the pelvis (a process known as pelvimetry) to evaluate the risk of complications in pregnant patients. This process focuses on measuring 3 diameters of the pelvis and involves measuring certain distances in the pelvic region (called conjugates) in 3 different ways.
The obstetric conjugate, which is the smallest fixed distance inside the pelvic inlet, is of particular relevance. Although it can’t be measured directly, it can be estimated. This measurement can provide important info: a smaller obstetric conjugate measurement might indicate a higher risk for complications during delivery. There exist some techniques such as ultrasound imaging to estimate the obstetric conjugate during pregnancy, but they aren’t a standard practice yet as the benefits of such assessments are still not certain.
During delivery, the baby needs to rotate inside the lesser pelvis to ensure that the larger parts of their head and shoulders can pass through. The rotation doesn’t always occur smoothly, especially in larger babies, and sometimes the baby’s shoulders can get stuck – this is when shoulder dystocia occurs.
To relieve shoulder dystocia, we perform the McRoberts maneuver. This involves bending the mother’s legs sharply towards her abdomen, which helps open up the pelvic outlet. This maneuver also changes the angles inside the pelvic region, creating more space and thus aiding the delivery process.
Why do People Need McRoberts Maneuver
When a baby’s shoulder gets stuck during childbirth, a procedure called the McRoberts maneuver is often used first. This is done when certain signs of the baby’s shoulder getting stuck, known as shoulder dystocia, are noticed. One of these signs might be the baby’s head pulling back against the mother’s body after the head has been delivered (this is sometimes referred to as the “turtle sign”). Another sign could be if the baby’s shoulder doesn’t come out even when the doctors are gently pulling. Some doctors might choose to use this maneuver even before the baby’s head is delivered if they think there’s a high chance of shoulder dystocia.
Unfortunately, predicting whether shoulder dystocia will happen can be quite tricky and it’s not something that can always be prevented. Some of the biggest risk factors include the mother having diabetes, a previous case of shoulder dystocia, and the baby being very large for its age in the womb, also known as fetal macrosomia. With diabetes, the baby may receive high sugar levels from the mother, causing it to produce more insulin, growth hormone, and insulin-related growth factors than usual. This can result in a larger baby with bigger shoulders and a higher ratio of belly size to head size, potentially making it difficult for the baby to fit through the mother’s pelvis during birth. But, most of the time, shoulder dystocia happens in non-diabetic moms with babies of average size. At the same time, many moms with diabetes or large babies don’t experience shoulder dystocia at all.
If a woman has previously had a pregnancy where shoulder dystocia occurred or where the baby had a nerve injury in its arm (known as a brachial plexus injury), her chances of experiencing shoulder dystocia again are at least 10%. Because of this, she might consider having a planned C-section during future pregnancies. But if she chooses to try a vaginal birth, then the doctors and nurses need to be ready for the chance of shoulder dystocia happening again. In these situations, the McRoberts maneuver might be used proactively, right when the baby is being delivered. It’s important to note, however, that this maneuver hasn’t been proven to be beneficial until signs of shoulder dystocia have appeared. The good news is, there’s very little risk in using the McRoberts maneuver before those signs show up.
There are other risk factors for shoulder dystocia as well, such as having given birth to a large baby before, gaining a lot of weight during pregnancy, being overweight or obese, and having a baby pass away in the womb. Some signs during childbirth that shoulder dystocia might happen include a long second stage of labor, the baby’s head not moving down as expected, and needing to use medical tools (like forceps or a vacuum) to help get the baby’s head out.
When a Person Should Avoid McRoberts Maneuver
The McRoberts maneuver is usually safe for most pregnant women to undergo. However, if a woman has abnormalities in her hip, pelvis, or spine, it may not be safe. These can be things like deformities or fractures that make it hard to bend the thighs excessively, which is needed for the maneuver. Also, it might be more difficult if the woman struggles to get into the needed position. This could be the case for women who are obese, women with disorders that affect their muscles or nerves, women with severe arthritis, or women with other conditions that cause joint damage.
Equipment used for McRoberts Maneuver
The McRoberts maneuver, a technique used during labor, doesn’t need any special equipment. It can be useful though, to lower the height of the birthing bed and to have small step stools by each side of the bed. This allows the doctors and nurses helping with the delivery to best assist the mother. This setup also makes it easier to perform any additional procedures that may be needed during labor.
Who is needed to perform McRoberts Maneuver?
The McRoberts maneuver, a technique used during childbirth, usually needs the help of two assistants in addition to the doctor delivering the baby. Each assistant is tasked to hold one of the mother’s legs. It is preferable if these assistants are skilled birth professionals like nurses specializing in childbirth or another doctor. These individuals should always be in the delivery room, especially if there are any risks associated with the birth.
However, this manoeuvre is quite simple to perform. So, in cases where trained helpers aren’t available or when there’s an unexpected situation, the mother and anyone in the room willing to support can be given instructions on how to help with the maneuver. This can be done while waiting for additional trained help to arrive.
Preparing for McRoberts Maneuver
Before a baby is born, it’s very important that those looking after the mother and baby are aware of certain risk factors that might cause a complication known as ‘shoulder dystocia.’ This is a condition where the baby’s shoulder gets stuck during delivery which can be dangerous and requires an immediate response. The health care team including the nurses, doctors, anesthetists, and pediatricians need to know about this so they can be ready to act quickly and safely if the situation arises. Preparations should include having extra staff on hand and arranging the room in a way that makes it as easy as possible to manage the situation.
