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

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.