Obstetric maneuvers for shoulder dystocia and associated fetal morbidity
Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, USA. American Journal of Obstetrics and Gynecology
(Impact Factor: 4.7).
07/1998; 178(6):1126-30. DOI: 10.1016/S0002-9378(98)70312-6
We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery.
A retrospective review of 285 cases of shoulder dystocia that occurred between January 1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1) those resolved with McRoberts' maneuver, suprapubic pressure, or proctoepisiotomy or a combination of these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm, or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral fracture, or fetal death caused by asphyxial complications.
The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%) clavicular fractures, and 12 (4.2%) humeral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of 158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs 21/158, p = 0.1).
Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated with an increased rate of bone fracture or brachial plexus injury.
Available from: Antonio Ragusa
- "Both perinatal morbidity and mortality are higher in deliveries complicated by shoulder dystocia. Brachial plexus injury is one of the most important foetal complications, complicating 2 – 16% of such deliveries (Gherman et al. 1998). Poor neonatal outcomes aft er shoulder dystocia have been associated with inappropriate management (Croft s et al. 2008). "
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ABSTRACT: Condensation: In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.
Available from: Cantekin Iskender
- "To a large extent, CF is unpredictable and unpreventable, as most cases occur following uncomplicated vaginal deliveries , , . Several risk factors for CF have been identified in the literature, including fetal macrosomia –, shoulder dystocia , , , , gestational diabetes mellitus (GDM), oxytocin use to augment labor , operative delivery , prolonged second stage of labor  and meconium staining of amniotic fluid . Among these factors, only increased fetal birth weight has been consistently associated with neonatal CF. "
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To describe the risk factors and labor characteristics of Clavicular fracture (CF) and brachial plexus injury (BPI); and compare antenatal and labor characteristics and prognosis of obstetrical BPI associated with shoulder dystocia with obstetrical BPI not associated with shoulder dystocia.
This retrospective study consisted of women who gave birth to an infant with a fractured clavicle or BPI between January 2009 and June 2013. Antenatal and neonatal data were compared between groups. The control group (1300) was composed of the four singleton vaginal deliveries that immediately followed each birth injury. A multivariable logistic regression model, with backward elimination, was constructed in order to find independent risk factors associated with BPI and CF. A subgroup analysis involved comparison of features of BPI cases with or without associated shoulder dystocia.
During the study period, the total number of vaginal deliveries was 44092. The rates of CF, BPI and shoulder dystocia during the study period were 0,6%, 0,16% and 0,29%, respectively. In the logistic regression model, shoulder dystocia, GDM, multiparity, gestational age >42 weeks, protracted labor, short second stage of labor and fetal birth weight greater than 4250 grams increased the risk of CF independently. Shoulder dystocia and protracted labor were independently associated with BPI when controlled for other factors. Among neonates with BPI whose injury was not associated with shoulder dystocia, five (12.2%) sustained permanent injury, whereas one neonate (4.5%) with BPI following shoulder dystocia sustained permanent injury (p = 0.34).
BPI not associated with shoulder dystocia might have a higher rate of concomitant CF and permanent sequelae.
Available from: Leonie Penna
- "Shoulder dystocia can feel like an " obstetric nightmare " for both women and healthcare workers . It is associated with significant maternal and fetal morbidity, including postpartum hemorrhage and fetal brachial plexus injury . Following concerns about the safety of vaginal breech deliveries , planned cesareans for breech presentation have led to a reduction in the amount of exposure that healthcare professionals have to the former type of delivery. "
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To evaluate whether eponymous maneuvers and mnemonics taught for the management of shoulder dystocia, vaginal breech delivery, and uterine inversion were remembered and understood in practice.
A questionnaire was distributed to obstetricians and midwives collecting information about the HELPERR and PALE SISTER mnemonics. Three extended matching questions evaluated participants’ knowledge of the correct maneuvers, with their matching eponyms, used in the management of shoulder dystocia, vaginal breech delivery, and uterine inversion.
Of the 112 participants, 90% were familiar with the HELPERR mnemonic, with 79% using it in their practice. Of those who used it, only 32% could correctly decipher it (P = 0.032). PALE SISTER was mostly unfamiliar. The percentages of correct maneuvers used for managing shoulder dystocia, breech delivery, and uterine inversion were 84.6%, 58.3%, and 28.6%, respectively. However, the eponyms were correctly matched to their maneuvers in only 33.3%, 14.3%, and 0% of cases, respectively (P < 0.01).
The meanings of the mnemonics for obstetric emergencies were frequently recalled incorrectly. This, together with the poor correlation between knowledge of maneuvers and their eponyms, limits their usefulness and indicates that teaching should focus on learning without relying on mnemonics and eponyms.
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