Article

Analysis of McRobertsʼ Maneuver by X-Ray Pelvimetry

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Abstract

To document radiographically the changes in pelvic dimensions created by McRoberts' maneuver. Women at least 37 weeks' pregnant who presented to labor and delivery were eligible for study entry. Anterior-posterior and lateral x-rays were taken with women in the dorsal lithotomy position and after application of McRoberts' maneuver, in which the maternal legs were hyperflexed 45 degrees onto the maternal abdomen. A two-tailed paired t test was used to assess the changes in the pelvic diameters, with P < .05 considered statistically significant. Thirty-six subjects were enrolled in the study and 34 x-rays were suitable for analysis. McRoberts' maneuver was associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory (51.53 +/- 2.03 versus 38.07 +/- 1.96 degrees, P < .001). There was a 24% decrease in the angle created by drawing a line bisecting the symphysis pubis relative to the horizontal (P < .001). With McRoberts' maneuver the angle created by a line bisecting the longitudinal axis of the fifth lumbar vertebra and the longitudinal axis of the upper sacrum also increased (133.75 +/- 2.25 to 140.14 +/- 2.12 degrees, P = .04). Ours are the first systematic observations of pelvic changes associated with McRoberts' maneuver, confirming the traditional thinking that the maneuver causes a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum.

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... The unique strength of our analysis is the highly precise quantification and characterization of pelvic tilt and lordosis during the McRoberts manoeuvre using a motion analysis system. A single prior biomechanical study involved anterior-posterior and lateral X-rays taken with gravidas in the dorsal lithotomy position and after application of the McRoberts manoeuvre [8]. ...
... Our study is further limited because our motion capture methodology was unable to assess the size of the pelvic inlet and dimensions of the pelvis outlet, as previously reported by Gherman [8]. The notion that abduction affects the pelvis size dates to back to 1969, when Russell noticed that "if the thighs are flexed and abducted the femora act as lever on the innominate bones to open the bony outlet" [9]. ...
... A modification of pelvic size during McRoberts' manoeuvre, with a wide abduction of the thighs, could modulate our conclusion about the impact of thigh abduction. Nevertheless, the change in pelvic size is tenuous and limited to some millimetres, and the potential effect of additional abduction must be tempered [8]. Therefore, additional studies are needed to measure the size of the pelvis during the McRoberts manoeuvre performed with thighs in maximum abduction. ...
Article
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Background: Guidelines and description about the achievement of the McRoberts manoeuvre are discordant, particularly concerning the need for abduction before the beginning of the manoeuvre. We sought to compare the biomechanical efficiency of the McRoberts' manoeuvre, with and without thigh abduction. Methods: In a postural comparative study, twenty-three gravidas > 32 weeks of gestational age and not in labour were assessed during three repetitions of two McRoberts' manoeuvre that differed in terms of starting position. For the (i) McRoberts, the legs were initially placed in stirrups; for the (m) McRoberts, the legs were resting on the bed, with thighs in wide abduction. For each manoeuvre, flexion of the plane of the external conjugate of the pelvis on the spine (ANGce), hip flexion and abduction, were assessed using an optoelectronic motion capture system. Lumbar curve were assessed with Epionics Spine® system. Temporal parameters including movement duration or acceleration of the external conjugate were also computed. All values obtained for the two types of manoeuvres were compared using a Wilcoxon matched-pairs signed-ranks test. The significance level was defined as p < 0.05. Results: The starting position of McRoberts' otherwise had no effect on the maximum ANGce (p = 0.199), the minimal lordosis of the lumbar curve (p = 0.474), or the maximal hip flexion (p = 0.057). The other parameters were not statistically different according to the starting position (p > 0.005). Conclusion: Regardless of the starting position, the McRoberts' manoeuvre allows ascension of the pubic symphysis and reduction of the lumbar lordosis. This results imply that the McRoberts' manoeuvre could be performed with the legs initially placed in the stirrups.
... These pioneering studies were complemented by radiology-based findings by Gherman et al. For the first time, this research assessed the effects of thigh flexion on the lumbar spine and the pelvis orientation throughout McRoberts manoeuvres 12 . From this previous work, we learned that hyperflexion of the thighs decreases lumbar lordosis as well as the cephalic rotation of 20° with respect to the pubic symphysis 12 . ...
... For the first time, this research assessed the effects of thigh flexion on the lumbar spine and the pelvis orientation throughout McRoberts manoeuvres 12 . From this previous work, we learned that hyperflexion of the thighs decreases lumbar lordosis as well as the cephalic rotation of 20° with respect to the pubic symphysis 12 . However, the mobilization of the thighs with the goal of achieving an optimal birthing position with an "obstetrical chute shape of the pelvic drive" remains to be addressed 13,14 . ...
... The action by the psoas muscle might then reduce the effects of hip flexion on the lumbar curve. The independent effects of the thighs on the pelvic orientation and lumbar curve constitute new biomechanical data that contradict current opinions on the subject, state that hip flexion mechanically causes a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum 12 . ...
Article
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The study aimed to assess the associations between the pelvis orientation, lumbar curve and thigh postures throughout pregnancy in a population of healthy women. Additionally, optimal mechanical birth conditions in terms of the pelvic inlet and lumbar curve were researched. The individuals' posture was assessed with three-dimensional motion analysis and the lumbar curve with the Epionics SPINE system. The association between the hip joint angles (flexion and abduction), the pelvis external conjugate, and lumbar curve position was assessed with a generalized linear mixed model (GLMM) adjusted to individuals' characteristics. Joint laxity was assessed with a modified Jobbin's extensometer. For all of the subjects, hip flexion and hip abduction were significantly associated with the angle between the external conjugate and spine, with higher correlation in the multivariate regression model. The association between hip flexion and the lumbar curve was less significant in multivariate than univariate regression analysis. Optimal birth conditions were never reached. The findings contribute to the understanding of the association between the hip position (flexion and abduction), pelvic orientation, and lumbar curve adjusted for joint laxity in healthy pregnant women. They lay the groundwork for future research in the field of obstetrical biomechanics.
... Même si cela peut être quelque part compréhensible, du fait des difficultés pour y parvenir, il semble étonnant que cela ne constitue pas une piste de recherche. Une étude que nous avons déjà citée a mis en évidence l'intérêt d'agir sur la mobilisation de la parturiente dans un cas particulier de dystocie: la dystocie des épaules (71). Cette pathologie survient lorsque les épaules restent bloquées dans le bassin après la naissance ce qui expose le foetus à l'hypoxie et divers traumatismes (élongation du plexus brachial, et fractures humérales et/ou claviculaires entre autres). ...
