Article

The McRoberts' maneuver for the alleviation of shoulder dystocia: How successful is it?

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Abstract

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.

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... In a retrospective review of 250 shoulder dystocia cases that occurred between 1991 and 1994 at Los Angeles County-University of Southern California, the McRoberts' manoeuvre alone was found to have a success rate of 42%. More than half (54.2%) of the shoulder dystocias were resolved with the combination of McRoberts', suprapubic pressure, and/or proctoepisiotomy [3]. The mechanism of action of the McRobert's manoeuvre perform a rapidly marked anterior rotation of the pubic symphysis and by flattening the sacrum. ...
... The mechanism of action of the McRobert's manoeuvre perform a rapidly marked anterior rotation of the pubic symphysis and by flattening the sacrum. This manoeuvre might allow for anterior foetal shoulder elevation, pushing of the posterior foetal shoulder over the sacrum, and brings the pelvic inlet perpendicular to the maximum expulsive forces [3]. ...
... The values obtained during each manoeuvre were recorded and averaged over the three repetitions of each manoeuvre. Based on the previous results of Gherman et al. [3], we considered as significant, a 4°(5%) increasing of ANGce. With this hypothesis, 22 participants are necessary with of power of 90% and a risk of type I error of 5%. ...
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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.
... However, even well conducted McRoberts' manoeuvre and suprapubic pressure do not guarantee success of delivery without injury. Studies from previous cohorts have claimed success rates ranging from 23.2 to 58 % for McRoberts' manoeuvre alone or in combination with suprapubic pressure [5,13,15]. In order to perform McRoberts' manoeuvre and suprapubic pressure correctly and effectively, there must be adequate staff available, including two persons to hyperflex the maternal hips (one on each side), a third one to apply suprapubic pressure, and another one to apply traction on the fetal head. ...
... The root of this current review stems from two previous studies published by our group regarding the headto-shoulder delivery interval and perinatal outcomes of shoulder dystocia [2,3]. We subsequently noted that the 25 % success rate of McRoberts' manoeuvre and suprapubic pressure in our Asian centre was similar to a recently published paper from the Netherlands (23.8 %) [16], but was significantly lower than that reported in other predominantly Caucasian centres such as that of MacKenzie et al. and Gherman et al. (46 and 42 % respectively) [13,15]. There are only a few reports on the success rate of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia. ...
... Although the presence of prolonged second stage of labour and maternal BMI ≥30 kg/m 2 at the time of delivery was shown significant in univariate analysis, they lost significance on multivariate analysis. [13,15]. Notable differences between our cohort and those of Gherman et al. [15] and MacKenzie et al. [13] are that, Gherman et al's consisted mainly of multiparous women (86 %) with spontaneous vaginal deliveries (90.4 %) and ethnically Caucasian, as opposed to our cohort of 52 % multiparous and 48 % nulliparous women, who delivered predominantly by instrumental delivery (67.2 %), and were ethnically Asian. ...
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Background McRoberts’ and suprapubic pressure are often recommended as the initial choices of manoeuvres to manage shoulder dystocia, as they are believed to be less invasive compared to other manoeuvres. However, their success rates range from 23 to 40 %. This study aims to investigate the predictive factors for the success of McRoberts’ manoeuvre with or without suprapubic pressure (M+/−S). Methods All cases of shoulder dystocia in a tertiary hospital in South East Asia were recruited from 1995 to 2009. Subjects were analysed according to either ‘success’ or ‘failure’ of M+/−S. Maternal and fetal antenatal and intrapartum factors were compared by univariate and multivariate analysis. Results Among 198 cases of shoulder dystocia, M+/−S as the primary manoeuvre was successful in 25.8 %. The other 74.2 % needed either rotational or posterior arm manoeuvres or combination of manoeuvres. Instrumental delivery was the single most significant factor associated with an increased risk of failed M+/−S on logistic regression (p < 0.001, OR 4.88, 95 % CI 2.05–11.60). The success rate of M+/−S was only 15.0 % if shoulder dystocia occurred after instrumental delivery but was 47.7 % after spontaneous vaginal delivery. Conclusions When shoulder dystocia occurs after instrumental vaginal delivery, the chance of failure of M+/−S is 85 %, which is 4.7 times higher than that after spontaneous vaginal delivery. Hence all operators performing instrumental delivery should be proficient in performing all manoeuvres to relieve shoulder dystocia when M+/−S cannot do so.
... incidence of postpartum haemorrhage following shoulder dystocia (Gherman, Goodwin et al. 1997 ...
... ). Severe lacerations of the perineum, vagina or anus or combinations thereof have been reported to have incidences ranging from 3 to 19 % (elMadany, Jallad et al. 1991;Gherman, Goodwin et al. 1997). Uterine rupture and the requirement for laparotomy has also been reported(el Madany, Jallad et al. 1991;Gherman, Goodwin et al. 1997). ...
... ). Severe lacerations of the perineum, vagina or anus or combinations thereof have been reported to have incidences ranging from 3 to 19 % (elMadany, Jallad et al. 1991;Gherman, Goodwin et al. 1997). Uterine rupture and the requirement for laparotomy has also been reported(el Madany, Jallad et al. 1991;Gherman, Goodwin et al. 1997). ...
... 10 One of the most popular and least invasive interventions, the McRobert's maneuver, has a reported success rate in the range of 42% to 58%; the latter when combined with suprapubic pressure. 2,[10][11][12] The use of additional maneuvers beyond the McRobert's maneuver has been associated with higher fetal weights, longer labors, and higher rates of fetal injury. [2][3][4]10,11 Considering these associations, shoulder girdle dystocia not responding to initial maneuvers can be considered a more severe subset of this clinical problem. ...
... 2,[10][11][12] The use of additional maneuvers beyond the McRobert's maneuver has been associated with higher fetal weights, longer labors, and higher rates of fetal injury. [2][3][4]10,11 Considering these associations, shoulder girdle dystocia not responding to initial maneuvers can be considered a more severe subset of this clinical problem. ...
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Objective The main purpose of this article is to describe the technique and mechanism of action of a novel intervention for the relief of shoulder dystocia we are labeling Carit maneuver. Methods We report a cohort study of eight cases of shoulder dystocia not relieved by the combination of McRobert's maneuver and suprapubic pressure treated with the Carit maneuver. This intervention involves the use of the fetal head and neck as the grasping point of the fetus to exert a ventral rotation of the fetal trunk, reduce the bi-acromial diameter, and deliver the posterior shoulder by passive displacement. In all these cases, the direction of the original head restitution, direction of exerted rotation, and side and location of delivery of the first shoulder were recorded. Maternal and neonatal outcomes were reviewed and reported. Results In all cases, the Carit rotational maneuver resulted in the delivery of the posterior shoulder in the transverse (4), oblique anterior (2), or direct anterior (2) diameters. No instances of neonatal depression or fetal acidemia were noted in this cohort. Conclusion The Carit maneuver is an original and successful intervention in the management of shoulder dystocia unresponsive to McRobert's maneuver and suprapubic pressure.
... 8 By rotating the pelvis, the pubic symphysis is raised approximately 1 cm. 9,10 Considered from this geometric perspective, the reported effectiveness of McRoberts' maneuver in resolving approximately 40% of shoulder dystocia cases 11 is apparent, because a fetal bisacromial diameter of nearly average dimension or below 12 should subsequently fit within the anteroposterior diameter of the pelvic inlet with about this frequency. However, the same laboratory experiments also showed that the benefit of McRoberts' maneuver was limited to bisacromial widths up to 12 cm. ...