One way the healthcare team can be ready to handle a shoulder dystocia is to do regular practice drills. These situations can mimic emergencies and help the team to be prepared, find any potential issues, and improve communication skills. This kind of training has been proven to make deliveries safer for both moms and babies when complications arise.
How is McRoberts Maneuver performed
During childbirth, if the baby’s shoulder gets stuck, it is referred to as ‘shoulder dystocia.’ In these situations, the medical team needs to act quickly and effectively to help deliver the baby safely. The medical team in the room needs to be aware of the situation and should be ready for any necessary actions. The team may need to bring in extra help, reposition themselves, or start time-based documentation. They need to record essential details like what they did and how long it took.
The McRoberts Maneuver
This specific technique, known as the ‘McRoberts maneuver,’ is a common method used in such cases. It effectively requires the help of two assistants. Each assistant stands by one of the mother’s legs. They hold and support the mother’s foot and knee. Then, they gently push the mother’s feet towards her head so that her thighs rest on her belly. This move flexes the mother’s hips to an angle of about 135° when she’s lying down.
At the same time, the main doctor or midwife remains near the birthing area and tries to help the baby emerge by carefully pulling on the baby’s head. It’s important that this pull is towards the baby’s spine along a specific angle. It’s usually around 25° to 45° below the horizontal level when the mother is in a birthing position. The doctor or midwife should avoid pulling the baby to the side.
This technique is typically tried for about half a minute. If the baby doesn’t come out during this period with a gentle pull, the team will move on to other techniques. It’s important not to continue with this maneuver for an extended period as it can potentially harm the mother’s lower leg nerves due to pressure.
Suprapubic Pressure
This additional technique typically goes hand-in-hand with the McRoberts maneuver. It involves applying firm pressure above the pubic area to help dislodge and rotate the stuck baby’s shoulder. This implies that the baby’s shoulder should be directed towards its chest. The pressure, applied using the palm or fist, is directed downwards and at a slightly sideways angle depending on the position of the baby.
The main doctor or midwife should try to figure out the baby’s position and instruct the assistants on which direction the pressure should be applied and who should do it. For instance, if the baby is facing down and a little towards the mother’s left leg, then the left baby’s shoulder is stuck. In this case, the shoulder should be rotated clockwise, best done by the assistant standing by the mother’s right leg. They will then apply pressure downward and slightly away towards the mother’s left hip.
In contrast, if the baby is slightly towards the mother’s right leg, the assistant standing by the mother’s left leg should apply pressure towards the mother’s right hip, attempting to rotate the baby counter-clockwise. If the baby’s position isn’t defined, the assistant may just push straight down on direction from the main doctor or midwife.
Possible Complications of McRoberts Maneuver
Complications from using the McRoberts position, a technique often used to handle a situation called shoulder dystocia during childbirth, are not common. Shoulder dystocia is when a baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Rarely, a mother can experience nerve damage in the leg, particularly if the position is used for a long time. This can lead to weakness in the thigh muscle, making it harder for the mother to flex the hip and extend the knee. Some women may also feel tingling, numbness, and shooting pain down the side of their thigh. This condition can usually be managed with physical therapy, changes in sitting or sleeping positions, or medication for nerve pain.
Even rarer, some women might experience separation of the pubic bone or pain in the hip area, especially if the McRoberts position is held for a prolonged period. This can be managed with support belts, physical therapy, and pain relievers. Symptoms usually improve within 1 to 3 months, although some women might have long-term pain. Because of the potential risk of complications, it’s not recommended to hold the position for a long time, even if the mother is at high risk for shoulder dystocia.
For newborns, the risk from the McRoberts maneuver is very low. But, complications from shoulder dystocia itself can include possible injuries, lack of oxygen, and in extreme cases, death. Approximately 10% to 20% of babies can have injuries like nerve damage in the arm or a broken collarbone or upper arm bone. More severe problems like lack of oxygen leading to brain damage can occur even if the baby’s body is delivered within 5 minutes after the head. Complications are more common when shoulder dystocia lasts a long time or when more than five different procedures are used to deliver the baby.
What Else Should I Know About McRoberts Maneuver?
Shoulder dystocia, where a baby’s shoulder gets stuck behind the mother’s pelvic bone during childbirth, can be a difficult obstetric emergency. The McRoberts maneuver is a technique used by doctors as first-line management for this condition. Its appeal lies in its simplicity and effectiveness.
This maneuver involves the mother retracting her legs tightly to her abdomen, which can help free the baby’s shoulder around 42% of the time. When combined with suprapubic pressure (pressure applied just above the pubic bone), it can successfully resolve shoulder dystocia in about 54% of the cases.
Time is of the essence during childbirth, as delays between the delivery of the baby’s head and body may lead to a lack of oxygen for the baby. That’s why it’s crucial for the medical team to work well together, use efficient communication methods and follow set procedures to resolve the shoulder dystocia as quickly as possible. The McRoberts maneuver is advantageous in this situation as it often allows the baby’s shoulder to be delivered quickly, helping to avoid a drawn-out shoulder dystocia and reduce potential complications for the baby like brachial plexus injuries, which affect the nerves in the baby’s upper arm.
