Clinical Review

Pearls on the McRoberts maneuver

OBG Manag. 2002 February;14(2):49-53

References

1. Gherman RB, Goodwin TM, Souter I, Neumann K, Ouzounian JG, Paul RH. The McRoberts maneuver for the alleviation of shoulder dystocia: how successful is it? Am J Obstet Gynecol. 1997;176:656-661.

2. McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynecol Obstet. 1996;55:219-224.

3. Shushan A, Younis JS. McRoberts maneuver for the management of the aftercoming head in breech delivery. Gynecol Obstet Invest. 1992;34:188-189.

4. Gherman RB, Tramont J, Muffley P, et al. Analysis of McRoberts maneuver by x-ray pelvimetry. Obstet Gynecol. 2000;95:43-47.

5. Gonik B, Stringer CA, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol. 1983;145:882-884.

6. Buhimschi CS, Buhimschi IA, Malinow A, Weiner CP. Use of McRoberts position during delivery and increase in pushing efficiency. Lancet. 2001;358:470-471.

7. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies. New York: Churchill Livingstone; 2001;473-501.

8. Cunningham FG Gant NF LevenoKJ Gilstrap LC Hauth JC Wenstrom KD eds. Williams Obstetrics. New York: McGraw-Hill; 2001;461-463.

9. Gonik B, Allen R, Sorab J. Objective evaluation of the shoulder dystocia phenomenon: effect of maternal pelvic orientation on force reduction. Obstet Gynecol. 1989;74:44-47.

10. Heath T, Gherman RB. Symphyseal separation, sacroiliac joint dislocation, and transient lateral femoral cutaneous neuropathy associated with McRoberts maneuver: a case report. J Reprod Med. 1999;44:902-904.

11. Gherman RB, Ouzounian JG, Incerpi MH, Goodwin TM. Symphyseal separation and transient femoral neuropathy associated with the McRoberts maneuver. Am J Obstet Gynecol. 1998;178:609-610.

12. O’Leary JA, Pollack NB. McRoberts maneuver for shoulder dystocia: a survey. Int J Gynecol Obstet. 1991;35:129-131.

13. O’Leary JA. McRoberts maneuver. In: O’Leary JA, ed. Shoulder Dystocia and Birth Injury: Prevention and Treatment. New York: McGraw-Hill; 1992;128136.

With increased fetal bisacromial diameters, a condition that occurs in infants of mothers with diabetes, the protective effects of McRoberts appear to be reduced while the incidence of brachial plexus palsy is increased.¹ Even so, objective testing indicates that the McRoberts maneuver may reduce fetal-shoulder extraction forces and brachial plexus stretching.⁹

Complications. Care should be taken to avoid prolonged or overly aggressive application of the McRoberts maneuver, as the fibrocartilaginous articular surfaces of the symphysis pubis and surrounding ligaments may be unduly stretched. In addition, when the maternal thighs are markedly flexed and abducted, pressure from the overlying inguinal ligament may lead to femoral nerve injury.

My colleagues and I have experienced 2 cases in which significant maternal morbidity was associated with the McRoberts maneuver. In one, a patient who was maintained in McRoberts throughout her 2-hour, 11-minute second stage of labor suffered a 5-cm symphyseal separation, dislocation of the sacroiliac joint, and transient lateral femoral cutaneous neuropathy. These abnormalities required closed reduction of the left hemi-pelvis, followed by an open reduction and internal fixation of the symphysis pubis 2 weeks after failing conservative treatment.¹⁰ A previous report described similar pelvic findings following an exaggerated McRoberts maneuver for suspected fetal macrosomia.¹¹

The long view. In 1991, a survey of 108 major teaching institutions in the United States found that only 64% were familiar with the McRoberts maneuver and only 40% taught the maneuver to house staff.¹² Yet, William A. McRoberts, Jr, MD, practiced his maneuver with great success for more than 40 years at Hermann Hospital and the University of Texas Medical School in Houston.¹³ As we continue into the new millennium, I believe it is important to teach residents to initially employ the McRoberts maneuver whenever shoulder dystocia occurs.

TABLE 1

Potential mechanical benefits of the McRoberts maneuver

Anterior fetal shoulder elevation Fetal spine flexion Pushing of posterior fetal shoulder over the sacrum Straightening of maternal lordosis Removal of sacral promontory as point of obstruction Removal of weight-bearing force from the sacrum Pelvic inlet opened to maximum Pelvic inlet brought perpendicular to maximum expulsive force

The author reports no financial relationship with any companies whose products are mentioned in this article.

SERMs: Protection without worry?

Pearls on the McRoberts maneuver

References

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