Distocia de hombros: propuestas de resolución de acuerdo con las diferentes posiciones de parto según la movilidad de la pelvis

Introducción. La distocia de hombros es una complicación del parto vaginal que se produce por dificultad en el parto de los hombros fetales. Puede desencadenarse en forma impredecible e imprevista, por lo que debería ser considerada como riesgo potencial de todo nacimiento. La mayoría de las recomendaciones sobre las maniobras de resolución de distocia de hombros lo hacen desde la posición de litotomía y sin considerar los movimientos intrínsecos de la pelvis durante el parto. Objetivos. Analizar las maniobras de resolución de distocia de hombros a partir del conocimiento de la biomecánica de la pelvis y su relación con los hombros fetales, teniendo en cuenta las diferentes posiciones de parto. Métodos. Revisión bibliográfica no sistematizada. Resultados. Ante la distocia del hombro anterior, si la gestante se encuentra en litotomía podría recomendarse la maniobra de McRoberts con presión suprapúbica seguida de la extracción del brazo posterior. Si la gestante se encuentra en posición vertical, se sugiere pasar a posición de cuatro apoyos y una variante original resultado del análisis de los movimientos de la pelvis llamada 'cuatro apoyos en asimetría'. Esta puede ser realizada desde cualquier posición, no es invasiva y requiere un mínimo de entrenamiento. Conclusiones. La resolución de distocia de hombros no posee un único algoritmo; dependerá del tipo de distocia, la posición de la gestante, el contexto y la mayor o menor habilidad de una maniobra sobre otra. La postura de Gaskin y cuatro apoyos en asimetría debería ser tenida en cuenta antes de realizar maniobras internas para la resolución de la distocia de hombros.

Introduction: Shoulder dystocia is a complication of vaginal delivery caused by a difficulty in delivering the fetal shoulders. It can be triggered in an unpredictable and unplanned manner, so it should be considered as a potential risk for every vaginal birth. Most of the recommendations on shoulder dystocia resolution maneuvers are made from the lithotomy position and without considering the intrinsic movements of the pelvis during labor. Objectives : To analyze the maneuvers for resolving shoulder dystocia based on knowledge of the biomechanics of the pelvis and its relationship with the fetal shoulders, considering the different birthing positions. Methods: Non-systematized bibliographic review. Results : In the case of anterior shoulder dystocia, the McRoberts maneuver with suprapubic pressure followed by extraction of the posterior arm could be recommended for a birthing woman in lithotomy position. If the birthing woman is in an upright position, it is suggested to move to the four-support position and an original variant resulting from the analysis of the biomechanics of the pelvis called 'four-lying in asymmetry'. These maneuvers are non-invasive techniques, require minimal training and resources, and can be performed from any childbirth position. Conclusions : The resolution of shoulder dystocia does not have a single algorithm; it will depend on the type of dystocia, the position of the birthing woman, the context, and the greater or lesser ability of one maneuver over another. Gaskin maneuver and four supports in asymmetry should be considered before performing internal maneuvers for the resolution of shoulder dystocia.

A case of foetal macrosomia

Fetal macrosomia is an upcoming challenge in the field of obstetrics due to its rising incidence. The incidence varies according to ethnicity, genetic differences and anthropometric discrepancies between populations. Obesity, previous history of macrosomia, multiparity, diabetes and post-dated pregnancy are few risk factors associated with macrosomia. Management of macrosomia is a big challenge as no precise guidelines have been set. Macrosomia is associated with multiple maternal and foetal complications like operative delivery, post partum haemorrhage, perineal trauma, shoulder dystocia, brachial plexus injury, skeletal injury, birth asphyxia etc. We report a case of foetal macrosomia, weighing 5.5kg which was delivered by LSCS to a woman having BMI - 26.6kg/m² with 39 weeks of pregnancy with history of previous LSCS. There was no maternal or foetal complication. There was no history of diabetes in present pregnancy and inter conception period. Because of rarity of this condition we report this case of foetal macrosomia with a short review of literature.

