Outcomes associated with introduction of a shoulder dystocia protocol.

The objective of this study was to assess outcomes that are associated with the implementation of a shoulder dystocia protocol that is focused on team response. We identified women who had a shoulder dystocia during 3 time periods: 6 months before (period A), 6 months during (period B), and 6 months after (period C) the institution of a shoulder dystocia protocol. Documentation and health outcomes were compared among the time periods. During the study period, 254 women (77, 100, and 77 in periods A, B, and C, respectively) had a shoulder dystocia. There were no differences among study periods in patient characteristics. However, complete and consistent documentation increased (14% to 50% to 92%; P < .001), and brachial plexus palsy that was diagnosed at delivery (10.1% to 4.0% to 2.6%; P = .03) and at neonatal discharge (7.6% to 3.0% to 1.3%; P = .04) declined.

Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia?

Obstetrical brachial plexus palsies (OBPP) have been historically attributed to the impaction of the fetal shoulder behind the symphysis pubis and to excessive lateral traction of the fetal head during maneuvers to deliver the fetal shoulders in shoulder dystocia. Shoulder dystocia is indeed a major risk factor as it increases the risk for OBPP 100-fold. The incidence of OBPP following shoulder dystocia varies widely from 4% to 40%. However, a significant proportion of OBPPs are secondary to in utero injury. The propulsive forces of labor, intrauterine maladaptation, and compression of the posterior shoulder against the sacral promontory as well as uterine anomalies are possible intrauterine causes of OBPP. Many risk factors for OBPP may be unpredictable. Early identification of risk factors for shoulder dystocia, as well as appropriate management when it occurs, may improve our ability to prevent the occurrence of OBPP in those cases that are caused by shoulder dystocia.

Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation.

OBJECTIVE: This study was undertaken to objectively compare delivery traction force, fetal neck rotation, and brachial plexus elongation after 3 different initial shoulder dystocia maneuvers: McRoberts', anterior Rubin's, and posterior Rubin's. STUDY DESIGN: We developed a laboratory birthing simulator comprised of a maternal model with a 3-dimensional bony pelvis, an instrumented fetal model, a force-sensing glove, and a computer-based data acquisition system. A single operator performed 30 simulated shoulder dystocia deliveries using standard downward traction after 1 maneuver was performed. Ten deliveries simulated McRoberts' maneuver with fetal shoulders in the anteroposterior diameter. Ten deliveries involved approximately 30-degree oblique rotation of the anterior shoulder with the spine oriented anteriorly (anterior Rubin's maneuver). Ten deliveries involved approximately 30-degree rotation of the posterior shoulder to the opposite oblique pelvic diameter, with the spine oriented posteriorly (posterior Rubin's maneuver). Peak traction force, brachial plexus elongation, and neck rotation were compared between groups using analysis of variance, with P < .05 considered significant. RESULTS: Rubin's maneuvers were found to require less traction force than McRoberts': 16.2 +/- 2.1 lbs for McRoberts' compared with 8.8 +/- 2.2 lbs and 6.5 +/- 1.8 lbs for posterior and anterior Rubin's respectively (P < .0001). Brachial plexus extension was significantly lower after anterior Rubin's maneuver compared with McRoberts' or posterior Rubin's maneuvers. CONCLUSION In a laboratory model of initial maneuvers for shoulder dystocia, anterior Rubin's maneuver requires the least traction for delivery and produces the least amount of brachial plexus tension. Further study is needed to validate these results clinically.

Obstetric shoulder injury. Associated risk factors, prediction and prognosis.

A prospective case-control study was made to estimate the incidence of clavicular fracture and brachial plexus palsy, to find out possible risk factors during pregnancy and labor associated with these injuries, and to ascertain the prognosis of injured infants. Clavicular fracture occurred in 165 (3.2%) and brachial plexus palsy in 10 (0.2%) of the 5082 infants born during the study period. From maternal characteristics the Body Mass Index (kg/m2) and pregnancy weight gain were significantly greater in the cases than in the controls. Symphysis-to-fundus height was, on average, higher in the case group. There were no more instrumental vaginal deliveries in cases than in controls. The shoulder injured infants were in every way bigger, but only in 30% of the cases macrosomic (birthweight over the 90th percentile), and they were more often males than in the controls. The prediction of shoulder injury by ultrasound was not successful in our study. The prognosis of injured infants was good, all children except one recovered soon after birth.