... Indeed, McRoberts' maneuver will successfully resolve many cases of shoulder dystocia without trauma to the infant. 8,11 However, persistent use of this method during ...
... College of Obstetricians and Gynecologists' (ACOG) practice bulletins on the topic, for example, published in 2002 and 2017, noted that maternal complications with shoulder dystocia include a postpartum hemorrhage rate of 11% and a 3 rd and 4 th degree perineal laceration in 4% of cases 1,22 . In both practice bulletins, ACOG referenced the same publications, which is a single center, has a small sample size, was published decades ago and is the only reference cited from the US, which reported on frequently encountered complications 23 . Thus, the benchmark rate of frequent maternal complications with shoulder dystocia may not be applicable in contemporary practice in the US. ...
... The major strength of our analysis that differs from prior studies is that the current data derives from 19 hospitals stemming from 12 unique and geographically dispersed centers 24,25 . Unlike prior studies which focus primarily on neonatal complications, we were able to analyze both maternal and neonatal complications from shoulder dystocia 23 . The large sample size also permitted us to adjust for several potential confounders. ...
Article
Background While the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity occurring with this obsetetric emergency is infrequently reported. Objective To assess the composite maternal and neonatal adverse outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia. Material and Methods This is a secondary analysis of Consortium of Safe Labor, an observational obstetrical cohort of all deliveries occurring at 19 hospitals (from 2002-2008) who delivered vaginally and had data on the occurrence of shoulder dystocia. The composite maternal adverse outcome included 3rd or 4th degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean section), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score < 7 at 5 min, birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (CI). Area under the receiver operating characteristic curve (AUC) was constructed to determine if clinical factors would identify shoulder dystocia. Results Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them shoulder dystocia was documented in 2,159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; aRR 1.71, 95% CI 1.64-2.01). The most common maternal morbidity with shoulder dystocia was 3rd or 4th degree laceration (aRR 2.82; 95% CI 2.39-3.31). The risk of the composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without (2.4%; aRR 5.18, 95% CI 4.60-5.84). The most common neonatal morbidity was birth injury (aRR 5.39, 95% CI 4.71-6.17). AUC for maternal characteristic to identify shoulder dystocia was 0.66 and 0.67 for intrapartum factors. Conclusions Though shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. Focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.
... Shoulder dystocia, which is associated with increased rates of maternal and fetal morbidities, occurs in approximately 0.2% to 3.0% of vaginal births [2]. For the mother, shoulder dystocia increases the risk of postpartum hemorrhage as well as third-and fourth-degree perineal lacerations [3,4]. Similarly, in neonates, shoulder dystocia increases the risk of asphyxia, permanent Erb's palsy, and fetal fractures [5]. ...
Article
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Shoulder dystocia is defined as vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has been delivered and gentle traction has failed. A bigger difference between the transverse abdominal diameter (TAD) (abdominal circumference [AC]/π) and biparietal diameter (BPD) (TAD-BPD) has been reported as a risk factor for shoulder dystocia in different countries; however, it remains unclear if this relationship is relevant in Japan. This study aimed to clarify the association between TAD-BPD and shoulder dystocia after adjusting for potential confounding factors in a Japanese cohort. We retrospectively examined 1,866 Japanese women who delivered vaginally between 37+0 and 41+6 weeks of gestation at the University of Yamanashi Hospital between June 2012 and November 2018. The cutoff value of TAD-BPD associated with shoulder dystocia and the association between TAD-BPD and shoulder dystocia were evaluated. The mean maternal age was 32.5±5.3 years; the patients included 1,053 nulliparous women (57.5%), 915 male infants (49.0%), 154 women with gestational diabetes mellitus (GDM) (8.3%), and 5 infants with macrosomia (0.3%). The mean TAD-BPD was 9.03±4.7 mm. The overall incidence of shoulder dystocia was 2.4% (44/1866). The cutoff value to predict shoulder dystocia was 12.0 mm (sensitivity, 61.4%; specificity, 73.8%; likelihood ratio, 2.34; positive predictive value, 5.4%; negative predictive value, 98.8%). We then used a multivariable logistic regression analysis to examine the association between TAD-BPD and shoulder dystocia while controlling for the potential confounding factors. In multivariate analyses, TAD-BPD ≥12.0 mm (adjusted odds ratio [OR], 4.39; 95% confidence interval [CI], 2.35–8.18) and GDM (adjusted OR, 3.59; 95% CI, 1.71–7.52) were associated with shoulder dystocia. Although TAD-BPD appears to be a relevant risk factor for shoulder dystocia, sonographic fetal anthropometric measures do not appear to be useful in screening for shoulder dystocia due to a low positive predictive value.
... The combination of the McRoberts maneuver and supra pubic pressure solves more than 50% of SD cases [60]. ...
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.
... 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]. However, in severe cases when the McRoberts maneuver does not work it may in fact contribute to the occurrence of BPI, and for this reason we do not recommend its use. ...
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.
... Shoulder dystocia was diagnosed when the contraction that followed the emergence of the fetal head was not sufficient for the delivery of the shoulders. In 1 dystocia patient, the McRoberts maneuver was sufficient to achieve delivery [26]. In the remaining 2 dystocia patients, delivery was achieved after performing the McRoberts maneuver followed by the anterior Rubin maneuver [27]. ...
Article
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Objective: This study aimed to evaluate the relationship between second- and third-trimester clavicle length and birth weight and shoulder dystocia. Methods: This prospective observational study included 181 patients who presented to the Private Etlik Lokman Hekim Hospital for routine pregnancy visits between March 2019 and March 2020. In addition to routine pregnancy examinations, the patients also underwent ultrasonography twice at weeks 20-23 and 33-36 to determine the length of the fetal clavicle. The patients were evaluated for shoulder dystocia in the second stage of labor. The birth weight of the neonates was recorded. The primary objective of this study was to establish the relationship between third-trimester clavicle length and shoulder dystocia. Results: Fetal clavicle length increases in the second trimester with the advancing gestational week but does not significantly change in the third trimester. We didn't observe significant difference for second trimester clavicle length between type of delivery, birth weight, or shoulder dystocia. Also, we didn't observe any significant difference for third trimester clavicle length between type of delivery. However, we found a significant relationship between third trimester clavicle length and birth weight and shoulder dystocia. The median third-trimester clavicle length was 39.5 mm (range: 30.7-43.9) in neonates who did not develop shoulder dystocia and 42.5 mm (range: 41.4-43.1) in the 3 neonates who developed shoulder dystocia. The third-trimester clavicle length cut-off for shoulder dystocia was calculated as 41.35 mm (sensitivity: 100.00%, specificity: 83.82%, accuracy: 84.5%). The third-trimester clavicle length cut-off for macrosomia (defined as birth weight of ?4100 g) was 40.75 mm (sensitivity: 87.50%, specificity: 77.56%, accuracy: 78.05%). Conclusion: Third-trimester fetal clavicle length, an important component of biacromial diameter, as measured by ultrasonography is a practical and significant method for predicting macrosomia and shoulder dystocia.
... Shoulder dystocia was diagnosed when the contraction that followed the emergence of the fetal head was not sufficient for the delivery of the shoulders. In 1 dystocia patient, the McRoberts maneuver was sufficient to achieve delivery [26]. In the remaining 2 dystocia patients, delivery was achieved after performing the McRoberts maneuver followed by the anterior Rubin maneuver [27]. ...