Maternal and neonatal complications in macrosomic pregnancies

 Background: Fetal macrosomia is a common problem in obstetrics which leads to morbidity and mortality to both mothers as well as to the new-born due to complications of fetal macrosomia like prolonged labour, operative delivery, postpartum haemorrhage, perineal trauma, shoulder dystocia, birth trauma, perinatal asphyxia and perinatal mortality. This prospective study was conducted on fetal macrosomia to help future identification of such pregnancies, anticipate complications and to plan proper management.Methods: Maternal, fetal and neonatal consequences of macrosomia with specific attention to etiology of macrosomia in 170 pregnant women having gestational age of 37 weeks or more and high risk of fetal macrosomia were studied. Clinical estimation of fetal body weight was done using Leopold’s maneuvers and patient then referred for ultrasonography.  Data was collected about mode of delivery, nature and severity of birth trauma.Results: It was found that maternal age (51.76%), multiparity (61.76%), maternal diabetes (20.59 %) was significantly associated with macrosomia. Total caesarean rate in macrosomia was 26.4%. We got only 8 cases of birth trauma out of 170 macrosomic births.Conclusions: Pregnancies complicated by fetal macrosomia can be best managed by giving a trial of labour for babies with fetal weight below 5000 gram. Post gestation, multiparity found to be main risk factor for macrosomia.

Neonatal Clavicle Fracture: A Review of Fourteen Cases in East Coast Peninsular Malaysia

Introduction: The purpose of this study is to identify the incidence of clavicle fractures in newborn associated with fetal, maternal and process of deliveries in Kuantan General Hospital from June 2012 until January 2014. This study is to determine epidemiological data of clavicle fractures, maternal and baby risk factors associated with clavicle fractures of newborn and its’ outcome. Methods: This is a prospective study. 13 patients were identified to fulfill the inclusion criteria of the study. The data of sociodemographic, associated fetal and maternal risk factors and the outcomes were recorded using proforma. The statistical data analysis was done using SPSS 12.0. Results: Out of 20,257 live births at our centre during the study period, 13 infants were diagnosed to have clavicle fractures, giving an incidence of 0.64 per 1000 live births. There were 5 (38.5%) left, 7 (53.8%) right and one (7.7%) bilateral fracture. All fractures located at the mid shaft of the clavicle and none have associated brachial plexus injuries. All infants were delivered through vaginal delivery (61.5%); five through assisted delivery (instrumental); 2 (15.4%) forcep and 3 (23.1%) vacuum. Two of the babies developed shoulder dystocia. The average birth weight was 3371 grams (SD 0.269) and mean gestational age was 38.7 weeks (SD 1.16). Five of the mothers (38.5%) were primigravida and eight (61.5%) were multigravida in which,7 (53.8%)were healthy without other co-morbidty, 5 (38.5%) having gestational diabetis and one (7.7%) hypertension. The average maternal weight was 62.0 kg and height 1.58 metres with average BMI of 24.16 (3.29SD). All eventually had a complete recovery at 6 weeks with clinical and radiological evident of fracture union. Conclusions: In conclusion, all patients with clavicle fractures were found following vaginal delivery. There were no associations between neonatal clavicle fractures with maternal or baby risk factors. All fractures healed without any complications.

Effectiveness of Manikin Demonstration over Conventional Lectures for Teaching Shoulder Dystocia.

Background: Shoulder dystocia management necessitates a sound knowledge in diagnosis and applications of appropriate maneuvers. Conventionally this topic is taught with lectures in our institution. Objectives: 1. To compare the effectiveness of manikin demonstration to didactic lecture in teaching shoulder dystocia to undergraduate students. 2. To assess the attitude of students regarding inclusion of demonstrations sessions with manikin to their teaching schedule. Methods: This comparative study was conducted on 60 students attending their 8th semester posting in OBG in Kannur Medical College. Students were divided in to two batches, one receiving a didactic lecture class and the other a manikin demonstration on shoulder dystocia, following which a posttest evaluation was carried out with MCQs. The next day students were crossed over and classes taken using the two methods following which feedback from students were obtained and analyzed. Results: The posttest scores revealed that the group taught by manikin demonstration scored better when compared to the batch taught by lecture which was statistically significant. Feedback analysis showed that all students found manikin demonstration a more interesting method and majority felt this was the better method and helped in understanding the maneuvers. Peer opinion was that though manikin demonstration was more interesting, theoretical aspects could be better covered by a lecture and hence should be used as a complementary method to lecture. Conclusion: Manikin demonstration was more effective in teaching shoulder dystocia when compared to conventional lectures and was also associated with better learner satisfaction.

A Five-year retrospective review of infants with Erb-Duchenne's palsy at a teaching Hospital in North Trinidad / Revisión retrospectiva quinquenal de infantes con la parálisis de Erb Duchenne en un Hospital docente en el Norte De Trinidad

Birth injuries are devastating to parents and carers alike. They carry the possibility of residual loss of function to the infant and thus the potential for litigation. The aim of this study was to determine the incidence of Erb-Duchenne's palsy and the identification of any contributing factors. A retrospective review over a five-year period, 2005-2009, was performed and an incidence of 0.94 per 1000 live births was noted. An association between both macrosomia and shoulder dystocia and the development of Erb-Duchenne palsy in the newborn was noted. The authors recommended the use of partograms and improved note documentation in the management of labour.