... Dans leur étude, Gherman et coll. ont tenté d'objectiver la mobilisation du détroit supérieur et de la colonne vertébrale lombaire lors de la manoeuvre de McRoberts (71). D'après leurs résultats, cette manoeuvre s'accompagne d'une rotation céphalique de la symphyse pubienne ainsi qu'une diminution de la lordose lombaire (71) (cf. Figure 6). ...
... En l'absence de rayon X, nous n'avons en effet pas pu analyser les effets éventuels de la deuxième variante de la manoeuvre sur les dimensions du bassin comme Gherman et coll. l'ont tenté sans résultats avec la manoeuvre classique(71). Or, ces dimensions du bassin sont importantes puisque qu'une augmentation de ces dimensions rendrait sans aucun doute plus efficace la manoeuvre. ...
Thesis
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Lorsque l'on s'intéresse aux positions d'accouchement, les avis sont très partagés. D'après la littérature, les positions dites verticales parmi lesquelles figure la position accroupie semblent aboutir à des issues materno-fœtales plus favorables que les positions horizontales qui comprennent la position gynécologique. Seulement, l'origine de ces bénéfices notamment du point de vue de la mécanique obstétricale reste incertaine. Il apparait que ce manque de clarté provient avant tout d'un manque de définition des postures segmentaires retrouvées lors de ces positions d'accouchement. L'objectif premier de ce travail était donc de définir les postures segmentaires au cours de différentes positions d'accouchement et de préciser en particulier le rôle de la posture des cuisses sur des éléments jugés importants en mécanique obstétricale à savoir l'orientation du plan du détroit supérieur et la courbure lombaire. En premier lieu, une enquête épidémiologique régionale a été effectuée afin d'attester les positions d'accouchement les plus fréquemment adoptées et d'identifier les facteurs associés à leur adoption. Par une méthode dérivée entre autres des méthodes d'analyse du mouvement par système optoélectronique, l'influence de la posture des cuisses (flexion et abduction) sur la posture du plan du détroit supérieur et du rachis lombaire a été analysée tout d'abord en position gynécologique puis en position accroupie. Enfin, l'importance de la posture initiale des cuisses sur les mouvements segmentaires a été évaluée au cours d'une manœuvre obstétricale (Mac Roberts), manœuvre couramment utilisée en cas de dystocie des épaules.Ce travail a permis de mettre en évidence l'importance de la caractérisation des postures segmentaires pour la compréhension des bénéfices d'une position d'accouchement sur une autre.
... Thus it has been shown that some positions, such as on all fours or squatting may increase some pelvic dimensions by 6-8 mm, in particular the bispinous diameter [37,38]. On the other hand, a more recent radiologic study studying pelvic movement during MacRoberts' manoeuvre ( Fig. 3) shows that this position does not modify pelvic diameter [39]. (Two points may explain these divergent results. ...
... Some authors have successfully attempted to act on the orientation of the pelvic inlet and any lumbar lordosis, as for example, Ghermann et al. have done, using MacRoberts' maneuver (see Fig. 3) [39]. The particularity of this maneuver, from a biomechanical perspective, is that this position solicits the lumbarpelvic-femoral complex. ...
... The McRoberts maneuver also straightens out the lumbosacral lordosis and the sacral promontory and removes the compressive force of the delivery table on the sacrum. Radiologic studies evaluating the changes in the pelvis that occur have documented a significant increase in the size of the pelvic inlet with flattening of the sacral prominence (44). In addition, it pushes the anterior shoulder superiorly and places the pelvic inlet perpendicular to the axis of the fetus. ...
... The most frequent severe disability for the fetus is Erb's palsy, usually of the posterior arm (7). This will resolve spontaneously in about 90% to 95% of cases (9,11,18,44). There may be some increase in speech dysfunction (7). ...
... Unfortunately, only case reports describe the applications of these principles to dystocia [7,8,12]. Among the potential fields of action for the laborist, flexion of thighs on the trunk, such as the McRoberts' maneuver, affects pelvis orientation and lumbar curve (especially in cases of lordosis) [15]. ...
... We searched Medline and the Cochrane Library for relevant systematic reviews, meta-analyses, randomized controlled trials, and other clinical studies of childbirth biomechanics. This literature comes mainly from radiological, MRI (magnetic resonance imaging), and ultrasound findings [15,24,25]. Simulation models with finite element methods are also used as teaching tools today as well as to understand and teach obstetrical mechanics, but not to assess the effect of various positions on childbirth biomechanics [25]. ...
Article
Background: An overview of labor based only on epidemiological data cannot identify or explain the mechanisms involved in childbirth. Data about the position that women should take in giving birth are discordant. None of the studies of birth positions adequately define or describe them or their biomechanical impact (pelvic orientation, position of the back). The measurement of the effect of one position relative to that of another requires precise definitions of each position and of their maternal biomechanical consequences, as well as safe measurement methods. Methodology: We have developed a system to analyze the position of labor by quantifying the posture of the woman's body parts (including thighs, trunk, and pelvis), using an optoelectronic motion capture device (Vicon™, Oxford Metrics) widely used in human movement analysis and a system for measuring the lumbar curve (Epionics spine system). A specific body model has also been created to conduct this biomechanical analysis, which is based on external markers. With this methodology and model, it should be possible to define: (1) the hip joint angles (flexion/extension, abduction/adduction, internal/external rotation); (2) the ante/retroversion of the pelvis; (3) the lumbar curve. Discussion: This methodology could become a reference for assessing delivery postures, one that makes it possible to describe the relation between the postures used in the delivery room and their impact on the pelvis and the spine in an integrated and comprehensive model. Trial registration: No. Eudract 2013-A01203-42.
... This straightens the sacrum with respect to the lumbar spine and decreases the angle of inclination of the pelvis. 7 Suprapubic pressure is applied directly downward onto the anterior presenting shoulder or using a rocking motion from the fetal back toward the front. The aim of this maneuver is to decrease the bisacromial diameter by adducting the anterior shoulder and to deflect the bisacromial diameter to an oblique plane. ...
... There is evidence of changes in pelvic dimension with the hand-to-knee and squatting positions [8]. Also, it has been confirmed that the McRoberts' maneuver, in which the maternal legs were hyperflexed 45°onto the maternal abdomen, causes changes in pelvic dimension [27]. However, none of these trials detail the internal rotation degree of the hip joint in each position. ...