Article
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on the relationship of fetal clavicle measurement with macrosomia and shoulder dystocia
... In a previous study, direct fetal manipulation techniques used to overcome shoulder dystocia were not found to be associated with an increased rate of brachial plexus injury (18) . A study conducted in 1997 concluded that the McRoberts' maneuver was associated with a significant degree of success in relieving shoulder dystocia and may be associated with decreased morbidity compared with other maneuvers (19) . Although the Cochrane review concluded that prophylactic maneuvers should not be used to prevent shoulder dystocia, if a recognizable risk factor for shoulder distocia is present in our institution, a prophylactic McRoberts maneuver is used most of the time (20) . ...
Article
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Objective To present some features and incidence of cases of brachial plexus injury in deliveries at the Department of Obstetrics and Gynecology of Zeynep Kamil Maternity and Children’s Training and Research Hospital, from January 2010 through December 2014. Materials and Methods In total, 38.896 deliveries in the Department of Obstetrics and Gynecology of Zeynep Kamil Maternity and Children’s Training and Research Hospital, from January 2010 through December 2014 were screened from a prospectively collected database. We recorded gravidity, parity, body mass index, maternal diabetes, labor induction, gestational age at delivery, operative deliveries, malpresentations, prolonged second stage of deliveries, shoulder dystocies, clavicle and humerus fructures, estimated fetal weight, biparietal diameter, abdominal circumference, femur length, fetal sex, route of delivery, maternal age, and fetal anomalies. Results There were 28 (72/100.000) cases of brachial plexus injury among 38.896 deliveries. In the 6-year study period, there were 18.363 deliveries via c-section, whereas 20.533 were vaginal deliveries. Conclusion Sonographic fetal weight estimation and clinical examination performed by experienced obstetricians, and active appropriate management of shoulder dystocias seemed to attenuate the incidence of brachial plexus injury in the at risk population in our tertiary referral center.
... It is described as the inability to deliver the fetus' shoulders after head delivery. Even if 2 of 10 all recommended measures are adopted, there is a high risk of catastrophic neonatal and maternal morbidity and mortality [1][2][3]. Multiple risk factors for shoulder dystocia were investigated. The link between fetal macrosomia and ShD was established [4], and the American College of Obstetricians and Gynaecologists recommends a cesarean delivery (CD) to prevent ShD in diabetic women with an estimated fetal weight (EFW) over the 4500 g and in non-diabetic women who had an EFW of at least 5000 g [5]. ...
Article
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Background and objectives: Shoulder dystocia (ShD) is one of most dangerous obstetric complication. The objective of this study was to determine if the ultrasonographic fetal biacromial diameter (BA) and derived parameters could predict ShD in uncomplicated term pregnancies. Materials and methods: We conducted a prospective observational study in a tertiary care university hospital from March 2021 to February 2022. We included all full-term pregnancies accepted for delivery that received an accurate ultrasonography (USG) scan before delivery. USG biometry and estimated fetal weight (EFW) were collected. Therefore, we evaluated the diameter of the mid-arm, the transverse thoracic diameter (TTD) and the biacromial diameter (BA). BA was estimated using Youssef's formula: TTD + 2 mid-arm diameters. The primary outcome was the evaluation of BA and its related parameters (BA/biparietal diameter (BPD), BA/head circumference (HC) and BA-BPD in fetuses with ShD versus fetuses without ShD. Diagnostic accuracy for ShD of BA, BA/BPD, BA/HC and BA-BPD was evaluated using receiver operator curve (ROC) analysis. Results: 90 women were included in the analysis, four of these had ShD and required extra maneuvers after head delivery. BA was increased in fetuses with ShD (150.4 cm; 95% CI 133.2 cm to 167.6 cm) compared to no-ShD (133.5 cm; 95% CI 130.1 cm to 137.0 cm; p = 0.04). Significant differences were also found between ShD and no-ShD groups for BA/BPD (1.66 (95% CI 1.46 to 1.86) vs. 1.44 (95% CI 1.41 to 1.48); p = 0.04), BA/HC (0.45 (95% CI 0.40 to 0.49) vs. 0.39 (95% CI 0.38 to 0.40); p = 0.01), BA-BPD (60.0 mm (95% CI 42.4 to 77.6 cm) vs. 41.4 (95% CI 38.2 to 44.6); p = 0.03), respectively. ROC analysis showed an overall good accuracy for ShD, with an AUC of 0.821 (p = 0.001) for BA alone and 0.881 (p = 0.001), 0.857 (p = 0.016) and 0.867 (p = 0.013) for BA/BPD, BA-BPD and BA/HC, respectively. Conclusions: BA alone, as well as BA/BPD, BA/HC and BA-BPD might be useful predictors of ShD in uncomplicated term pregnancies. However, such evidence needs extensive confirmation by means of additional studies with large sample sizes, especially in case of pregnancies at high risk for ShD (i.e., gestational diabetes).
... Inicia-se com a manobra de Mc Roberts, trazendo-se as nádegas da paciente 8 a 10 cm para fora da mesa de parto e flexionando-se as coxas da parturiente em direção ao abdomen. Quando associada à pressão supra-púbica, realizada por um auxiliar, objetivando rodar o ombro fetal para liberá-lo da impactação na pube, atinge 42 a 54% de sucesso sem risco de lesar o feto (11) . É uma manobra médica, e caso algum parente esteja acompanhando o parto, não deve participar. ...
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Resumo Paralisia obstétrica é uma lesão do plexo braquial ao nas-cimento. Em nosso meio, sua prevalência não é conhecida, mas as disfunções do membro comprometido são muitas ve-zes frequentes e duradouras. Distócia de ombro é definida como a necessidade de manobras para o desprendimento dos ombros, ou um intervalo maior que 60 segundos entre a saída da cabeça e a dos ombros, estando relacionada a 50% dos casos de lesão do plexo braquial. A maioria dos casos ocorre na ausência de fatores de risco. As manobras de assistência ao parto com distócia de ombro devem ser treinadas e me-morizadas. A abordagem da lesão braquial deve ser multidis-ciplinar. Fisioterapia, reconstrução microcirúrgica do plexo, correção de deformidades articulares secundárias e transpo-sições musculares são empregadas com sucesso. O papel do tratamento conservador e operatório deve ser regularmente revisado. O objetivo deste trabalho foi realizar uma revisão da literatura sobre a paralisia obstétrica do plexo braquial. Descritores: 1. Paralisia braquial congênita; 2. Injúria braquial congênita; 3. Lesão obstétrica de plexo braquial; 4. Paralisia obstétrica de plexo braquial; 5. Distócia de ombro; 6. Tratamento cirúrgico.
... Postpartum bleeding due to birth canal injury is one of the major causes of the maternal morbidity and mortality [26,27]. ...
Article
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Shoulder dystocia is a condition where there is a difficulty in the delivery of the shoulder of the fetus occurs. This is an obstetric emergency. It happens when the fetalbiacromial diameter is larger than the biparietal diameter or the maternal pelvic brim is flat rather than gynecoid, If this frightening situation is not manage properly, in time and by expert hand it can cause severe fetal and maternal outcome. All doctors should require proper training and knowledge for the management of this emergency situation. Well-trained health professionals can improve the outcome of the delivery when shoulder dystocia occurs. There is no any strong evidence to prevent shoulder dystocia because it is so unpredictable. But good control of blood glucose level of diabetic mother will reduce the incidence of macrosomic baby. Elective caesarean section is recommended for suspected fetal macrosomia to prevent brachial plexus injury.
