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Gurewitsch Allen E. Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial. Am J Obstet Gynecol 2024; 230:S1014-S1026. [PMID: 38462247 PMCID: PMC10925798 DOI: 10.1016/j.ajog.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 03/12/2024]
Abstract
This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.
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Affiliation(s)
- Edith Gurewitsch Allen
- Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
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Grossman L, Pariente G, Baumfeld Y, Yohay D, Rotem R, Weintraub AY. Trends of changes in the specific contribution of selected risk factors for shoulder dystocia over a period of more than two decades. J Perinat Med 2020; 48:567-573. [PMID: 32598318 DOI: 10.1515/jpm-2019-0463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/12/2020] [Indexed: 11/15/2022]
Abstract
Objectives Shoulder dystocia (SD) is an obstetrical emergency with well-recognized risk factors. We aimed to identify trends of changes in the specific contribution of risk factors for SD over time. Methods A nested case control study comparing all singleton deliveries with and without SD was undertaken. A multivariable logistic regression model was used in order to identify independent risk factors for SD and a comparison of the prevalence and the specific contribution (odds ratio (OR)) of the chosen risk factors in three consecutive eight-year intervals from 1988 to 2014 was performed. Results During the study period, there were 295,946 deliveries. Of them 514 (0.174%) were complicated with SD. Between 1988 and 2014 the incidence of SD has decreased from 0.3% in 1988 to 0.1% in 2014. Using a logistic regression model grandmultiparity, diabetes mellitus (DM), fetal weight, and large for gestational age (LGA) were found to be independent risk factors for SD (OR 1.25 95% CI 1.04-1.51, p=0.02; OR 1.53 95% CI 1.19-1.97, p=0.001; OR 1.002 95% CI 1.001-1.002, p < 0.001; OR 3.88 95% CI 3.09-4.87, p < 0.001; respectively). While the OR for grandmultiparity, fetal weight, and LGA has significantly changed during the study period with a mixed trend, the OR of DM has demonstrated a significant linear increase over time. Conclusions The individual contribution of selected risk factors for the occurrence of SD has significantly changed throughout the years. The contribution of DM has demonstrated a linear increase over time, emphasizing the great impact of DM on SD.
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Affiliation(s)
- Leah Grossman
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gali Pariente
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yael Baumfeld
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Yohay
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, affiliated with the Hebrew University Medical School of Jerusalem, Jerusalem, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Komorowski J, Andrighetti T, Benton M. Modification of Obstetric Emergency Simulation Scenarios for Realism in a Home‐Birth Setting. J Midwifery Womens Health 2016; 62:93-100. [DOI: 10.1111/jmwh.12527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 06/30/2016] [Accepted: 07/05/2016] [Indexed: 12/20/2022]
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Wilson TJ, Chang KWC, Chauhan SP, Yang LJS. Peripartum and neonatal factors associated with the persistence of neonatal brachial plexus palsy at 1 year: a review of 382 cases. J Neurosurg Pediatr 2016; 17:618-24. [PMID: 26799409 DOI: 10.3171/2015.10.peds15543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neonatal brachial plexus palsy (NBPP) occurs due to the stretching of the nerves of the brachial plexus before, during, or after delivery. NBPP can resolve spontaneously or become persistent. To determine if nerve surgery is indicated, predicting recovery is necessary but difficult. Historical attempts explored the association of recovery with only clinical and electrodiagnostic examinations. However, no data exist regarding the neonatal and peripartum factors associated with NBPP persistence. METHODS This retrospective cohort study involved all NBPP patients at the University of Michigan between 2005 and 2015. Peripartum and neonatal factors were assessed for their association with persistent NBPP at 1 year, as defined as the presence of musculoskeletal contractures or an active range of motion that deviated from normal by > 10° (shoulder, elbow, hand, and finger ranges of motion were recorded). Standard statistical methods were used. RESULTS Of 382 children with NBPP, 85% had persistent NBPP at 1 year. A wide range of neonatal and peripartum factors was explored. We found that cephalic presentation, induction or augmentation of labor, birth weight > 9 lbs, and the presence of Horner syndrome all significantly increased the odds of persistence at 1 year, while cesarean delivery and Narakas Grade I to II injury significantly reduced the odds of persistence. CONCLUSIONS Peripartum/neonatal factors were identified that significantly altered the odds of having persistent NBPP at 1 year. Combining these peripartum/neonatal factors with previously published clinical examination findings associated with persistence should allow the development of a prediction algorithm. The implementation of this algorithm may allow the earlier recognition of those cases likely to persist and thus enable earlier intervention, which may improve surgical outcomes.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Kate W C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health Science Center, Houston, Texas
| | - Lynda J S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
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Abstract
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.