Article
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This study was conducted to evaluate the effects of an alternative model of birth (AMB) on the incidence of assisted vaginal delivery (AVD) and perineal trauma (PT). One hundred ninety-nine women with epidural anesthesia were randomized to a traditional model of birth (TMB) (n = 96) or AMB (n = 103). Women in TMB pushed immediately after complete dilatation and delivered in lithotomy position. In AMB, women followed a postural changes protocol while they delayed pushing and used a specific lateral position for delivery. AMB was associated with a significant reduction in AVD compared with TMB (19.8% vs 42.1%, p<0.001). TMB was strongly associated with AVD (OR = 4.49; p< 0.05), which, in turn, was significantly associated with nulliparity (OR = 5.52; p<0.005) and fetal head unengaged at full dilatation (OR = 5.35; p<0.05). AMB significantly increased the intact perineum rate compared with TMB (40.3% vs 12.2%, p<0.001). Episiotomy rate was significantly reduced in AMB (21.0% vs 51.4%, p<0.001). A combination of postural changes during the passive expulsive phase of labor and lateral position during active pushing time is associated with reductions in AVD and PT.
... 21,22 The mother's thighs are flexed towards her chest to tilt her pelvis forwards, thereby producing a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum. 23 While encouraging the mother to bear down, pressure is applied above her pubic symphysis to push the baby's anterior shoulder away from the midline and into the pelvis. ...
Article
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The definition of shoulder dystocia and the incidence vary. Worldwide, shoulder dystocia may be increasing. In this update we look at the complications for both mother and fetus, and review the risk factors and strategies for possible prevention. Management options include the McRoberts position, techniques to deliver the anterior and posterior shoulder, and finally salvage manoeuvres, which include posterior axillary sling traction (PAST), the Zavanelli manoeuvre and fracture of the clavicles. In cases of fetal death associated with undelivered shoulder dystocia, one can consider the trans-abdominal performance or facilitation of traditional vaginal manoeuvres. We suggest a simplified mnemonic, 'MAPS' - M: McRoberts, A: anterior shoulder, P: posterior shoulder, and S: salvage. A video teaching programme will be available shortly on the World Health Organization Reproductive Health Library (www.who.int/rhl; [email protected] /* */).
... Those are: Woods maneuver, Rubin shoulder rotation, Kinch shoulder rotation and releasing back arm. If the listed manipulations do not manage to release the shoulders, the following obstetric procedures must be done: iatrogenic humeral fracture, clavicle fracture and Zavaneli maneuver (12)(13)(14). ...
Article
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Shoulder dystocia (SD) is defined as unpredictable and urgent obstetric complication that happens when the pelvis of a mother is spread sufficiently to deliver fetal head, but insufficiently to deliver fetal shoulders. It is associated with high percentage of maternal and fetal morbidity. Fetal lethality from hypoxia ranges from 2-16%.We observed the case of vaginal delivery in a multiparous woman in the 39th gestational week. Head delivery was performed by using vacuum extraction. Because of the shoulder dystocia, we applied McRoberts’ maneuver with Resnik’s suprapubic pressure and performed one more episiotomy. Since these maneuvers did not give the expected result, we did the aspiration of the upper respiratory paths of the fetus, after which we performed Hibbard’s cord with simultaneous Kristeler’s maneuver. It led to releasing the shoulders and fetal delivery. On delivery, male fetus was 6000 g/60 cm, estimated with Apgar 1. The urgent reanimation was undertaken. After few hours, the baby was transferred to Pediatric Surgical Clinic for further treatment of present pneumotorax and humerus fracture. After many days, the baby being in normal state, was referred to physical rehabilitation treatment. Today, the baby is without sequelae.SD is one of the most difficult, hardly predictable perilous obstetric complications with high percentage of maternal morbidity and fetal morbidity and mortality. It requires caution, training and skills of obstetric-neonatal team. Liberalization of the use of Caesarian section in managing SD decreases the appearance of injuries in both mother and child. However, regardless of very rapid development of perinatology and the use of modern diagnostic-therapeutic protocols, some questions from classical, practical obstetrics remain unanswered.
... It has the advantages of simplicity, ease of application and no requirement for skillful manipulation. Full flexion of the mother's knees and hips against her abdomen may alter pelvic dimensions to favor delivery [88]. It is successful in a substantial number of cases [89]. ...
Article
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Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury.
... Traditionally, the manoeuvre was thought to free an impacted fetal shoulder by alteration of mechanical interactions through cephalad rotation of the mother's pubic symphysis and straightening of the lumbar vertebrae. 3 We tested whether McRoberts' manoeuvre increased intrauterine pressure, which could be another mechanism to release impacted fetal shoulders. ...
Article
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McRoberts' position is used during the second stage of labour to facilitate delivery of the fetal shoulders. Few clinical studies have been done to measure its efficacy. We measured intrauterine pressure in 22 women in term labour, after the vertex reached 3+ station, in the dorsal lithotomy position. Patients pushed with legs either in stirrups or hyperflexed by 1358 (McRoberts' position). Maternal valsalva transiently increased the expulsive force by 32% over naturally occurring contractions. Use of McRoberts' position almost doubled the intrauterine pressure developed by contractions alone (from 1653 mm Hg s to 3262 mm Hg s [97%]).
... This allows the posterior shoulder to descend into the pelvis such that the fetus can be delivered (6). Rotation of the symphysis and flattening of the sacrum is docu- mented by X-ray investigation during McRobert's maneuver (97). In addition to the McRobert's maneuvre, rotation of the shoulders by either the Wood's 'screw' method or Robins' modification can be utilized (6). ...
Article
Large for gestational age fetuses, also called macrosomic fetuses, represent a continuing challenge in obstetrics. We review various problems with large for gestational age fetuses. We have performed a literature search, mainly through the database PubMed (includes the Medline database). The clinical problem is discussed from the primary care provider's, the patient's and the obstetrician's point of view. Macrosomia is arbitrarily defined as having a fetal weight of above the 90th percentile, a birth weight of above 4000 g or 4500 g, or a birth weight of over +2 standard deviation of the mean birth weight by gestational age. The diagnosis of macrosomia is difficult, both by palpation and symphysis fundus measurement; even with sophisticated sonographic measures. The combination of biparietal diameter, femur length and abdominal circumference appears to be no better than abdominal circumference alone. Based on the literature, labor should not be induced in nondiabetic pregnancies. The best policy is to await spontaneous birth or to induce labor after 42 weeks completion. A great number of cesarean sections have to be performed to avoid a single case of plexus brachialis paresis resulting from a difficult shoulder delivery. Cesarean section should not be considered in nondiabetic pregnancies unless the estimated fetal weight is above 5000 g. In pregnancies complicated by diabetes mellitus there are reasons for selective induction of labor if macrosomia is suspected and for cesarean section if the calculated birth weight is above 4000 g. Each department should have a strategy to handle such a situation because the problem with the difficult shoulder delivery cannot be completely avoided. Different procedures of managing difficult shoulder delivery are described.