... L'absence de consensus sur la définition de la dystocie des épaules est responsable d'une grande variabilité de son incidence dans les différentes publications (161). Certains auteurs incluent dans leur définition la seule nécessité de pratiquer une manoeuvre obstétricale (McRoberts, Wood, extraction du bras postérieur) et rapportent une incidence de 0,13 à 2,1 % (162).Sur le plan foetal, la macrosomie est corrélée à la survenue de cette complication(163).La dystocie des épaules s'accompagne d'une morbidité périnatale importante : hémorragie de la délivrance, lésions périnéales de haut degré, lésion du plexus brachial, fracture de la clavicule, fracture de l'humérus, hypoxie néonatale et décès néonatal(161),(164).Dans la plupart des études, les manoeuvres obstétricales réalisées pour la gestion de la dystocie des épaules sont peu détaillées et peu évaluées. Les plus fréquemment utilisées sont la manoeuvre de McRoberts (l'appui supra pubien) et la manoeuvre de Jaquemier(161). ...
... minutes versus 84.7±75.4 minutes, p< 0.00001) 8 . Nevertheless, 15 minutes of difference does not seem clinically relevant and, moreover, parity and spinal anesthesia have not been taken into account for the statistical analysis. ...
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Introduction: Shoulder dystocia (SD) is known for being an unpredictable and unpreventable event associated to substantial morbidity to the mother and neonate. The aim of this study was to determine the incidence of SD in a tertiary care hospital and the morbidity according to the type of maneuvers (McRoberts' maneuver and suprapubic pressure versus rotational maneuvers or delivery of the posterior arm) used to resolve the dystocia. Methods: This was a prospective cohort study of pregnancies complicated with SD carried during two years and a half. Maternal characteristics, duration of second stage of labor, type of delivery, fetal weight, neonatal morbidity (Apgar score
... Gherman ve ark. da pubik basının McRobert manevrası ile birlikte uygulandığında başarı oranının %54.2-58'e ulaştığı- nı belirtmişlerdir (19,20). Gurewitsch ve ark. ...
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The risk factors and perinatal outcomes of shoulder dystocia during delivery Objective: SD (shoulder dystocia) is an uncommon and unpredictable event complicating 0.2–3% of all vaginal deliveries. We sought to examine the current risk factors and perinatal outcomes of all cases of shoulder dystocia in a single institution over a five years period. Material and Method: This is a retrospective study carried out at a large tertiary referral center serving a single urban population over a 5 years period from 1998-2013. Shoulder dystocia was defined as failure to deliver the shoulders at the first attempt in singleton cephalic vaginal deliveries. Details of maternal demographics, intrapartum characteristics and neonatal outcomes were recorded prospectively on a computerized database for analysis. Results: Last five years, total number of vaginal birth was 31,497 and the incidance of shoulder dystocia was %0.1 (n=33) in this period. In the shoulder dystocia cases %21 (n=7) of them had gestational diabetes mellitus and only 21% of the patients (n=7) were nulliparous. In %39 (n:13) of newborns who had sshoulder dystocia were observed signs of brachial plexus injury like moro reflex loss. Newborns who had shoulder dystocia, %39 (n:13) had 4000 gr and above birthweight but only one of the newborns (%3) who had shoulder dystocia had antenatal ultrasonographic measurement of estimated fetal weight over 4000 grams (4050 gr). 3(%9) of newborns needed to be followed up in neonatal intensive care unit. Newborns who had shoulder dystocia were divided into two groups: babies with (n=18, %54) or without (n=15, %46) complication because of shoulder dystocia. Brachial plexus palsy was significantly more common among episiotomy + maneuver, compared with maneuver-only and episiotomy-only (p:0.046). Conclusion: We consider this robust and significant data relating to contemporary antecedents and outcomes of SD. As a complication which carries a significant risk of persistent neurological injury for the infant and consequent medicolegal implications for the clinician, continuous audit and high levels of awareness and training for all birth attendants should now be standard practice.
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
This article reports the findings of three audits relating to shoulder dystocia carried out over a 3–year period. It demonstrates how audit can change practice and that audit is an important part of guideline development. Shoulder dystocia is an obstetric emergency that can result in significant neonatal and maternal morbidity. With the clinical and medicolegal implications of shoulder dystocia it is important that midwives are able to recognize and handle such an emergency with appropriate assistance.
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
Shoulder dystocia occurs in less than 1% of births but can have severe consequences for both the mother and baby. It is also the third most common cause of litigation in the UK. A structured approach to management has been shown to help practitioners provide effective care, and since 2000 many Trusts have implemented the HELPERR mnemonic developed by the Advanced Life Support in Obstetrics group (ALSO) as a basis for care. In 2012, the Royal College of Obstetricians and Gynaecologists (RCOG) updated guidance on managing shoulder dystocia and moved away from the use of the mnemonic HELPERR; however, our midwifery students reported that they felt daunted by the RCOG algorithm and preferred to use a mnemonic to help them provide systematic care. This article sets out a modified approach and adapted version of the HELPERR mnemonic for use in practice that incorporates the latest RCOG guidance for use in the management of shoulder dystocia.
Article
Objective To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme.DesignInterrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996–99), (ii) Early training (2001–04), and (iii) Late training (2009–12).SettingSouthmead Hospital, Bristol, UK, with approximately 6000 births per annum.PopulationInfants and their mothers who experienced shoulder dystocia.MethodA bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000.Main OutcomesNeonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval).ResultsCompliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training.Conclusions There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia.
Article
Shoulder dystocia is an unpredictable obstetric emergency. Prompt intervention is necessary in order to decrease risk of maternal-fetal trauma and long-term sequella. A thorough knowledge of what to do should this crisis occur is essential for perinatal nurses to ensure the best outcome possible for the woman and fetus. Although generally shoulder dystocia is impossible to predict, there are reasonable steps that providers can take once shoulder dystocia is identified. Key nursing interventions include calling for additional help, calm supportive actions, and working in sync with the physician or certified nurse midwife (CNM) who is directing the maneuvers to deliver the impacted shoulder. Numerous risk factors for shoulder dystocia have been discussed in the literature; however, despite many attempts by researchers to develop predictive models, no single risk factor or combination of risk factors has been shown to predict shoulder dystocia. Interventions described in the literature to relieve the impacted shoulder include suprapubic pressure, the McRoberts, Woods, Schwartz-Dixon, Gaskin, and Zavanelli maneuvers, and symphisiotomy. There is no clear evidence-based order for using these maneuvers. The essential issue is to continue to intervene using an organized expeditious series of steps until the infant has been delivered. If an injury occurs as a result of shoulder dystocia despite the best efforts of the obstetric providers, it is likely that litigation will follow. This article will review what is known about risks for shoulder dystocia, appropriate nursing interventions, and suggestions for risk management.
