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Shoulder Dystocia 10/12/20njm Shoulder Impaction a.k.a. Fetal Expulsion Disorder or Shoulder Dystocia Background What is mild shoulder dystocia? What is moderate shoulder dystocia? What is severe shoulder dystocia? If you ask 10 maternity providers, then you will probably get 10 different answers to each of the above questions. What is subjectively referred to as varying degrees of shoulder impaction is more objectively defined by the interval from delivery of the head to expulsion of the fetal body. The upper limit of normal for head-to-body delivery time was considered to be two standard deviations above this mean value (24 seconds) or 60 seconds. (Spong 1995) A prospective series found that deliveries complicated by a head-to-body expulsion time greater than 60 seconds or use of ancillary maneuvers to effect delivery described a subpopulation of infants who had higher birth weight, lower one-minute Apgar scores, and a greater prevalence of birth injury than infants who did not meet these criteria. (Beall 1998) Utilizing the work of Spong and Beal above, it may be more accurate to state the length of time for fetal expulsion and use of any additional maneuvers used for fetal expulsion. Hence another term is: fetal expulsion disorder. Fetal expulsion disorder is described 1.) by the length of time of head to body delivery and 2.) any extra maneuvers utilized to facilitate delivery. As previously defined, shoulder impaction occurs in 0.2 to 3 percent of all births and represents an obstetric emergency. The overall incidence of shoulder impaction varies based on fetal weight, occurring in 0.3 to one percent of infants with a birth weight of 2500 to 4000 grams, and increasing to five to seven percent in fetuses weighing 4000 to 4500 grams. Over 50 percent of shoulder impactions occur in the normal birth weight fetus and are unanticipated. Few shoulder impactions can be anticipated and prevented, as most occur in the absence of risk factors. Once a shoulder impaction occurs, even if all actions are appropriately taken, there is an increased risk of complications. These include third and fourth degree lacerations, post partum hemorrhage, and neonatal brachial plexus palsies. (Grobman 2011) Definition Fetal expulsion disorder (FED) exists if the head to body expulsion time is greater than 60 seconds, or if any ancillary maneuvers are utilized to facilitate delivery. Fetal expulsion disorder (FED) is best managed by additional obstetric maneuvers to effect delivery of the fetal shoulders at the time of vaginal delivery. Therefore, the provider must be prepared to recognize a FED immediately and proceed through an orderly sequence of steps to affect delivery in a timely manner. The goal of management is to prevent fetal asphyxia and permanent Erb's palsy, while avoiding physical injury (eg, bone fractures, maternal trauma), but the latter are acceptable if needed to prevent permanent injury in the child. PATHOPHYSIOLOGY — The fetal biacromial diameter (the distance between the outermost parts of the fetal shoulders) normally enters the pelvis at an oblique angle with the posterior shoulder ahead of the anterior one, rotating to the anterior-posterior position at the pelvic outlet with external rotation of the fetal head. The anterior shoulder can then slide under the symphysis pubis for delivery. If the fetal shoulders remain in an anterior-posterior position during descent or descend simultaneously rather than sequentially into the pelvic inlet, then the anterior shoulder can become impacted behind the symphysis pubis; alternately or additionally, the posterior shoulder may be obstructed by the sacral promontory. If descent of the fetal head continues while the anterior or posterior shoulder remains impacted, then stretching of the nerves in the brachial plexus may occur and may result in nerve injury. Injuries diagnosed at birth may have resulted from prenatal insults, trauma related to labor and the impacted shoulder itself, or from the provider's attempt to deliver the infant. The most common injuries can result in Erb’s or Erb-Duchenne palsy (injury to the upper brachial plexus nerve roots, C5-C6) or Klumpke’s palsy (injury to the lower nerve roots C8-T1). In 2014 the ACOG Task Force on Neonatal Brachial Plexus Palsy (NBPP) reviewed the current literature, including consensus opinion as well as multiple published cases of peer reviewed literature related to brachial plexus injury. This report concludes that NBPP occurs in 1.5 of 1000 births. Only 50% of NBPP cases are preceded by shoulder impaction. Greater than 80% of cases of NBPP occur in women with no known risk factors. In fact, NBPP has not only been associated with routine vaginal deliveries not complicated by shoulder impaction but even with routine Cesarean delivery in 4% of cases. NBPP is associated with 4-40% of clinically apparent cases of shoulder impaction. Most injuries resolve, however, the incidence of