... The McRobert's is performed by removing the legs from the bed/stirrups and sharply flexing the maternal thighs up onto her abdomen. This procedure results in a straightening of the woman sacrum relative to the lumbar vertebrae with consequent cephalic rotation of the symphysis pubis[96]. Suprapubic commonly administered by an assistant, is given immediately before or in direct conjunction with the McRobert's manoeuvre. This pressure is usually directed posteriorly, in an attempt to force the anterior shoulder under the symphysis pubis while downward traction is applied ...
Article
Fetal macrosomia is defined as birth weight >4000g and is associated with several maternal and fetal complications such as maternal birth canal trauma, shoulder dystocia and perinatal asphyxia. Early identification of risk factors could allow preventive measures to be taken so as to avoid adverse perinatal outcomes. Prenatal diagnosis is based on two-dimensional ultrasound formulae, but accuracy is low, particularly at advanced gestation. Three-dimensional ultrasound could be an alternative to soft tissue monitoring allowing better prediction of birth weight than two-dimensional ultrasound. In this article, we describe the definition, risk factors, diagnosis, prevention, ultrasound monitoring, prenatal care and delivery in fetal macrosomia cases.
... It consists of the hyperflexion, and not divergence, of the maternal thighs on the abdomen, with the accompanying moderate spread of the knees without external rotation of the feet. This maneuver does not increase the diameters of the pelvis in an absolute sense, but reduces the angle of inclination of the symphysis and flattens the sacrum [58]. The goal is to slide the anterior shoulder below the pubic symphysis, which actually happens very frequently (Fig. 40.3 from Ayres-de-Campos). ...
Chapter
In this chapter we will explain what shoulder dystocia (SD) is and how it is defined. We will also talk about the risk factors and focus, in particular, on the three most important risk factors: fetal macrosomia, diabetes and previous shoulder dystocia. We will explain that whatever method is used to estimate the fetal weight at term of pregnancy, it has a high margin of error and this error increases with increasing fetal weight. We will explain why, in most cases, shoulder dystocia is unpredictable and unforeseeable so that, generally, the induction of labour or elective caesarean section, for all women with suspected fetal macrosomia are not indicated. We will explain why it is very important to take human factors into account, when trying to solve SD, and why it is good to continually practice the simulation. Finally, we will focus on how to diagnose and manage SD in the best possible way.
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Transvaginal uterosacral ligament fixation (USLF), often called "high" USLF, is associated with a 1.0% to 10.9% ureteral obstruction rate. Anatomic relations and pelvic rotation with positioning imply "high" (cephalad) suture placement may bring sutures closer to the ureter. We examined the ureteral obstruction rate with a "deep" (dorsal/posterior) uterosacral ligament suture placement modification of a standard USLF procedure. At the University of Massachusetts and Tufts, 411 consecutive patients underwent Mayo culdoplasty utilizing > or = 3 uterosacral sutures placed "deep" bilaterally. Intraoperative cystoscopy was performed. One patient (0.24% [.01%-1.35%]) had ureteral obstruction attributable to USLF. Two had obstruction secondary to concomitant procedures. Compared with previous published series, the odds of ureteral injury secondary to USLF was 4.6 times lower (95% CI 2.31-9.24; P < .0001). Placement of USLF sutures "deep" (dorsal/posterior) increases the margin of safety for the ureter and, in this study, decreased the ureteral injury rate nearly 5-fold.
Article
Shoulder dystocia and brachial plexus injury occur in 0.5% to 1.5% of all births. Risk factors for both include maternal obesity, excessive prenatal weight gain, maternal diabetes, protracted labor, and fetal macrosomia. These factors are involved in only about 50% of births complicated by shoulder dystocia or brachial plexus injury. Shoulder dystocia has a low recurrence rate (9.8%-16.7%), although history of previous shoulder dystocia is the most reliable predictor of occurrence. Brachial plexus injury is the most common morbidity associated with shoulder dystocia, but 50% of newborns who present with this injury were not subject to shoulder dystocia at birth. Most brachial plexus injuries are transient, although 5% to 22% become permanent. Shoulder dystocia followed by permanent brachial plexus injury or mental impairment is one of the leading causes of malpractice allegations. Prompt assessment and management of shoulder dystocia and preparation to maximize the efficiency of shoulder dystocia maneuvers are critical. Documentation of the appropriate use of maneuvers to relieve shoulder dystocia demonstrates standard of care practice, thereby decreasing the potential for successful malpractice allegations.
Article
Full-text available
Shoulder Dystocia (SD) is the nightmare of obstetricians. Despite its low incidence, SD still represents a huge risk of morbidity for both the mother and fetus. Even though several studies showed the existence of both major and minor risk factors that may complicate a delivery, SD remains an unpreventable and unpredictable obstetric emergency. When it occurs, SD is difficult to manage due to the fact that there are not univocal algorithms for its management.Nevertheless, even if it is appropriately managed, SD is one of the most litigated cause in obstetrics, because it is frequently associated with permanent birth-related injuries and mother complications.All the physicians should be prepared to manage this obstetric emergency by attending periodic training, even if SD is difficult to teach for its rare occurrence and because in clinical practice it is often handled by experienced obstetricians.THE PURPOSE OF THIS STUDY IS TO REVIEW THE LITERATURE CONCERNING THE EVERLASTING PROBLEMS OF SD: identification of risk factors for the early detection of delivery at high risk of SD and a systematic management of this terrifying obstetric emergency in order to avoid the subsequent health, medico-legal and economic complications.
Chapter
Die Schulterdystokie zählt zu den seltenen, aber besonders gefährlichen Geburtskomplikationen. Neben der Geburtsasphyxie stehen Frakturen und Armplexusparesen im Vordergrund. Die fetale Makrosomie ist der wichtigste Risikofaktor; gerade Kindsgewichte >4000 g werden häufig stark unterschätzt. Eine sinnvolle Prävention, z. B. durch frühzeitigere Geburtseinleitung, steht allenfalls bei fetaler Makrosomie in Kombination mit maternalem Diabetes mellitus oder Gestationsdiabetes zur Diskussion. Die klinische wie sonographische Makrosomiediagnostik ist für die Indikationstellung zur Sectio caesarea zu unpräzise. Die Eltern sollten über individuelle Risikofaktoren (z. B. Makrosomieverdacht, Z. n. Schulterdystokie) und Behandlungsalternativen (Einleitung/Sectio caesarea) aufgeklärt werden. Bei einer manifesten Schulterdystokie sollte zunächst das McRoberts-Manöver genutzt werden, da es wenig traumatisierend ist und häufig schon ohne additive Maßnahmen die Geburt der Schultern ermöglicht.