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Affiliation(s)
- Meghan G Hill
- Department of Obstetrics & Gynecology, University of Arizona College of Medicine, Tuscon, AZ 85724, USA
| | - Wayne R Cohen
- Department of Obstetrics & Gynecology, University of Arizona College of Medicine, Tuscon, AZ 85724, USA
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Duff SV, DeMatteo C. Clinical assessment of the infant and child following perinatal brachial plexus injury. J Hand Ther 2015; 28:126-33; quiz 134. [PMID: 25840493 PMCID: PMC4425986 DOI: 10.1016/j.jht.2015.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/05/2015] [Accepted: 01/07/2015] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Literature review. INTRODUCTION After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome. PURPOSE To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians. METHODS We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians. DISCUSSION With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.
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Affiliation(s)
- Susan V. Duff
- Thomas Jefferson University, Department of Physical Therapy, 901 Walnut St., Suite 510, Philadelphia, PA 19107,
| | - Carol DeMatteo
- McMaster University, School of Rehabilitation Science, 1400 Main St West, Hamilton, Ontario, Canada, L8S 1C7,
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Iffy L. Prevention of shoulder dystocia related birth injuries: Myths and facts. World J Obstet Gynecol 2014; 3:148-161. [DOI: 10.5317/wjog.v3.i4.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 07/14/2014] [Accepted: 09/10/2014] [Indexed: 02/05/2023] Open
Abstract
Traditionally, brachial plexus damage was attributed to excessive traction applied on the fetal head at delivery. Recently, it was proposed that most injuries occur spontaneously in utero. The author has studied the mechanism of neurological birth injuries based on 338 actual cases with special attention to (1) fetal macrosomia; (2) maternal diabetes; and (3) methods of delivery. There was a high coincidence between use of traction and brachial plexus injuries. Instrumental extractions increased the risk exponentially. Erb’s palsy following cesarean section was exceedingly rare. These facts imply that spontaneous neurological injury in utero is extremely rare phenomenon. Literary reports show that shoulder dystocia and its associated injuries increased in the United States several-fold since the introduction of active management of delivery in the 1970’s. Such a dramatic change in a stable population is unlikely to be caused by incidental spontaneous events unrelated to external factors. The cited investigations indicate that brachial plexus damage typically is traction related. The traditional technique which precludes traction is the optimal method for avoiding arrest of the shoulders and its associated neurological birth injuries. Effective prevention also requires meticulous prenatal care and elective abdominal delivery of macrosomic fetuses in carefully selected cases.
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Epidemiologic aspects of shoulder dystocia-related neurological birth injuries. Arch Gynecol Obstet 2014; 291:769-77. [DOI: 10.1007/s00404-014-3453-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/29/2014] [Indexed: 12/14/2022]
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Kotaska A, Campbell K. Two-Step Delivery May Avoid Shoulder Dystocia: Head-to-Body Delivery Interval Is Less Important Than We Think. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:716-720. [DOI: 10.1016/s1701-2163(15)30514-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.
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Affiliation(s)
- Shobha H Mehta
- Department of Gynecology, Obstetrics, and Women's Health, Henry Ford Health System, MI.
| | - Robert J Sokol
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, MI
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Parantainen J, Palomäki O, Talola N, Uotila J. Clinical and sonographic risk factors and complications of shoulder dystocia – a case-control study with parity and gestational age matched controls. Eur J Obstet Gynecol Reprod Biol 2014; 177:110-4. [DOI: 10.1016/j.ejogrb.2014.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/25/2014] [Accepted: 04/08/2014] [Indexed: 12/21/2022]
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Del Portal DA, Horn AE, Vilke GM, Chan TC, Ufberg JW. Emergency department management of shoulder dystocia. J Emerg Med 2013; 46:378-82. [PMID: 24360351 DOI: 10.1016/j.jemermed.2013.08.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/18/2013] [Indexed: 10/01/2022]
Abstract
BACKGROUND Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome. OBJECTIVE To review multiple techniques for managing a shoulder dystocia in the ED. DISCUSSION We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort. CONCLUSIONS Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.