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
Analyser la gestion d’une série de dystocies des épaules au regard des recommandations anglo-saxonnes. L’étude a également analysé la morbidité maternelle et néonatale associée à cet accident.Matériel et méthodesÉtude rétrospective, observationnelle et monocentrique menée à l’hôpital Foch-de-Suresnes entre le 1er janvier 2004 et le 31 décembre 2008, incluant les difficultés et les dystocies des épaules.RésultatsL’étude a permis le recensement 192 dystocies des épaules soit une incidence voisine de 2%. La manœuvre de Mac Roberts et la pression sus-pubienne ont été réalisées en première intention dans 85,9 % des dystocies et ont été à elles seules efficaces dans 58,6 % des cas. La contre-rotation et l’expression abdominale ont été deux pratiques respectivement utilisées dans 19,6 et 14,1 % des cas alors qu’elles ne font l’objet d’aucune recommandation dans cette situation. Six lésions périnéales du 3e degré (3,1 %) et neuf lésions du plexus brachial (4,7 %) ont été observées mais aucun lien de causalité n’a été mis en évidence entre la nature des manœuvres utilisées et les lésions observées.Conclusion La manœuvre de Mac Roberts et la pression sus-pubienne restent les premières manœuvres pratiquées en cas de dystocie des épaules. Dans plus de 40 % des cas, elles doivent être complétées par des manœuvres adaptées. En revanche, la pratique de la contre-rotation et l’expression abdominale, encore largement utilisées, doivent être proscrites. Pour qu’elles ne soient plus pratiquées, il semble donc essentiel que des recommandations pour la pratique clinique concernant la prise en charge des dystocies des épaules soient publiées par nos sociétés savantes car seule l’harmonisation de nos pratiques permettra d’améliorer la prise en charge de cet accident.
Article
Resumen La distocia de hombros (DH) complica el 1% de los partos. Su principal factor de riesgo es la macrosomía, pero la gran mayoría de los fetos macrosómicos pesan entre 4.000-4.500 g y presentan un riesgo individual de DH inferior al 2%. Además, la estimación ecográfica del peso fetal es imprecisa. Por estos motivos, sólo se recomienda una cesárea programada cuando el peso fetal estimado es superior a 5.000 g en mujeres no diabéticas y superior a 4.500 g en mujeres diabéticas. Aparte de estas situaciones poco frecuentes, la DH es un acontecimiento impredecible. La maniobra de MacRoberts se recomienda en primera instancia porque es sencilla, pero solamente permite eliminar la distocia en alrededor del 50% de los casos y provoca una parálisis del plexo braquial en el 5-10% de ellos. Es indispensable que todos los asistentes al parto estén formados en otras maniobras, en particular en la maniobra de Jacquemier. La parálisis obstétrica del plexo braquial (POPB) complica el 8-16% de las distocias de hombros. Sin embargo, aproximadamente un 50% de las POPB ocurre en ausencia de una DH reconocida y/o en recién nacidos de peso ordinario, lo que sugiere una pluralidad de mecanismos etiológicos. Es probable que algunas POPB se constituyan antes de la liberación completa de la cabeza, bajo la influencia de fuerzas endógenas (contracciones uterinas [CU] y esfuerzos expulsivos [EE]), pero también y sobre todo exógenas (parto instrumental [PI], presión sobre el fondo uterino). En la práctica, los procedimientos medicolegales tienen que ver principalmente con las POPB graves y no regresivas, que justifican un intento de reparación quirúrgica del plexo braquial. Estas formas casi nunca se presentan tras un nacimiento simple y espontáneo.
Article
Shoulder dystocia as an unpredictable intrapartal emergency with incidence from 0,6-1,4% represents one of the most important problems among obstetric controversies today. Medico-legal approach for shoulder dystocia is based upon good clinical practice according to algorithms of modern obstetrics. Well trained and cool-headed obstetrician with correct and appropriate diagnosis right on time, as well as organized entire medical team, have straight impact for neonatal and maternal outcome. Obstetric procedures for shoulder dystocia should be well trained within ob/gyn residency and during educational courses. According to legal, forensic, obstetric and ethical aspect it is mandatory for shoulder dystocia to be recorded and properly documented. Obstetric failure includes unrecognized shoulder dystocia, inappropriate obstetric management with consequent imapirment of child and/or mother, Kristeller maneuver, and inadequate medical documentation.
Article
Background: Results from epidemiological studies about the association between maternal pre-pregnancy obesity and the risk of shoulder dystocia are inconsistent. Objective: To evaluate the effect of maternal pre-pregnancy obesity on the risk of shoulder dystocia. Search strategy: We searched PubMed and Web of Science database for all relevant studies up to 5 August 2016 and reviewed the reference lists of identified articles. Selection criteria: Observational studies that investigated the association between pre-pregnancy obesity and the risk of shoulder dystocia were included. Data collection and analysis: A total of 20 articles involving 2 153 898 participants were included in this meta-analysis. A random effects model was used to calculate the pooled relative risks (RRs) with 95% confidence intervals (CIs). Main results: For obese versus non-obese, the pooled RR of shoulder dystocia was 1.63 (95% CI 1.33-1.99). The findings remained significant in the cohort studies (RR = 1.59, 95% CI 1.28-1.97) and case-control studies (RR = 1.92, 95% CI 1.03-3.57). With regard to the subgroup of continents, there was significant association between obesity and the risk of shoulder dystocia in Europe (RR = 1.51, 95% CI 1.18-1.92) and Asia (RR = 2.59, 95% CI 1.15-5.83). The result from the sensitivity analysis for studies adjusted for gestational diabetes was significant (RR = 1.61, 95% CI 1.05-2.47). The pooled RRs for obesity classes I, II and III versus non-obese were 1.29 (95% CI 1.06-1.57), 1.94 (95% CI 1.26-2.98) and 2.47(95% CI 1.56-3.93), respectively. Authors' conclusion: This meta-analysis suggests that maternal pre-pregnancy obesity is associated with increased risk of shoulder dystocia. This article is protected by copyright. All rights reserved.
Article
Objective: We sought to develop a machine learning (ML) model for prediction of shoulder dystocia (ShD) and to externally validate the model accuracy and potential clinical efficacy in optimizing the use of cesarean delivery (CD) in the context of suspected macrosomia. Study design: We used electronic health records (EHR) from the Sheba Medical Center in Israel to develop the model (derivation cohort) and EHR from the University of California San Francisco Medical Center to validate the model accuracy and clinical efficacy (validation cohort). Subsequent to inclusion and exclusion criteria, the derivation cohort consisted of 686 deliveries [131 complicated by ShD], and the validation cohort of 2,584 deliveries [31 complicated by ShD]. For each of these deliveries, we collected maternal and neonatal delivery outcomes coupled with maternal demographics, obstetric clinical data and sonographic biometric measurements of the fetus. Biometric measurements and their derived estimated fetal weight were adjusted (aEFW) to the date of the delivery. A ML pipeline was utilized to develop the model. Results: In the derivation cohort, the ML model provided significantly better prediction than the current paradigm: using nested cross validation the area under the receiver operator characteristics curve (AUC) of the model was 0.793 ± 0.041, outperforming aEFW and diabetes (0.745 ± 0.044, p-value = 1e-16). The following risk modifiers had a positive beta > 0.02 increasing the risk of ShD: aEFW (0.164), pregestational diabetes (0.047), prior ShD (0.04), female fetal sex (0.04) and adjusted abdominal circumference (0.03). The following risk modifiers had a negative beta < -0.02 protective of ShD: adjusted biparietal diameter (-0.08) and maternal height (-0.03). In the validation cohort the model outperformed aEFW and diabetes (AUC = 0.866 vs. 0.784, p-value = 0.00007). Additionally, in the validation cohort, among the subgroup of 273 women carrying a fetus with aEFW above 4,000 g, the aEFW had no predictive power (AUC = 0.548), and the model performed significantly better (0.775, p-value = 0.0002). A risk-score threshold of 0.5 stratified 42.9% of deliveries to the high-risk group that included 90.9% of ShD cases and all cases accompanied by maternal or newborn complications. A more specific threshold of 0.7 stratified only 27.5% of the deliveries to the high-risk groups that included 72.7% of ShD cases, and all those accompanied by newborn complications. Conclusion: We developed a ML model for prediction of ShD. We externally validated the model performance in a different cohort. The model predicted ShD better than EFW+ maternal diabetes and was able to stratify the risk of ShD and neonatal injury in the context of suspected macrosomia. This article is protected by copyright. All rights reserved.
