C:RUBIN 2 MANEUVER POSTERIOR PART OF ANTERIOR SHOULDER- ROTATE FORWARD

C:RUBIN 2 MANEUVER (POSTERIOR PART OF ANTERIOR SHOULDER-> ROTATE FORWARDS

Reading File

Finding Sources

Reading File

Here is a complete breakdown of the Rubin II Maneuver for shoulder dystocia:

Rubin II Maneuver - Shoulder Dystocia

Core Concept

Rubin II is a rotational/internal maneuver used when McRoberts + suprapubic pressure have failed to resolve shoulder dystocia.

Key action: The provider inserts fingers vaginally and applies pressure to the posterior aspect of the anterior shoulder, pushing it toward the fetal chest (forward/anteriorly) - this is an adduction movement.

Why It Works

The anterior shoulder is impacted behind the symphysis pubis. By pushing on its posterior surface and rotating it toward the fetal chest, you:

Adduct the shoulder - this physically reduces the biacromial (shoulder-to-shoulder) diameter
Rotate the fetal shoulders out of the AP pelvic diameter and into the oblique diameter, where there is more room

This is the fundamental biomechanical principle: adduction of a shoulder compresses and narrows the biacromial diameter, freeing the impacted shoulder from behind the symphysis.

How to Perform It

Enter the vagina with your hand (an episiotomy may be needed to create room)
Locate the posterior surface of the anterior shoulder (the surface facing the fetal back, i.e., the surface facing away from you)
Apply firm pressure pushing that surface forward/toward the fetal chest
This rotates the anterior shoulder in the oblique direction and reduces the effective shoulder diameter

(Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed.)

Comparison with Related Maneuvers

Maneuver	Where you push	Direction
Rubin II	Posterior surface of anterior shoulder	Toward fetal chest (adduction, rotates forward)
Woods Screw	Anterior surface of posterior shoulder	Toward fetal back (abduction)
Rubin II + Woods combined	Both shoulders simultaneously	Counter-rotation (screw effect)
Reverse Woods	Anterior surface of anterior shoulder + posterior surface of posterior shoulder	Reverse rotation

Rubin II is considered superior to the classic Woods maneuver alone because adduction (pushing toward the chest) reduces the biacromial diameter, whereas abduction (pushing toward the back as in Woods) actually increases it. As Creasy & Resnik note: Rubin's approach is "a substantial improvement on the commonly described Woods maneuver, which involves pushing the shoulder toward the fetal back." (Creasy & Resnik's Maternal-Fetal Medicine)

Place in the HELPERR Mnemonic (ALSO Protocol)

The ALSO (Advanced Life Support in Obstetrics) HELPERR sequence positions Rubin II under "E - Enter the vagina for rotational maneuvers", which comes after:

H - Help (call for help)
E - Evaluate for episiotomy
L - Legs (McRoberts maneuver)
P - Pressure (suprapubic)
E - Enter for internal maneuvers ← Rubin II, Woods, Reverse Woods here
R - Remove the posterior arm
R - Roll to all-fours (Gaskin maneuver)

(Swanson's Family Medicine Review)

Memory Hook

"C: Rubin II = posterior part of anterior shoulder → rotate FORWARDS (toward chest)"

Think: Rubin = adduct = chest-ward = diameter DECREASES. The "C" shape of your fingers cupping the posterior aspect of the shoulder then pushing forward rotates the baby like a screw to free the impacted shoulder.

Mechanism simple how to do

Rubin II - Simple Mechanism & How to Do

The Problem (Why Shoulder Dystocia Happens)

Symphysis Pubis
      ↓
  [ANTERIOR SHOULDER STUCK]————[POSTERIOR SHOULDER]
      ↑
   Too wide to fit through = biacromial diameter too large

The two shoulders are lined up front-to-back (AP diameter) - the widest and worst position.

The Fix (Mechanism in 1 Line)

Push the BACK surface of the FRONT shoulder → toward the CHEST = shoulder adducts = biacromial diameter SHRINKS = baby rotates free

Visual Logic

BEFORE Rubin II:
   Symphysis
      |
  [ANT SHOULDER] ←— stuck here
      |
  biacromial = WIDE

AFTER Rubin II (adduction):
  [ANT SHOULDER] rotates inward ↻
      |
  biacromial = NARROWER ✓ → slips through

How to Do It - 3 Steps

Step 1 - Enter Insert your hand into the vagina posteriorly (cut episiotomy if needed for space)

Step 2 - Find Feel the anterior shoulder → go to its back/posterior surface (the side facing the baby's spine)

Step 3 - Push forward Push that surface toward the baby's chest/face (like closing a door)

This = adduction = shoulder folds inward = diameter narrows = rotates baby into oblique (easier) position

One-Line Memory

"Back of front shoulder → push to chest" = Rubin II done ✓

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