Article
Any delivery in the emergency department is considered a precipitous birth and is an anxiety-producing event. Many deliveries proceed without incident. However, the emergency physician must be prepared for several dreaded scenarios, such as nuchal cord, shoulder dystocia, and breech birth. This article reviews the basics, complications, and management of such deliveries.
Chapter
Die Schulterdystokie zählt mit einer mittleren Inzidenz von 0,7 % (0,1–2,3 %) zu den seltenen, aber besonders gefährlichen Komplikationen unter der Geburt. Mangels klinischer Routineerfahrung kann das adäquate Vorgehen nur im Rahmen von Trainingsprogrammen mit ausreichender Sicherheit vermittelt werden. Diese werden auch von den Gerichten gefordert, die aufgrund der hohen Morbidität von Mutter und Kind häufig in Anspruch genommen werden. Neben asphyxiebedingten Schäden stehen v. a. Frakturen (Klavikula 5–23%, Humerus 1,1%) und Armplexusparesen (4,7–15%) des Kindes im Vordergrund. Die fetale Makrosomie stellt zwar den bedeutendsten Risikofaktor für das Auftreten einer Schulterdystokie dar, ist aber nicht zuverlässig diagnostizierbar, da insbesondere Kindsgewichte von mehr als 4000 g häufig unterschätzt werden. Eine medizinisch sinnvolle Prävention bezüglich dieser schwerwiegenden Komplikation, z. B. durch frühzeitigere Geburtseinleitungen, steht allenfalls bei erkannter fetaler Makrosomie in Kombination mit einem maternalen Diabetes oder Gestationsdiabetes zur Diskussion. Die klinisch wie sonographisch zu unpräzise Makrosomiediagnostik ist in der Regel keine ausreichende Indikation für eine primäre Sectio caesarea. Dies gilt um so mehr, weil nahezu die Hälfte aller Schulterdystokien bei Kindern mit einem Geburtsgewicht < 4000 g zustande kommen. Allerdings sollte jede Schwangere mit deutlich erhöhtem Risiko (z. B. sonographisch makrosomes Kind bei adipöser Gestationsdiabetikerin) über die Möglichkeit einer Schnittentbindung aufgeklärt werden. Für die Behandlung der Schulterdystokie wurden zahlreiche Verfahren empfohlen. Als prophylaktische Maßnahme oder bei erschwerter Schulterentwicklung eignet sich die frühzeitige äußere Überdrehung des kindlichen Kopfes. Bei manifester Schulterdystokie sollte zunächst das McRoberts-Manöver genutzt werden, da es wenig traumatisierend ist und häufig schon ohne additive Maßnahmen die Geburt der Schultern ermöglicht. Mit diesem können konsekutiv alle anderen Methoden kombiniert werden, wobei die Lösung des hinteren Armes aus der Sakralhöhle die wohl erfolgversprechendste ist.
Chapter
Een ongecompliceerde baring, zoals beschreven is in H. 10.1007/978-90-368-2279-4_6, wordt over het algemeen niet van het ene op het andere moment een gecompliceerde baring. Geleidelijk doen zich één of meerdere symptomen voor die extra monitoring, diagnostiek of interventie vereisen. Nog elk jaar neemt het aantal verwijzingen durante partu toe. Dat komt gedeeltelijk door nieuwe medische inzichten, maar ook door ongeduld bij de barende vrouw en de verloskundig professional. Met enige medicamenteuze ondersteuning, zoals bijstimulatie of pijnbehandeling, maken de meeste vrouwen een verder ongecompliceerde baring door. Nederland behoort tot een van de weinige hogelonenlanden met een sectiopercentage < 20 %. In dit hoofdstuk komen de stoornissen aan de orde die het verloop van het eerste, tweede, derde en vierde tijdperk van de baring kunnen compliceren, alsook de acute verloskundige situaties.
Article
In obstetric science, it is unknown whether the inherent biomechanical features of the squatting position can be achieved and/or transposed to the supine birth position. In this study Biomechanical features of the squatting position were compared with 2 hyperflexed supine positions for giving birth. Thirteen pregnant women past the 32 weeks of gestational age not in labor were assessed first in the squatting position with the feet flat on the floor, then in the hyperflexed supine position, and finally in the optimal supine position “crushing” the hand of the caregiver onto the bed. For each position, the flexion of the spine associated with the plane of the external conjugate (ANGce) and the pelvis, hip flexion, and abduction were quantified using an optoelectronic motion capture system. A non-invasive strain-gauge-based measuring system was used to track the lumbar curve. An optimal position was defined with a flat lumbar spine and a pelvic inlet plane perpendicular to the lumbar spine (ANGce=0°±5°). For the 13 participants, hip flexion, hip abduction, and the lumbar curve did not differ significantly for the three positions (squatting position, hyperflexed supine position, and OS) in the post-hoc analyses. The optimal supine position induced an ANGce closer to the perpendicular plane than the squatting position (p=0.002). In the squatting position or in hyperflexed supine position positions, none of the subjects fulfilled the two conditions considered necessary to reach the optimal position.The squatting position was not significantly different from the supine hyperflexed supine position with or without voluntary lordosis correction.
Preprint
Background Guidelines and description about the achievement of the McRoberts manoeuvre are discordant, particularly concerning the need for abduction before the beginning of the manoeuvre. We sought to compare the biomechanical efficiency of the McRoberts’ manoeuvre, with and without thigh abduction. Methods In a postural comparative study, twenty-three gravidas > 32 weeks of gestational age and not in labour were assessed during three repetitions of two McRoberts’ manoeuvre that differed in terms of starting position. For the (i) McRoberts, the legs were initially placed in stirrups; for the (m) McRoberts, the legs were resting on the bed, with thighs in wide abduction. For each manoeuvre, flexion of the plane of the external conjugate of the pelvis on the spine (ANGce), hip flexion and abduction, were assessed using an optoelectronic motion capture system. Lumbar curve were assessed with Epionics Spine® system. Temporal parameters including movement duration or acceleration of the external conjugate were also computed. All values obtained for the two types of manoeuvres were compared using a Wilcoxon matched-pairs signed-ranks test. The significance level was defined as p < 0.05. Results The starting position of McRoberts’ otherwise had no effect on the maximum ANGce ( p = 0.199), the minimal lordosis of the lumbar curve ( p = 0.474), or the maximal hip flexion ( p = 0.057). The other parameters were not statistically different according to the starting position ( p > 0.005). Conclusion Regardless of the starting position, the McRoberts’ manoeuvre allows ascension of the pubic symphysis and reduction of the lumbar lordosis. This results imply that the McRoberts’ manoeuvre could be performed with the legs initially placed in the stirrups.