Article
Introduction: Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia. Methods: We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (< 0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise. Results: Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, p 0.01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR 1.8, 95% confidence interval (CI) 0.9–3.3; OR 1.6, 95% CI 0.8–3.2; OR 1.7, 95% CI 0.7–3.9; and OR 1.8, 95% CI 0.6–5.3; respectively), however this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR 3.3, 95% CI 1.5–7.1, OR 4.8 95% CI 1.3–17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls.
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Obstetric Decision-Making and Simulation - edited by Kirsty MacLennan March 2019
Article
Objective: To determine the incidence and risk factors for recurrent shoulder dystocia in women. Methods: We searched Medline, Pubmed, Embase, and CINAHL for relevant articles in English and French from 1980 to February 2018 that described risks of recurrent shoulder dystocia undergoing a trial of labour in subsequent pregnancies. A total of 684 articles were found, of which 13 were included as they met criteria. We extracted data on study characteristics, incidence of recurrent shoulder dystocia, degree of neonatal injury, and presence of known risk factors. Results: There was a wide variation in the incidence of shoulder dystocia in subsequent pregnancies from 1–25%. The largest cohort reported a risk of 13.5%. The most important risk factor for recurrent shoulder dystocia is an increase in birthweight in the subsequent pregnancy compared to the index pregnancy (OR 7–12). Prolonged second stage, instrumental delivery, maternal diabetes, increased maternal BMI, and severe neonatal morbidity in the index pregnancy were also associated with an increased risk of recurrent shoulder dystocia. However, many of these risk factors were present in women who did not have a recurrent shoulder dystocia. In addition, women with recurrent shoulder dystocia rarely had identifiable risk factors, other than the history of previous shoulder dystocia. Sample sizes were low as most studies are single centre, retrospective cohorts with low rates of subsequent pregnancy and vaginal birth as many women may have elected to have a caesarean section in subsequent pregnancies or were lost to follow up. There was a high rate of reporting bias and heterogeneity, prohibiting formal meta-analyses. Conclusion: Recurrent shoulder dystocia is an unpredictable obstetric complication with potentially devastating consequences. Individual assessment and thorough counselling should be offered to women contemplating a subsequent planned vaginal birth with specific attention paid to those women where the estimated birthweight is >4000 g or greater than in the index pregnancy.
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
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
Shoulder dystocia is a term that evokes terror and fear among many physicians, midwives, and health care providers as they recollect at least 1 episode of shoulder dystocia in their careers. Shoulder dystocia can result in significant maternal and neonatal complications. Because shoulder dystocia is an urgent, unanticipated, and uncommon event with potentially catastrophic consequences, all practitioners and health care teams must be well-trained to manage this obstetric emergency. Preparation for shoulder dystocia in a systematic way, through standardization of process, practicing team-training and communication, along with technical skills, through simulation education and ongoing quality improvement initiatives will result in improved outcomes.
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Obstetrical emergencies contribute to significant morbidity and mortality in both mothers and fetuses. The major emergencies include postpartum hemorrhage, shoulder dystocia, cord prolapse, head entrapment, seizure, cardiac arrest, and perimortem cesarean delivery. Although risk factors exist for each emergency, the majority cannot be predicted. Subsequent mitigation of all obstetrical emergencies requires dedicated training, predesigned protocols, and timely multidisciplinary approaches.
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Schulterdystokie ist eine meist überraschende, aber oft schwerwiegende Komplikation der Geburt (bis ca. 1,5 % der vaginalen Geburten). Gutes Training und Kenntnisse der Risikofaktoren reduzieren das Risiko, dass es als Folge der Schulterdystokie zu einer Plexusparese oder zu anderen schwerwiegenden Komplikationen beim Kind kommt.
Article
La dystocie des épaules est une complication redoutable de l’accouchement par voie vaginale pouvant entraîner des lésions du plexus brachial parfois irréversibles, voire le décès néonatal. À la différence de la plupart des séries, nous définissons strictement la dystocie des épaules comme l’enclavement des deux épaules fœtales au-dessus du détroit supérieur, situation ne pouvant être résolue que par une manœuvre sur le bras postérieur (la référence étant la manœuvre de Jacquemier). Le but de cette étude était d’analyser une série personnelle de cette complication avec sa morbimortalité maternelle et néonatale ; et de comparer d’éventuels facteurs de risques identifiés à ceux déjà développés dans la littérature.
Article
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The "all fours" maneuver for managing shoulder dystocia appears to be a rapid, safe and effective technique in women in labor with this problem. We report a case of shoulder dystocia managed successfully with complete vaginal delivery and no injury to mother and newborn after using the "all fours" maneuver. A brief literature review includes descriptions of other maneuvers for the problem of shoulder dystocia.
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.
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
Shoulder dystocia is an infrequently encountered obstetric emergency varying in incidence from 0.15 to 0.60% of all deliveries. Previously identified risk factors include maternal obesity, previous infants weighing greater than 4 kg, maternal diabetes, and fetal macrosomia (greater than 4 kg). To evaluate the role of prolonged second stage of labor (PSS) as a warning sign for shoulder dystocia, 9864 deliveries at LAC-USC Women's Hospital were retrospectively reviewed. Ninety percent delivered vaginally and 4.89% had PSS with midpelvic delivery. Shoulder dystocia occurred in 0.37% of all vertex vaginal deliveries. In the absence of PSS and midpelvic delivery, the incidence of shoulder dystocia was 0.16%. However, with PSS and midpelvic delivery, the incidence of shoulder dystocia was 4.57% (P less than 0.01). Infants weighing in excess of 4 kg were at increased risk of shoulder dystocia compared with infants weighing less than 4 kg. When PSS occurred and midpelvic delivery was attempted, the incidence of shoulder dystocia was 21% in infants weighing in excess of 4 kg; 8% had had failed vaginal delivery. All shoulder dystocias and failed vaginal deliveries occurred after use of the vacuum extractor. Immediate neonatal injury was apparent in 47% of infants with shoulder dystocia after PSS with midpelvic delivery. There were no maternal or fetal deaths related to shoulder dystocia during the study period.
Article
A total of 75,979 women who were delivered vaginally in the period 1970 to 1985 were stratified into diabetic and nondiabetic groups. Overall, the incidence of macrosomia (greater than or equal to 4000 gm) was 7.6% (5674/74390) in the nondiabetic group and 20.6% (328/1589) in the diabetic group. Patients were further subdivided by weight categories at 250 gm intervals. Eight percent of shoulder dystocia occurred in the diabetic group when fetal weight was greater than or equal to 4250 gm. In contrast, 20% of shoulder dystocia in the nondiabetic group could have been prevented by elective cesarean section when the fetal weight was greater than or equal to 4500 gm. Furthermore, logistic regression analysis demonstrated that birth weight, diabetes, and labor abnormalities were the principal contributors to shoulder dystocia. Elective cesarean section is strongly recommended for diabetics with fetal weights greater than or equal to 4250 gm, and trial of vaginal delivery for nondiabetic fetuses with weights greater than or equal to 4000 gm is recommended. In all cases the clinician must be watchful for labor abnormalities in macrosomic fetuses.