persistent NBPP at one year of life ranges from 0.5%-1.6%. (ACOG 2014, Torki 2012) Acidemia may result from compression of the umbilical cord, from compression of the vessels in the fetal neck by a tight nuchal cord, or a combination of factors. In general, the operator has up to seven minutes to deliver a previously well-oxygenated term infant before an increased risk of asphyxial injury occurs. The mean umbilical artery pH at term is 7.27 and umbilical artery pH is estimated to theoretically fall 0.04 pH units per minute in the interval between delivery of the fetal head and trunk. The Confidential Enquiries into Stillbirths and Deaths in Infancy Fifth Annual Report noted that 47% of the infants died within 5 minutes of the head being delivered. (CESDI 1998) Diagnosis FED should be suspected when the fetal head retracts into the perineum (ie, turtle sign) after expulsion due to reverse traction from the shoulders being impacted at the pelvic inlet. The diagnosis is made when the routine practice of gentle, downward traction of the fetal head fails to accomplish delivery of the anterior shoulder. This guideline will use a head to expulsion of the body of > 60 seconds or use of ancillary maneuvers to effect delivery as the definition of FED. Example This could be reported as “…fetal expulsion disorder with the use of McRoberts maneuver, suprapubic pressure, and removal of the posterior arm with a head to body expulsion time of 65 seconds….” Prevention No intervention has been identified that predicts or prevents all or even most cases of NBPP or clinically apparent shoulder impaction or FED. Anticipation of FED in the presence of risk factors such as suspected macrosomia, a history of a prior shoulder impaction, or prolonged second stage has been attempted. However, the occurrence of FED cannot be accurately predicted by antenatal risk factors or labor abnormalities. Since at least 50% of pregnancies complicated by FED have no identifiable risk factors, the predictive value of any one or combination of risk factors for FED is low (< 10%). It is clear, however, that maternal diabetes and macrosomia are the strongest risk factors for FED and that the highest risk of FED occurs when these risk factors occur together due to the combined effects of the unfavorable anthropomorphic dimensions of the infant of a diabetic mother and large absolute size. A Cochrane review concluded that prophylactic use of maneuvers typically used to relieve FED such as McRoberts maneuver or application of suprapubic pressure, does not significantly reduce the occurrence of FED. As well, performing routine prophylactic cesarean delivery or induction of labor for pregnancies with suspected macrosomia is not generally indicated. On the other hand, if a non-diabetic patient has an EFW of >5,000 grams or a diabetic patient has an EFW >4,500 grams, then cesarean delivery may be a reasonable management option. Offering elective cesarean delivery for women whose previous delivery was complicated by FED when a non-transient brachial plexus injury occurred can be associated with a large number of unnecessary procedures. Delpapa (1991) reported that among fetuses with estimated birth weights of 4,000 g or more; an additional 76 cesarean deliveries would have prevented only five cases of shoulder impaction, none of which resulted in permanent injury. A 1996 study using a decision analysis model estimated an additional 2,345 cesarean deliveries would be required—at a cost of $4.9 million annually—to prevent one permanent injury resulting from shoulder impaction if all fetuses suspected of weighing 4,000 g or more underwent cesarean delivery. (Rouse 1996) The rate of shoulder dystocia in women who have had a previous shoulder dystocia has been reported to be 10 times higher than the rate in the general population. (RCOG 2012) There is a reported recurrence rate of shoulder dystocia of between 1% and 25%.(RCOG 2012) However, this may be an underestimate owing to selection bias, as caesarean delivery might have been advocated for pregnancies after severe shoulder impaction, particularly with a neonatal poor outcome. There is no requirement to recommend elective caesarean birth routinely but factors such as the severity of any previous neonatal or maternal injury, predicted fetal size and maternal choice should all be considered and discussed with the woman and her family when making plans for the next delivery. (RCOG 2012) Even in cases in which an elective cesarean delivery is offered, the incidence of NBPP is low and with proper informed consent, multiple clinical circumstances exist in which these risk factors alone may not dictate a specific course of management (ACOG NBPP 2014). Shoulder impaction is not a reliably predictable event in labor. Although the risk of shoulder impaction is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forceps delivery, the majority of cases occur without these risk factors.
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