Article
A precipitous delivery can be among the most stressful events an emergency physician encounters. The physician must assess 2 patients (mother and fetus) and be prepared to manage a variety of complications that may arise during delivery. A majority of precipitous deliveries result in good outcomes for both mother and baby, but emergency physicians must be prepared to manage feared complications, such as tight nuchal cords, shoulder dystocia, and breech presentation. An understanding of the labor process as well as advanced planning can help decrease the stress and chaos inherent to any precipitous delivery.
Article
Intrapartum angle of progression (AoP) is the leading sonographic parameter for the assessment of fetal head descent in labor. An AoP > 120° in the second stage of labor was correlated with spontaneous vaginal delivery and AoP > 145.5° with successful vacuum extraction.1-3.
Chapter
Precipitous or emergency department (ED) delivery is a stressful event that requires preparation to comfortably approach and safely manage—often including development of ED delivery checklists or kits and appropriate expedited consultant notification (i.e., paging lists). Complications are rare but include shoulder dystocia, prolapsed umbilical cord, and breech presentation. If a shoulder dystocia is encountered, an algorithm of maneuvers can be employed and should start with McRoberts maneuver and application of suprapubic pressure and proceed to include rotational or internal maneuvers. Management of a prolapsed umbilical cord should start with elevation of the presenting fetal part to alleviate pressure on the umbilical cord and expedited obstetric assistance for emergent cesarean section. Breech delivery is best managed by allowing the mother to deliver the fetus with no assistance in delivery until the umbilicus is visualized.
Chapter
It is a real intrapartum emergency defined as difficulty in delivery of shoulders and trunk after head has come out of introitus with a delay by more than 60 s and further requiring certain maneuvers. The incidence is related to some macrosomic babies of diabetic or nondiabetic mothers weighing 4–4.5 kg or more. Some postmature babies may have it. The incidence in general is 0.2–1.75 %. In many situations, it has been under or over reported as figures are derived from labor room records. To know its real incidence, standardized criteria for registry have been defined. The management aim is to reduce head to body delivery time in order to release cord compression early and to avoid fetal and maternal injury due to aggressive manipulations. No single maneuver is superior to others in releasing impacted shoulder and reducing risk of injury. When diagnosed, shoulder dystocia drill is recommended. McRoberts’ maneuver with suprapubic pressure is a preferred initial approach. Maternal morbidity is due to lacerations of genital tract, extension of episiotomy, and rupture uterus. There may occur postpartum hemorrhage due to uterine atony, prolonged labor, large infant, and increased blood loss from vaginal tears. Fetal injuries of neuromusculoskeletal type cause morbidity and mortality. About 11 % neonates suffer from serious neonatal trauma. Mostly shoulder dystocia is neither accurately predicted nor prevented. Elective induction of labor or elective cesarean section for all macrosomic babies is not appropriate. Elective cesarean is indicated for estimated fetal weight 5000 g (4500 g in Indians) in nondiabetic and 4500 g (4000 g in Indians) in diabetes mellitus. Counseling and documentation of events save from the medicolegal problems.
Article
Objectives: Shoulder dystocia is an uncommon but serious complication occurring in 0.2 to 3% of deliveries. We carried out a study in order to assess the midwives experience, knowledge and practices on shoulder dystocia, at the maternity hospital of Saint-Denis, Reunion Island. Methods: The first part is a confidential questionnaire addressed to midwives working in the delivery unit. The second part is a retrospective desk review of shoulders dystocia which occurred from 2004 to 2014. Results: (1) The population was made up of 28 midwives, having between 1 to 27 years of experience. Seventy-five percent of them had been faced with shoulder dystocia, and 62% had realized Jacquemier's maneuver. However, only 25% received this maneuver training. Less than a third of them answered correctly to at least 7 from the 8 theoretical questions about the Jacquemier's maneuver. (2) We studied 34 shoulders dystocia, occurring between 36+5 to 41+2 gestational weeks, mostly with no risk factors found. Mac Roberts' maneuver is used as first-line in 88% of situations. Jacquemier's maneuver is used in 52.9% of cases (5.9% as first-line, 47% as second-line). In 26.4% of situations, the midwife is not able to reduce the dystocia. She usually carries out a combination of maneuvers. The gynecologist is asked only for 23.5% of dystocia and he usually uses Jacquemier's maneuver (70% of situations). Conclusion: The Jacquemier's maneuver is rarely practiced (uncommon situation, lack of training). Simulation trainings should be put in place, because neonatal sequels can be avoided.
Article
The frequency of shoulder dystocia in different reports has varied, ranging 0.2-3% of all vaginal deliveries. Once a shoulder dystocia occurs, even if all actions are appropriately taken, there is an increased frequency of complications, including third- or fourth-degree perineal lacerations, postpartum hemorrhage, and neonatal brachial plexus palsies. Health care providers have a poor ability to predict shoulder dystocia for most patients and there remains no commonly accepted model to accurately predict this obstetric emergency. Consequently, optimal management of shoulder dystocia requires appropriate management at the time it occurs. Multiple investigators have attempted to enhance care of shoulder dystocia by utilizing protocols and simulation training.
Article
Obesity increases all risks of adverse obstetric outcome including shoulder dystocia. Shoulder dystocia is a serious complication of childbirth, defined as a vaginal cephalic delivery requiring additional obstetric manoeuvres to deliver the fetus after routine traction has failed. Case-control studies have demonstrated a higher prevalence of obesity in pregnancies affected by shoulder dystocia, but maternal obesity itself is not an independent risk factor for shoulder dystocia. There is a direct relationship between shoulder dystocia and birth weight once the fetal weight exceeds 4 kg. Maternal diabetes particularly with fetal macrosomia is one of the best available predictors of shoulder dystocia probably due to difference in the anthropomorphic makeup of the infant. When it does occur in the obese patient, the management of shoulder dystocia is far more challenging and manoeuvres may need to be adapted. Early results from the UK Obstetric Surveillance System (UKOSS) indicate elective Caesarean section for women with BMI exceeding 50 may prevent shoulder dystocia without affecting maternal outcomes. © 2012 Springer-Verlag Berlin Heidelberg. All rights are reserved.
Article
Objective: The objective of this review is to propose recommendations on the management of shoulder dystocia. Materials and methods: The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted. Results: In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus). Conclusion: All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation.