Article
Shoulder dystocia (SD) is an event whose current diagnostic approach is based on subjective criteria alone. Since the risk for immediate neonatal morbidity is critically linked to recognition and appropriate management of this obstetric emergency, we hypothesized that infants having injuries consistent with SD are frequently delivered without the intrapartum identification of this condition. A retrospective analysis of 26,033 vaginal births from January 1979 to April 1987 identified 162 maternal cases in which SD was diagnosed during delivery (incidence, 0.62%). Within this subset of patients, 24 neonates (15%) were identified as having either brachial plexus or fractured clavicle injuries associated with delivery. An additional 60 neonates were identified as having similar injuries immediately following delivery but without obstetric recognition of SD. Therefore 71% of all the injured infants were the product of deliveries without SD recognition. A comparison was made of maternal and neonatal variables for three groups (SD, uninjured; SD, injured; unrecognized SD, injured). The SD, injured group distinguishes itself from the other two groups by significant differences in the degree to which variables previously associated with SD are present. Conversely, both other groups are similar in all parameters except for accepted SD maneuvers utilized. These results support our hypothesis that SD is underreported in the obstetric literature and that unrecognized SD is associated with an increased risk of neonatal injury. Efforts to define objectively the threshold forces associated with neonatal injury and to develop SD teaching models should improve this clinical dilemma.
Article
Although shoulder dystocia is an infrequent event it has assumed a position of great clinical importance because of our litigious environment. Many cases are preventable by the proper identification of risk factors, especially glucose intolerance, macrosomia, obesity, and postdate pregnancies. The severity of the problem can be rapidly graded or determined by the response to a systematic treatment plan; such a plan is outlined.
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.
Article
Trauma that occurs as a result of shoulder dystocia is an important cause of neonatal morbidity. If the occurrence of severe shoulder dystocia, resulting in fetal asphyxia and trauma, could be accurately predicted from maternal risk factors, then a cesarean section would be indicated to prevent the poor outcome. The information available in the obstetric literature, however, is contradictory regarding whether shoulder dystocia can be predicted. In the present study, the patients at greatest risk of shoulder dystocia (all 394 mothers delivering neonates with birth weights greater than or equal to 4000 gm over a 2-year period) were examined. A three-way discriminant analysis was used to determine if a model could be developed that could effectively predict those patients who would be included in each of the groups of no shoulder dystocia, shoulder dystocia without trauma (29 patients), and shoulder dystocia with trauma (20 patients). Three factors, including birth weight, prolonged deceleration phase, and length of second stage labor, were found individually to contribute significantly to the classification. However, when examined in detail, it was noted that while 94% of cases with no shoulder dystocia would be detected, only 16% of the cases of shoulder dystocia with trauma would be predicted by this model. We conclude that in the group of pregnancies delivering neonates greater than or equal to 4000 gm, the occurrence of shoulder dystocia cannot be predicted from clinical characteristics or labor abnormalities, and that the occurrence of shoulder dystocia is not evidence of medical malpractice.
Article
The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.
Article
For the majority of patients with obstetrical brachial plexus palsy, present-day conservative management yields good results. We now must direct our efforts toward improving the 10 to 15 per cent of patients who do not do well. Presently the role of microsurgical reconstruction of these injuries is undergoing evaluation. We must identify the patients with poor prognosis early: Babies should be examined at monthly intervals to document functional return, to supervise the child's exercise program, and to provide parental support. Babies who do not improve rapidly within the first 2 to 3 months should have an electromyogram and nerve conduction study. If this shows evidence of a severe lesion, these patients should be referred to a physician with a special interest in this area.
Article
The profile of the patient most likely to present with shoulder dystocia was determined to be a patient over 41 weeks' gestation with a prolonged decelerative phase of labor (8 to 10 cm) who was receiving epidural anesthesia before adequate descent of the vertex, resulting ina midforceps delivery. The patho-anatomic mechanism involves displacement of the anterior shoulder from a larger, i.e., oblique diameter, to a small (anteroposterior) diameter of the pelvis. The restitution of the shoulders to the oblique diameter is the hallmark of management. Proposed is an algorithm involving abdominal pressure to widening the episiotomy (bilateral if necessary) to displace the shoulders to the oblique diameter by corkscrewing or, if possible, careful delivery of the posterior shoulder. Cleidotomy is downplayed. The constant awareness of the possibility of the rapid development of shoulder dystocia, with its potentially lethal and always dangerous consequences, is espoused.
Article
From 1960 to 1980 at Memorial Hospital Medical Center--Miller Children's Hospital, the mean birth weight for term-size neonates increased from 3381 to 3458 g inspite of increases in ethnic groups known to have smaller neonates. More significantly, the incidence of macrosomic neonates (birth weight greater than 4000 g) increased from 7.0 to 10.7%. Because of this marked increase in the incidence of neonatal macrosomia, prospective study was designed to characterize the macrosomic neonate anthropometrically. The results of this study revealed that neonates experiencing shoulder dystocia had significantly greater shoulder-to-head and chest-to-head disproportions than did macrosomic neonates delivered by cesarean section for failed progress in labor or macrosomic neonates delivered without shoulder dystocia. In addition, neonates of diabetic mothers also showed significantly greater shoulder-head and chest-head size differences than did neonates of nondiabetic mothers of comparable weight. These data suggest that antenatal ultrasonic measurements to compare chest-head size difference in fetuses suspected to be macrosomic and in diabetic pregnancies could be of value in selecting patients for the appropriate route of delivery.
Article
Our objective was to determine the association between labor abnormalities and shoulder dystocia. All consecutive cases of shoulder dystocia from January 1986 to August 1994 were reviewed (n = 276). For purposes of comparison a control group of vaginally delivered patients was randomly selected in a 2:1 ratio (n = 600). Charts were reviewed for demographic information, labor and delivery events, and neonatal outcome. Labor abnormalities were comparable in the shoulder dystocia and control groups, both in the active phase and in the second stage. When patients with diabetes and those with macrosomic infants were analyzed separately, no significant differences in labor abnormalities were identified. The rate of operative vaginal delivery was significantly higher in the shoulder group, and one third of the operative deliveries were midpelvic. In addition, the induction rate was higher in the shoulder group. Our data suggest that labor abnormalities may not serve as clinical predictors for subsequent development of shoulder dystocia, thus emphasizing the unpredictability of this condition.
Article
It is clear that in the vast majority of cases, shoulder dystocia cannot be predicted by the physician. Although macrosomia is strongly associated with shoulder dystocia in retrospective analyses, there are no clinical or sonographic parameters that can reliably and prospectively identify the individual macrosomic fetus. Furthermore, more than 98% of patients with macrosomic fetuses who deliver vaginally do not have shoulder dystocia. Some investigators have advocated the use of cesarean delivery for suspected macrosomic fetuses to avoid potential birth trauma during vaginal delivery; however, this strategy has not been shown to be beneficial in the majority of cases. Boyd and colleagues report that an increase in the cesarean delivery rate for suspected macrosomia from 8% in the 1960s to 21% in 1980 did not improve overall perinatal outcome among macrosomic infants. Since 50% to 90% of cases of shoulder dystocia occur in normally grown fetuses, cesarean delivery for all suspected macrosomic fetuses would not be expected to prevent the vast majority of cases of shoulder dystocia and would expose many mothers to a substantially increased risk for morbidity and mortality. Management of this complex problem requires clinical judgment by the well-trained physician and individualized care for each patient. Because shoulder dystocia remains unpredictable in almost all cases, when it does occur it must be managed expeditiously but carefully with one or more of the maneuvers described. The sequence of manipulations reported herein represents one way of managing shoulder dystocia (Fig. 11). As noted before, however, there are no data to support improved efficacy of one particular sequence over another. The sequence of maneuvers chosen by the clinician should be based on the algorithm with which he or she is most familiar and which has proven successful in their hands. Permanent injury to the fetus fortunately is rare but does occur even in the well-managed case.
