A pregnant woman is undergoing a vaginal breech delivery. After delivering the baby’s body up to the umbilicus, the obstetrician notices winging of the baby’s scapula. To facilitate safe delivery of the baby’s shoulders and head, which of the following maneuvers is most appropriate?

Explanation

## Correct Answer: D. Lovset maneuver Lovset maneuver is the gold standard for managing shoulder dystocia in breech delivery, particularly when winging of the scapula indicates shoulder impaction. The maneuver involves rotating the baby's body 180° around the anteroposterior axis while maintaining gentle downward traction, which allows the posterior shoulder to sweep under the pubic symphysis first, followed by rotation to deliver the anterior shoulder. Winging of the scapula signals that the shoulder girdle is caught at the pelvic inlet—a critical obstetric emergency. Lovset maneuver specifically addresses this by converting the transverse diameter of the shoulders (which is wider) into the oblique diameter of the pelvis through controlled rotation. The procedure requires the operator to grasp the baby's pelvis with both hands, thumbs on the sacrum, and perform a 180° rotation in the direction that brings the posterior arm down first. This maneuver is preferred in Indian obstetric practice (as per FOGSI guidelines) because it avoids excessive traction that could cause brachial plexus injury and is more effective than other techniques when shoulder impaction is evident. The presence of scapular winging is the key discriminator—it indicates the shoulders are truly stuck, not just delayed descent. ## Why the other options are wrong **A. Mauriceau-Smellie-Veit maneuver** — This maneuver is used for delivery of the head in breech presentation after the body is delivered, not for shoulder dystocia. It involves supporting the baby's body while flexing the head for delivery through the pelvic outlet. It does not address shoulder impaction and would be inappropriate when scapular winging indicates the shoulders are still trapped at the pelvic inlet. **B. Pinard maneuver** — Pinard maneuver is used to deliver the arm in breech presentation by sweeping it across the chest, but it is a secondary maneuver for arm delivery, not the primary approach for shoulder dystocia. It does not address the fundamental problem of the shoulder girdle being impacted at the pelvic inlet, which requires body rotation as in Lovset maneuver. **C. Burns Marshall maneuver** — Burns Marshall maneuver is an alternative technique for delivering the head in breech presentation by flexing and rotating the baby's body to bring the occiput under the pubic symphysis. It is used after shoulder delivery is complete and is not indicated for managing shoulder dystocia or scapular winging during the shoulder delivery phase. ## High-Yield Facts - **Scapular winging in breech delivery** = shoulder impaction at pelvic inlet; requires immediate Lovset maneuver, not head delivery techniques. - **Lovset maneuver mechanism**: 180° rotation of baby's body around anteroposterior axis to convert transverse shoulder diameter into oblique pelvic diameter. - **Lovset technique**: Grasp baby's pelvis with both hands (thumbs on sacrum), rotate 180° to deliver posterior shoulder first, then anterior shoulder. - **Contraindication to traction**: Excessive downward pull in shoulder dystocia risks brachial plexus injury; Lovset maneuver uses gentle traction + rotation instead. - **FOGSI recommendation**: Lovset maneuver is first-line for breech shoulder dystocia in Indian obstetric practice; Pinard maneuver is secondary if arms remain trapped. ## Mnemonics **LOVSET = Lateral Oblique Vertical Spiral Extraction Technique** Rotate the baby's body 180° (spiral) to convert the transverse shoulder diameter into the oblique pelvic diameter. Use when scapular winging signals shoulder impaction. **Breech Delivery Maneuver Sequence (LAMP)** **L**ovset (shoulders stuck) → **A**rm delivery (Pinard if needed) → **M**auriceau-Smellie-Veit (head delivery) → **P**ull gently throughout. Lovset comes first when you see scapular winging. ## NBE Trap NBE pairs scapular winging with head delivery maneuvers (Mauriceau-Smellie-Veit, Burns Marshall) to trap students who confuse the phase of delivery—these maneuvers are for head delivery after shoulders are free, not for shoulder dystocia. The key discriminator is recognizing that winging indicates the shoulders are still impacted, requiring body rotation (Lovset), not head manipulation. ## Clinical Pearl In Indian tertiary centers, when a breech baby's scapulae wing during delivery, it is a red-flag sign of impending brachial plexus injury. Lovset maneuver, performed promptly with controlled rotation and minimal traction, prevents permanent nerve damage and ensures safe delivery—this is why it is the standard of care in all Indian obstetric training programs. _Reference: DC Dutta's Textbook of Obstetrics (7th ed.), Ch. 23 "Breech Presentation"; FOGSI Clinical Practice Guidelines on Breech Delivery Management_