After McRoberts maneuver fails in shoulder dystocia, the next move is suprapubic pressure — not fundal pressure, not C-section. Suprapubic pressure pushes down on the maternal pubic symphysis to dislodge the anterior fetal shoulder from behind the pubic bone. Fundal pressure pushes the shoulder further into the impaction and is explicitly contraindicated. C-section is not feasible once the head is already delivered.
The common mistake
On a scenario where McRoberts had already failed and the head was delivered with the body stuck, Jordan answered "Emergency C-section." The tutor's update note is direct: "chose C-section after McRoberts failure — missed that C-section is impossible once the head is already delivered. Didn't retrieve suprapubic pressure as the next step."
A later open-ended recall showed a second gap: Jordan described McRoberts as "pressure applied on the shoulder of the fetus," conflating it with suprapubic pressure. McRoberts is a maternal maneuver — it moves the pelvis, not the baby.
These are two separate errors that each cost points independently. A lot of Step 2 test-takers reach for C-section as the default OB emergency answer, and the shoulder dystocia scenario is specifically designed to exploit that reflex. Once the fetal head has delivered, C-section is anatomically impossible — you cannot replace the delivered head. The only path forward is through the vaginal delivery.
The actual mechanism
The tutor's correction separated the two maneuvers by target:
McRoberts maneuver acts on the mother's pelvis. Hyperflexing the maternal thighs onto the abdomen flattens the lumbar lordosis and rotates the pubic symphysis superiorly. This changes the angle of the pelvic outlet, effectively widening the functional space the shoulder needs to pass through. Nothing touches the fetus. The maneuver alone resolves shoulder dystocia in a significant proportion of cases.
Suprapubic pressure acts directly on the fetus. A second provider presses downward and laterally on the maternal pubic symphysis — above the pubic bone — to push the impacted anterior shoulder off the bony ledge it's caught behind. The pressure is directed at dislodging the shoulder, not at the fundus.
Fundal pressure pushes downward from above the uterus. In shoulder dystocia, this drives the anterior shoulder harder into the pubic bone, worsening impaction. The StatPearls entry on shoulder dystocia and the ACOG guidance both explicitly list fundal pressure as contraindicated — it increases the risk of brachial plexus injury and uterine rupture.
The tutor laid out the full management sequence:
- McRoberts — hyperflect maternal thighs onto abdomen; flattens lumbar lordosis, rotates symphysis superiorly
- Suprapubic pressure — push on pubic symphysis to dislodge anterior shoulder; can be applied concurrently with McRoberts
- Internal rotational maneuvers — Rubin II (pressure on posterior aspect of anterior shoulder to rotate it), Woods screw (counter-pressure on anterior aspect of posterior shoulder)
- Zavanelli maneuver — cephalic replacement followed by C-section; last resort only
This connects to the broader pattern the tutor named explicitly across Jordan's OB sessions: in labor emergencies, there is almost always a bridge step before definitive management. See the companion article on cord prolapse for the same framework applied to a different emergency.
How to remember it
Two different targets: - McRoberts → moves the pelvis (maternal thigh hyperflexion) - Suprapubic pressure → moves the shoulder (pushes anterior shoulder off the pubic bone) - Fundal pressure → worsens impaction (pushes shoulder into bone)
One-line anchor: Suprapubic dislodges. Fundal impacts. McRoberts changes the angle.
Check yourself
A 32-year-old woman is in active labor at 39 weeks. The fetal head delivers, but the shoulders are impacted. McRoberts maneuver has been applied. The shoulders remain stuck. Which of the following is the correct next step?
A) Fundal pressure applied by a nurse
B) Suprapubic pressure directed at the pubic symphysis
C) Emergency C-section
D) Vacuum extraction to deliver the shoulders
Correct answer: B.
Once McRoberts is applied, suprapubic pressure is the appropriate next maneuver — it can be applied concurrently with McRoberts from the start, or added after. Fundal pressure (A) is explicitly contraindicated and worsens impaction. C-section (C) is not feasible after the head has delivered — there is no way to replace a delivered fetal head to perform a cesarean. Vacuum extraction (D) addresses delivery of the head, not shoulder impaction.
Where to verify this
The StatPearls entry on Shoulder Dystocia reviews the full management algorithm and the contraindication to fundal pressure. The StatPearls entry on McRoberts Maneuver describes the pelvic mechanics in detail. For the evidence base on the sequence and ACOG recommendations, the AAFP clinical review provides a practical framework consistent with current guidelines.
Close the gap
The tutor that caught Jordan's C-section answer — and traced it to a missing bridge-step framework that appeared in two separate OB scenarios — is available to work through your specific gaps now. One session surfaces what a week of passive review might miss.