Article
To generate an objective definition of shoulder dystocia by timing the events of the second and third stages of labor, and to define the true incidence of shoulder dystocia. In 34 arbitrarily selected 24-hour time periods, a nonparticipating observer prospectively timed intervals of the second stage of labor in all vaginal deliveries and recorded the use of obstetric maneuvers (McRoberts, episiotomy after delivery of the fetal head, intentional extension of initial episiotomy after delivery of the fetal head, suprapubic pressure, posterior arm rotation to an oblique angle, rotation of the infant by 180 degrees, delivery of the posterior arm, and general anesthesia) and whether the obstetric attendant identified a delivery with shoulder dystocia. All data are reported as mean +/- standard error of the mean. Two hundred fifty deliveries were timed and recorded prospectively. Mean intervals (in seconds) in nonmaneuver patients were as follows: head to anterior shoulder 14.8 +/- 1.0, anterior to posterior shoulder 3.9 +/- 0.6, posterior shoulder to body 5.4 +/- 0.8, and total head-to-body time 24.2 +/- 1.3. Three groups of patients were defined after delivery. The maneuver group consisted of 27 patients requiring any of the aforementioned obstetric maneuvers, although the obstetric attendant identified only 16 of these as shoulder dystocia. The prolonged delivery group included 29 patients with the head-to-body delivery interval exceeding the mean plus two standard deviations (60 seconds) of nonmaneuver patients. Sixteen of the 27 maneuver patients were identified as prolonged. The 210 not identified as maneuver or prolonged were considered to be normal. Normal patients had a significantly lower newborn birth weight (3269 +/- 38 g), and a lower proportion of 1-minute Apgar scores of 7 or less (11%) than did the maneuver (4247 +/- 86 g, 41%) and prolonged groups (3952 +/- 118 g, 34%). Defining shoulder dystocia as a prolonged head-to-body delivery time and/or the use of obstetric maneuvers identified 40 patients who had birth weights and 1-minute Apgar scores significantly different from the normal patients. The incidence of shoulder dystocia, as defined by the use of ancillary obstetric maneuvers, is higher than that reported previously, and the reporting of shoulder dystocia appears to be unreliable. The interval from head-to-body delivery is delayed significantly in patients with shoulder dystocia, despite the lack of recognition of shoulder dystocia. We propose defining shoulder dystocia as a prolonged head-to-body delivery time (eg, more than 60 seconds) or the need for ancillary obstetric maneuvers.
Article
To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. We conducted a 10-year (1980-1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forcepts delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.
Article
The three purposes of this study were to determine the incidence of fractured clavicle in newborns delivered at our hospital, to identify preventable risk factors associated with these fractured clavicles, and to identify the acute sequelae of fractured clavicle in these infants. We performed a retrospective chart review of all women delivered during an 8-month period. Newborns with radiologically proved fractured clavicles were compared with a control group of infants delivered immediately before and immediately after the study patient. Maternal, labor, delivery, and newborn factors were analyzed statistically. A fractured clavicle occurred in 0.9% (34/3880) of vaginally delivered newborns; none occurred with an abdominal delivery. The only statistically significant risk factors were gestational age, shoulder dystocia, and newborn weight. No infant with fractured clavicle had a 5-minute Apgar score < 7, an abnormal cord blood pH, or an abnormal neurologic examination. We did not identify a specific perinatal factor that can be changed to avoid clavicle fracture. The injury appears to be an unavoidable event without permanent sequelae. Thus it is not an indicator for quality improvement.
Article
The purpose of this study was to determine whether there is a risk profile for predicting or preventing shoulder dystocia and whether any of the obstetric maneuvers to disimpact a shoulder reduce the likelihood of permanent injury. A retrospective analysis of 14,297 parturients with 12,532 vaginal deliveries and 1765 cesarean sections (12.4%) from January 1986 through June 1990 was performed. A total of 204 maternal and infant charts, related to shoulder dystocia or neonatal injury, were reviewed in depth for age, parity, episiotomy, type of delivery, hemorrhage, maternal obesity, diabetes, weight gain, fetal weight, sex, and Apgar scores. In addition, the type of maneuver or combination thereof used to relieve the dystocia, type of injury to the infant, and follow-up of the injury were reviewed. The 185 coded episodes of shoulder dystocia represent 1.4% of all vaginal deliveries (12,532). There were 42 injuries recorded: 14 fractured clavicles and 28 brachial plexus injuries. An additional 19 patients, not coded for shoulder dystocia, sustained 14 fractured clavicles and five brachial plexus injuries. All but one of the brachial plexus injuries resolved by 6 months. The occurrence of shoulder dystocia increased in direct relationship to the birth weight and becomes significant in newborns over 4000 gm (p < 0.01). The occurrence of a previous large infant was also a significant risk factor (p < 0.01). Diabetes and midforceps delivery become significant factors only in the presence of a large fetus. Obesity, multiparity, postdate pregnancy, use of oxytocin, low forceps delivery, episiotomy, and type of anesthesia were unrelated to shoulder dystocia. No delivery method was without injury. This study clearly indicates that most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict. In addition, no delivery method in shoulder dystocia was superior to another with respect to injury. Thus no protocol should serve to substitute for clinical judgment.
Article
To assess our ability to detect macrosomic fetuses, and to examine the relationship between prenatal diagnosis of macrosomia and the incidence of shoulder dystocia and birth trauma. We instituted a protocol for routine detection of macrosomic fetuses, defined as weight estimated to be at least 4500 g. Fetal weight was estimated by ultrasonography when there was clinical suspicion of macrosomia. We collected data on these pregnancies as well as on deliveries of macrosomic infants, shoulder dystocia, and birth trauma. During the 14-month study period, there were 4480 deliveries. There were 23 macrosomic newborns (0.5%), of whom 17 were born vaginally. Six of these 17 (35%) vaginal deliveries were complicated by shoulder dystocia, and one infant sustained brachial plexus injury. The overall frequency of shoulder dystocia was 2%, the majority (93%) occurring in infants weighing less than 4500 g. Eleven newborns sustained brachial plexus injury (0.2%), and 39 had isolated clavicular fracture. Six of nine cephalic deliveries that resulted in brachial plexus injury were associated with shoulder dystocia. The sensitivity and predictive value of the study protocol were 17% (four of 23) and 36% (four of 11), respectively. Surprisingly, clinical estimation alone had a sensitivity of 43% (ten of 23) and a positive predictive value of 53% (ten of 19). The ability to predict macrosomia is limited. The predictive value of clinical estimation of fetal weight alone may be slightly higher than when it is combined with ultrasonography. Because most cases of shoulder dystocia and birth trauma occur in nonmacrosomic infants, these conditions are practically impossible to prevent.
Fetal distress and birth asphyxia.
  • American College of Obstetricians and Gynecologists
Objective evaluation of the shoulder dystocia phenomenon: effect of maternal pelvic orientation on force reduction.
  • Gonik B
  • Allen R
  • Sorb J.
Large-for-gestational age neonates: anthropometric reasons for shoulder dystocia.
  • Maidenly HD
  • Camitz G
  • Dorchester W
  • Freeman RK
  • Bose SK
Fractured clavicle is an unavoidable event.
  • Chen RA
  • Caplan S
  • Greenberg SL
  • Spellacy WN
Large-for-gestational age neonates: anthropometric reasons for shoulder dystocia
  • Maidenly