Article
Full-text available
Background: Shoulder dystocia is an unpredictable, unpreventable obstetric emergency fraught with a universally accepted definition, no consensus management, and a wide variation in reported incidence worldwide. Aim: The aim of this review is to create awareness to Obstetricians and residents in training, guidelines and a plan of action to the management of this obstetric emergency. Methods: Review of pertinent literature on shoulder dystocia, selected references, conference papers, technical reports, journal articles, abstracts, and internet articles using Medline, Google scholar and Pubmed databases were critically reviewed. Results: Shoulder dystocia is associated with 1% risk of serious long term disability or death in the neonates. The relative infrequency of shoulder dystocia and lack of standardized management means that few Obstetricians are truly experienced in the management of this obstetric emergency. Multiple maneuvers can be applied in an attempt to alleviate the dystocia. Conclusion: Shoulder dystocia is highly unpredictable obstetric emergency which requires that all labour ward practitioners must possess a detailed knowledge of the condition and how to overcome it
Article
To assess whether prophylactic use of the McRoberts maneuver and suprapubic pressure decreased the head-to-body time, as a proxy for shoulder dystocia, in at-risk patients.Methods Patients with estimated fetal weights over 3800 g were randomized to undergo the McRoberts maneuver and suprapubic pressure before delivery of the fetal head (prophylactic maneuvers) or to undergo maneuvers only after delivery of the head, if necessary (controls). A total of 185 patients were enrolled in the study. After exclusions (eg, abdominal delivery), there were 128 evaluable vaginal deliveries. The study had the power to detect a 30% difference in head-to-body time between groups.ResultsHead-to-body delivery times did not differ between the prophylactic and control patients (24 ± 18 seconds versus 27 ± 20 seconds, P = .38). In addition, the two groups did not differ in rates of admission of the infant to the special care nursery or in birth injuries. There was a significant increase in the risk of delivering by cesarean for patients randomized to the use of prophylactic maneuvers.Conclusion This study does not support the hypothesis that prophylactic use of the McRoberts maneuver and suprapubic pressure speeds delivery in a population of patients at increased risk for shoulder dystocia.
Article
Full-text available
Article
Shoulder dystocia is an obstetric emergency that has been reported to occur in 0.2–3% of all vaginal deliveries. Several characteristics of shoulder dystocia make it a particular challenge to manage effectively. It is relatively infrequent, the diagnosis cannot be made according to a single objective criterion that can be recognized to exist by all members of the care team who are present, it is unpredictable, and there is the need for coordinated actions of all members of the health care team who have come together on the day of the delivery and may not have worked together before or specifically during a shoulder dystocia. In general, there is evidence from different medical disciplines that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve shoulder dystocia outcomes.
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La Distocia de Hombros (DH) corresponde a una de las principales causas de trauma obstétrico con consecuencias en el ámbito clínico materno, perinatal y médico legal. Ocurre por una detención de la rotación interna de los hombros generalmente asociada a una retención del hombro bajo la sínfisis del pubis, lo que impide el desprendimiento del cuerpo fetal. Las fuerzas endógenas maternas como las contracciones y el pujo materno, producirían mayor presión y, por ende, mayor posibilidad de daño que las fuerzas ejercidas por el operador (fuerza exógena) para resolver el problema; por lo que debieran primero realizarse las maniobras tendientes a movilizar el hombro sobre el pubis, para dar luego lugar al pujo y contracciones uterinas maternas. La posición de McRoberts (MR) logra como maniobra inicial y única, una resolución de al menos el 43% de los casos de DH. La posición de MR no incrementa las dimensiones de la pelvis materna, sólo modifica su morfología, y su combinación con la compresión suprapúbica corresponde al manejo inicial de toda distocia de hombros. A diferencia de la litotomía, ha mostrado que reduce dos veces la fuerza de compresión del hombro sobre el pubis materno, favoreciendo el desplazamiento del hombro a través del pubis y el subsecuente desprendimiento de la cabeza fetal explicándose así la potencialidad del MR para prevenir una eventual DH. En la prevención de la DH, el uso de la posición de MR durante el desprendimiento del feto, presenta plausibilidad biomecánica e incluso podría reducir otras lesiones no asociadas a DH, como la fractura de clavícula y parálisis braquial. En consideración a las repercusiones clínicas, éticas y médico legales, recomendamosel consentimiento informado para definir la posición final materna. SUMMARY The shoulder dystocia (SD) is a major cause of obstetric trauma with implications in clinical maternal, perinatal, and medico legal. It occurs by the detention of internal rotation of the shoulders usually associated with a retention shoulder under the symphysis pubis, which prevents the release of the fetal body. Maternal endogenous forces like contractions and maternal pushing, produce more pressure and therefore more chance of damage that forces applied by the operator (exogenous force) to solve the problem so that should be made the maneuvers tending to mobilize the shoulder on the pubis, to continue with uterine contractions and maternal pushing. McRoberts position (MR) succeeds as initial maneuver, a resolution of at least 43% of cases of SD. The position of MR does not increase the size of the maternal pelvis, only modifies the morphology, and the combination with suprapubic compression correspond to the initial management of shoulder dystocia whole. Unlike lithotomy been shown to reduce twice the compression force on the shoulder over the maternal pubis, promoting the displacement of the shoulder through the pubis and the subsequent detachment of the fetal head, thus explain the potential of the MR for preventing possible SD. In the prevention of the SD, the use of MR position during the release of the fetus, presents biomechanical plausibility and might even reduce other injuries not associated to SD, as clavicle fracture and brachial paralysis. In consideration to clinical implications, ethical and medico-legal, we recommend the informed consent to define the final position in the maternal childbirth assistance. Key words: McRoberts, shoulder dystocia, maneuvers, prophylactic.
Article
Objective: Pubic symphysis diastasis that requires surgical repair is an uncommon condition with a frequency ranging from one in 300 to one in 30,000 vaginal deliveries with most patients responding to conservative therapy. Methods: This report reviews a case of a 33-year-old woman diagnosed with a 3.5-cm pubic symphysis diastasis after a 22-hour labor and delivery. Despite conservative therapy, she continued to have severe pain, disability, and stress urinary incontinence. Results: Surgical repair included open reduction and internal fixation of the pubic symphysis and a tension-free sling. Conclusion: Management of parturition-induced pelvic structural abnormalities is not a part of daily practice for most obstetricians and gynecologists. This case highlights the role of integrated medical care for such patients.