Las lesiones de nacimiento resultan devastadoras tanto para los padres como para los cuidadores. Ellos conllevan la posibilidad de pérdida residual de función para el infante y por ende la potencialidad de litigios. El objetivo de este estudio fue determinar la incidencia de la parálisis de Erb Duchenne y la identificación de cualquiera de los factores contribuyentes. Se llevó a cabo una revisión retrospectiva por un periodo de cinco años, 2005-2009, y se observó una incidencia de 0.94 por 1000 nacimientos vivos. Se observó una asociación entre macrosomía y distocia del hombro, por una parte, y el desarrollo de la parálisis de Erb Duchenne, por otra parte, en el recién nacido. Los autores recomendaron usar partogramas y mejorar la documentación de las notas clínicas durante el trabajo de parto.

Urgencias en obstetricia / Emergencies in obstetrics

Tradicionalmente, el embarazo es considerado un evento fisiológico. Sin embargo, cerca de un 20 por ciento de las embarazadas desarrolla patologías obstétricas que se asocian a mortalidad materna y perinatal. A nivel mundial, cada año medio millón de mujeres fallece durante el embarazo y parto debido a estas complicaciones. Desafortunadamente, un número significativo de las urgencias obstétricas ocurre en pacientes sin factores de riesgo, por lo que la prevención, identificación precoz e intervención a tiempo de estos eventos juegan un rol fundamental para contrarrestar un resultado perinatal adverso. En el presente capítulo hemos seleccionado las emergencias que concentran la mayor morbimortalidad de nuestra especialidad. Si bien algunas han quedado fuera, creemos que los temas aquí presentados representan las urgencias obstétricas más importantes que enfrentamos a diario, para las cuales debemos estar preparados con el fin de realizar un manejo óptimo del embarazo y parto para la obtención de un resultado perinatal favorable.

Traditionally, pregnancy is considered a physiologic condition. However, close to 20 percent of pregnant women develop obstetrical diseases that are associated to maternal and perinatal mortality. World wide, every year half a million of women die during pregnancy, labor and delivery due to these complications. Unfortunately, a significant number of obstetrical emergencies occur among patients without risk factors, so that prevention, early identification and timely intervention play a key role to overcome an adverse pregnancy outcome. In the present chapter, we have selected the emergencies that concentrate most of the morbidity and mortality of our field. Although some have not been included, we believe that the obstetrical emergencies presented here in represent the most important ones that we face daily, and for which we should be prepared in order to execute the best possible obstetrical care either during pregnancy or at the time of delivery to obtain a favourable perinatal outcome.

Paralisia obstétrica de plexo braquial: revisão da literatura / Obstetrics brachial plexus palsy: literature review

Paralisia obstétrica é uma lesão do plexo braquial ao nascimento. Em nosso meio, sua prevalência não é conhecida, mas as disfunções do membro comprometido são muitas vezes 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% doscasos 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 memorizadas. A abordagem da lesão braquial deve ser multidisciplinar. Fisioterapia, reconstrução microcirúrgica do plexo, correção de deformidades articulares secundárias e transposições musculares são empregadas com sucesso. O papel do tratamento conservador e operatório deve ser regularmenterevisado. O objetivo deste trabalho foi realizar uma revisão da literatura sobre a paralisia obstétrica do plexo braquial.

Obstetric palsy is a brachial plexus injury at birth. In our country, its prevalence is unknown, but the dysfunction of the affected limb are frequent and often long lasting. Shoulder dystocia is defined as the need to maneuver to the delivery of the shoulders, or a range greater than 60 seconds between deliveryng the head and shoulders. It is related to 50% of cases of brachial plexus injury. Most cases occur in the absence of risk factors. The maneuvers of assisted childbirth with shoulder dystociashould be trained and stored. The approach of the brachial injury must be multidisciplinary. Physiotherapy, microsurgical reconstruction of the plexus, secondary correction of joint deformities and muscle transpositionsare employed successfully. The role of conservative treatment and surgical procedures should be regularly reviewed. The aim of this study was performed a literature review about obstetrics brachial plexus palsy.