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Affiliation(s)
- Daniel A Del Portal
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Amanda E Horn
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California
| | - Jacob W Ufberg
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
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Øverland EA, Vatten LJ, Eskild A. Pregnancy week at delivery and the risk of shoulder dystocia: a population study of 2 014 956 deliveries. BJOG 2013; 121:34-41. [DOI: 10.1111/1471-0528.12427] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2013] [Indexed: 11/28/2022]
Affiliation(s)
- EA Øverland
- Department of Obstetrics and Gynecology; Akershus University Hospital and Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - LJ Vatten
- Department of Public Health; Medical Faculty; Norwegian University of Science and Technology; Trondheim Norway
| | - A Eskild
- Department of Obstetrics and Gynecology; Akershus University Hospital and Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Division of Mental Health; Norwegian Institute of Public Health; Oslo Norway
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Sharing best practices in teaching biomedical engineering design. Ann Biomed Eng 2013; 41:1869-79. [PMID: 23568150 DOI: 10.1007/s10439-013-0781-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
Abstract
In an effort to share best practices in undergraduate engineering design education, we describe the origin, evolution and the current status of the undergraduate biomedical engineering design team program at Johns Hopkins University. Specifically, we describe the program and judge the quality of the pedagogy by relating it to sponsor feedback, project outcomes, external recognition and student satisfaction. The general pedagogic practices, some of which are unique to Hopkins, that have worked best include: (1) having a hierarchical team structure, selecting team leaders the Spring semester prior to the academic year, and empowering them to develop and manage their teams, (2) incorporating a longitudinal component that incudes freshmen as part of the team, (3) having each team choose from among pre-screened clinical problems, (4) developing relationships and fostering medical faculty, industry and government to allow students access to engineers, clinicians and clinical environments as needed, (5) providing didactic sessions on topics related to requirements for the next presentation, (6) employing judges from engineering, medicine, industry and government to evaluate designs and provide constructive criticisms approximately once every 3-4 weeks and (7) requiring students to test the efficacy of their designs. Institutional support and resources are crucial for the design program to flourish. Most importantly, our willingness and flexibility to change the program each year based on feedback from students, sponsors, outcomes and judges provides a mechanism for us to test new approaches and continue or modify those that work well, and eliminate those that did not.
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Liu B, Xu Y, Liang JM, Voss C, Xiao HY, Sheng WY, Sun YH, Wang ZL. Intrauterine insulin resistance in fetuses of overweight mothers. J Obstet Gynaecol Res 2012; 39:132-8. [DOI: 10.1111/j.1447-0756.2012.01919.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Risk factors for neonatal brachial plexus paralysis. Arch Gynecol Obstet 2012; 286:333-6. [PMID: 22437188 DOI: 10.1007/s00404-012-2272-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The study was aimed to identify risk factors for neonatal brachial plexus paralysis. METHODS A retrospective case-control study was designed. A comparison was performed between cases of brachial plexus paralysis, with all consecutive deliveries during the same 5 months period, without brachial plexus paralysis. Statistical analysis was performed using the SPSS package. RESULTS The prevalence of brachial plexus paralysis was 1.62/1,000 (9/5,525) vaginal births. Independent risk factors for brachial plexus paralysis were shoulder dystocia (OR = 525; 95% CI 51-4,977, P < 0.001), vacuum delivery (OR = 16.4; 95% CI 3.7-70.5, P < 0.001), macrosomia (birth weight >4,000 g; OR = 16.3; 95% CI 3.7-70.2, P < 0.001), prolonged second stage (OR = 40.8; 95% CI 7.9-188.2, P < 0.001) and vaginal breech delivery (OR = 36.1; 95% CI 4.5-262.5, P = 0.032). CONCLUSIONS In our population, shoulder dystocia, macrosomia, labor dystocia, vacuum delivery and vaginal breech deliveries were significant risk factors for neonatal brachial plexus paralysis, while maternal characteristics such as obesity and diabetes were not. Despite our growing knowledge concerning the risk factors associated with brachial plexus paralysis, unfortunately, this condition cannot be predicted or prevented.
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Gherman RB, Chauhan SP, Lewis DF. A survey of central association members about the definition, management, and complications of shoulder dystocia. Obstet Gynecol 2012; 119:830-7. [PMID: 22433347 DOI: 10.1097/aog.0b013e31824be910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine practice patterns for shoulder dystocia and concepts dealing with brachial plexus palsy. METHODS An Internet-based 25-question survey was electronically disseminated to all current members of the Central Association of Obstetricians and Gynecologists. For those individuals who did not respond, an additional opportunity to complete the assessment was provided during the 2009 annual meeting. RESULTS Of 429 Central Association of Obstetricians and Gynecologists members, 268 (62%) responded, with 192 (78%) filling out the survey online. Nearly 90% of those queried believed that shoulder dystocia was unpredictable and unpreventable. Thirty-seven percent felt that an elective cesarean delivery should be offered for an estimated fetal weight of 4,500 g among nondiabetics. Just 40% would have allowed a trial of labor with a documented history of shoulder dystocia. Slightly more than half answered that they never used either lateral or excessive traction and obstetrician-gynecologists were more likely than maternal-fetal medicine specialists to conclude that traction applied by the clinician doing the delivery was the cause of shoulder dystocia-related brachial plexus palsy (36% compared with 12%, P=.005). Maternal-fetal medicine specialists were more likely to believe that 40-50% of brachial plexus palsies occur without concomitant shoulder dystocia (21% compared with 9%, P=.015). CONCLUSION Differences in practice patterns exist among with regard to management recommendations of the American College of Obstetricians and Gynecologists' Practice Bulletin on shoulder dystocia. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert B Gherman
- Department of Obstetrics and Gynecology, Franklin Square Hospital, Baltimore, MD, USA.
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