Transient recurrent laryngeal nerve paresis after shoulder dystocia

Obstetrics injuries during shoulder dystocia in a tertiary perinatal center

OBJECTIVES

This study will present our results in management of fetal shoulder dystocia with special consideration of maternal and neonatal outcome.

STUDY DESIGN

A retrospective study was performed at a university tertiary perinatal center. The study included data of singleton vaginal term deliveries in the period of 15 years (2006-2020). Analized informations include: obstetrics maternal and neonatal data and outcomes.

RESULTS

This period included 45,687 deliveries with diagnosed shoulder dystocia in 254 (0.7 %) cases in vaginal deliveries. Most of the deliveries were spontaneous births 69.7 %, induced deliveries 30.3 %, 47.2 % primiparas and preexisting or gestational diabetes in 21.7 %. The delivery was managed by vacuum extraction in 13.8 %, mediolateral episiotomy in 48.0 % of births, most of the shoulder dystocia were unilateral anterior, while only two cases were diagnosed as more difficult bilateral and 5 cases were recurrent. 87.4 % cases were resolved by McRobert's maneuver, 7.8 % by Barnum's 3.9 % by Wood's maneuver and one case was managed by Menticoglou and by Bourgoise-Siegemundin maneuver. 4.3 % injuries were classified as OASIS of III/IV degree, early postpartum hemorrhage due in 1.6 %. 54.3 % of newborns were male sex, 61.0 % of newborns had birth weight of above 4000 g (mean 4071 g). Maximal Apgar scores were atributed to 92.5 % in first and to 97.2 % in fifth minute, one case that requaired resuscitation. Clavicle fracture was found in 9.5 %, humerus fracture in 0.4 %, transient form of Duchenne Erb obstetrics brachial palsy was diagnosed in only in 7.5 % newborns, while we have not found any case of permanent brachial palsy.

CONCLUSIONS

Our results confirmed that strategy of prompt identification of shoulder dystocia accompanied by cessation of axial fetal head traction decrease the risk of brachial plexus strain, injury or tear, while performance of exact obstetrical maneuvers resulted in decanceration of fetal shoulders without permanent obstetrics brachial palsy or cerebral morbidity. We think that our good results corelate with our opinion that the performance of external obstetrical manoeuvres should be done without one minute postpone since efforts should be put in sooner shoulder liberation decreasing the time of fetal hypoxia.

A Forensic Aspect of Fetal Shoulder Dystocia

Fetal shoulder dystocia (FSD) is an unpredictable and critical obstetric intrapartum emergency, where an objective problem is the relationship between the mother's pelvis and the child, i. e., an anthropometric disorder of delivery mechanics and dynamics. It is evident that the need to perform other maneuvers indicates the severity of FSD, which in turn correlates with the consequent iatrogenic injury of the fetus and/or mother. FSD is certainly the most controversial forensic obstetric problem, with the most disputes, compensation for damages due to peripartum injury to the child and/or mother, pain suffered, the need for someone else's care, and permanent disability. Suboptimal procedures and inadequate documentation are factors of forensic risk and subsequent litigations. Prevention of FSD is generally not possible, although good antenatal care can sometimes exclude risky cases of FSD, and some rare, chronic intrauterine disorders can result in orthopedic and neurological sequelae, which is especially important in forensic analysis. Because FSD is largely impossible to predict, it must be viewed as an intrapartum acceptable risk. During childbirth, FSD may compromise the safety of the mother and unborn child, therefore education and skills acquisition are necessary for obstetric work. Risk control, proper procedures, and proper documentation, along with good communication with the pregnant women and their families, significantly reduce litigation procedures.