Article
Shoulder dystocia is an obstetric emergency that is often unpredictable and unanticipated. Despite the identification of various clinical risk factors, our ability to predict and prevent shoulder dystocia is very limited. Effective and timely clinical management is essential to offer the best chance of a satisfactory outcome. Upon diagnosis of the condition, a team working in tandem to resolve the problem is very effective. Use of the McRoberts maneuver, application of suprapubic pressure, with an adequate episiotomy allow resolution of over 50% of cases, with a low risk of fetal injury. Secondary maneuvers include rotation of the shoulders and delivery of the posterior shoulder. These are technically more challenging and may be associated with a higher risk of fetal injury. More drastic action may be considered in dire cases where even secondary maneuvers fail. These include the Zavanelli maneuver, symphysiotomy or iatrogenic clavicular fracture. These techniques, while seldom required, may be lifesaving in extremely severe cases. Upon resolution of the clinical event, it is essential to document the entire event, and to discuss the clinical problem and management with the parents. These actions will reduce the risk of medical litigation, and improve patient satisfaction with clinical care.
Book
During the past several years, there has been an extensive reappraisal of the physiologic changes of pregnancy and their associated disorders, along with a refinement of diagnostic procedures and evaluation of the therapeutic approaches that are of primary concern to the physician. In Shoulder Dystocia and Birth Injury: Prevention and Treatment, Third Edition, noted authority James A. O'Leary, M.D., with 40 years experience as an M.D. academician, lecturer, practitioner and clinical researcher with almost 200 contributions to the OB-GYN literature and textbooks, shares his insight on treatment techniques, identification and treatment of predisposing risk factors, current statistical data, ultrasound diagnosis and the necessary steps toward prevention, along with a thorough review of the important medical-legal issues. Shoulder Dystocia and Birth Injury: Prevention and Treatment, Third Edition supplements the limits of personal experience with the accumulated experience of many talented clinicians to aid physicians, midwives, and professionals in training with the most current information in this vital field. © Humana Press, a part of Springer Science+Business Media, LLC 2009. All rights reserved.
Article
This report describes the use of maternal pelvic and fetal models, a tactile sensing glove, and a microcomputer data acquisition system to measure fetal shoulder extraction forces. Sixty-nine experiments were carried out in the laboratory setting to simulate vaginal delivery of the aftercoming fetal shoulders. The tests were conducted using a variety of fetal biclavicular diameters (10-13 cm) and maternal pelvic angle positions (McRoberts, 10 degrees; lithotomy, 25 degrees). When comparing lithotomy versus McRoberts positioning, there was a consistent reduction in force needed to extract the fetal shoulders with the latter maneuver. No simulated clavicles were fractured during shoulder delivery until a biclavicular diameter of 12.0 cm was reached. At this point, five of eight clavicles (63%) were fractured at 25 degrees and zero of seven (0%) were fractured at 10 degrees (P less than .025). For all 69 experiments, fetal neck extension readings were consistently lower than the total traction forces recorded by the tactile sensing glove. This suggests that, in addition to the axially oriented fetal neck forces, a component of flexion (lateral force) was also present. As the difficulty of shoulder delivery increased, the impact of these inadvertent flexion forces became most pronounced at the level of the brachial plexus. This is the first study to measure shoulder extraction forces reproducibly using a laboratory model for shoulder dystocia and to describe the pathophysiology of specific neonatal injuries from a force perspective. The results document objectively that McRoberts positioning reduces shoulder extraction forces, brachial plexus stretching, and the incidence of clavicular fracture.
A method is presented whereby x-ray measurements can be corrected for divergence error quickly and accurately by means of a nomogram. Only one index line is required; there is no transfer axis requirement; no additional tables need be consulted or mathematical computations done. The nomogram provides a one-step, accurate, comprehensive simplification of the Ball pelvimetric technique.
Article
. Women throughout the ages preferred to be delivered with their trunks vertical and most delivery positions illustrated in historical texts indicate that an upright posture with abducted thighs has been the rule. There is evidence that such a position considerably increases the outlet measurement of the pelvis. Primitive delivery positions often accentuate the mechanical forces usually acting on the pelvis.
Article
Our purpose was to determine the rate of success of the McRoberts' maneuver as the initial treatment for shoulder dystocia and to compare the rate of maternal and neonatal morbidity with those cases of shoulder dystocia requiring additional obstetric maneuvers. A secondary goal was to assess those factors associated with successful McRoberts' maneuvers. A retrospective review of shoulder dystocia cases occurring between 1991 and 1994 was performed. The identified cases were divided into two groups on the basis of the maneuvers used to relieve the shoulder dystocia. The first group comprised cases in which the McRoberts' maneuver was used as the sole treatment and the second group consisted of cases in which additional maneuvers were subsequently used. Exclusion criteria included lack of documentation concerning the maneuvers used or cases in which the McRoberts' maneuver was not the initial technique used. The two groups were compared with respect to various antepartum, intrapartum, and neonatal characteristics. During the study period we identified 250 cases of shoulder dystocia among 44,072 vaginal deliveries, for an incidence of 0.57%. Of these, 236 cases (94%) fulfilled entry criteria. The McRoberts' position alone successfully alleviated the shoulder dystocia in 98 cases (42%). In the group of cases where the McRoberts' maneuver was the sole maneuver used, there were significantly lower mean birth weights (p = 0.008), shorter durations of the active phase of labor (p = 0.009), and shorter second stages (p < 0.0001). In the group of cases that required additional maneuvers to relieve the shoulder dystocia, there was a trend toward an increased incidence of postpartum hemorrhage and brachial plexus injury (p = 0.07). These data suggest that the McRoberts' maneuver is associated with a significant degree of success in relieving shoulder dystocia and may be associated with decreased morbidity compared with other maneuvers. On the basis of these findings, we recommend the McRoberts' maneuver as the initial technique for disimpaction of the anterior shoulder.
Article
Many authors have recommended the McRoberts' maneuver as the initial technique in the management of shoulder dystocia. There have been, however, no reported adverse maternal outcomes associated with this technique. We report a case of symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver. An overly exaggerated lithotomy position and thigh abduction stretches the articular surfaces of the symphysis pubis and places increased pressure on the femoral nerve by the overlying inguinal ligament.
Article
McRoberts' maneuver is often used prophylactically with the onset of active maternal expulsive efforts or immediately before delivery of the fetus. A 31-year-old woman, gravida 1, para 0, at 39 + 2 weeks' gestational age, was continuously maintained in an exaggerated lithotomy position while actively pushing during the second stage of labor. Immediately following spontaneous vaginal delivery of a 3,598-g infant, the patient noted left gluteal pain and left anterior thigh dysesthesia. Orthopedic evaluation revealed a 5-cm symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy. The patient underwent closed reduction of the left hemipelvis, followed by open reduction and internal fixation of the symphysis pubis two weeks later after failing conservative treatment. Although McRoberts' maneuver is generally safe, care should be exercised with use of excessive force or prolonged placement of the patient's legs in a hyperflexed position.