Distocia de ombro: erro médico? Subsídios da literatura médica para uma defesa / Shoulder dystocia: medical error? Subsidies of medical literature for a defense

Cada vez mais os médicos e, principalmente, os obstetras são responsabilizados por eventos desfavoráveis ocorridos durante sua atividade profissional. Muitos advogados aproveitam esta ocorrência para denunciá-los com o intuito de ganhar causas milionárias. A distocia de ombros é um evento obstétrico incidental, imprevisível em muitos casos e que, na maioria das vezes, causa tocotraumatismo, principalmente no feto, levando muitos advogados a pedirem indenização reparatória, às vezes por toda a vida da criança afetada, o que implica um desgaste moral, profissional e patrimonial do obstetra, o qual não é o responsável por tal ocorrência. Este trabalho teve por finalidade colher dados da literatura e da medicina baseada em evidências para dar subsídios científicos para formar a defesa do profissional, que sofrer tal incidente.

Each new day, doctors and, mainly, obstetricians are responsible by occurred favorable events during its professional activity. Many lawyers try to take advantage of this occurrence, denouncing them with the intention of gaining millionaire causes. The shoulders' dystocia is an incidental and unexpected delivery event in many cases, that most of the time causes traumatic delivery, mainly fetal trauma, which leads many lawyers to ask for ensuing litigation indemnity, to the times for all the life of the child affected and that it implies in a moral consuming, professional and patrimonial of obstetrician, who is not the responsible for such occurrence. This paper has as a purpose to collect literature and medicine based on evidences data to give scientific subsidies to form the defense of the professional, who suffers such incident.

Mecanismos patogénicos de la parálisis braquial congénita: [revisión] / Pathogenic mechanisms of congenital brachial palsy: [review]

Antecedentes: Se define clásicamente a la parálisis braquial congénita como la paresia flácida de una extremidad superior secundaria al estiramiento traumático del plexo braquial durante el parto, en la extracción del hombro anterior, en relación a la distocia de hombro. Numerosas series han reportado la falta de relación entre la parálisis braquial congénita y el estiramiento traumático del plexo braquial durante la distocia de hombro. Objetivo: Realizar una revisión de la literatura para identificar las causas relacionadas con la parálisis braquial congénita. Resultados: Hasta en un 50 por ciento de los casos la parálisis braquial congénita no se asocia a distocia de hombro. Estos casos, son de peor pronóstico, afectan principalmente al hombro posterior y se presentan en recién nacidos de menor peso al nacer, pudiendo presentarse en un parto cesárea. La parálisis braquial congénita no asociada a distocia de hombro reconoce múltiples mecanismos patogénicos como: postura viciosa fetal in útero, tracción del hombro posterior por el promontorio sacro, neoplasias fetales, tumores uterinos, y otras. Conclusión: La parálisis braquial congénita, debe ser entendida como un síndrome, clínicamente caracterizado por parálisis flácida de una de las extremidades superiores detectada en el recién nacido, que responde a diferentes mecanismos patogénicos y de pronóstico variable según el caso.

Background: Classically congenital brachial palsy was defined as a flaccid paresis of the upper limb, secondary to traumatic brachial plexus stretching during delivery of the anterior shoulder in the context of shoulder dystocia. Numerous series have reported the lack of relationship between congenital brachial palsy and traumatic stretching of the brachial plexus during shoulder dystocia, in a significant number of cases. Objective: To review the literature to identify the causes related to congenital brachial palsy. Results: Up to 50 percent of cases of congenital brachial palsy are not associated to shoulder dystocia. These cases, have worse prognosis, mainly affect the posterior shoulder, presents in infants of lower birth weight and may even be in a cesarean delivery. Congenital brachial palsy not associated with shoulder dystocia recognizes multiple pathogenic mechanisms such as: vicious fetal position in utero, traction of the posterior shoulder on the sacral promontory, fetal tumors, uterine tumors, and others. Conclusion: Congenital brachial palsy, should be understood as a syndrome, clinically characterized by flaccid paresis/paralysis of one upper limb detected in the newborn, being the consequence of different pathogenic mechanisms and having variable prognosis.

Shoulder Dystocia / 대한산부인과학회지

Shoulder dystocia refers to difficulty in delivery of fetal shoulders, and is one of the most dreaded and dramatic complications encountered in obstetrics. It is a true emergency, and when it occurs, it can result in high rate of maternal morbidity as well as neonatal morbidity and mortality. The occurrence of shoulder dystocia cannot be accurately predicted or prevented on the basis of antenatal risk factors or labor abnormalities. Therefore, the obstetrician must be prepared to recognize a shoulder dystocia immediately and proceed through an orderly sequence of steps to effect delivery in a timely manner. The goal of management is to prevent fetal asphyxia, while avoiding physical injury.