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OBGMANAGEMENT Henry M. Lerner, MD Clinical Instructor in and Gynecology, Harvard Medical School Newton-Wellesley Hospital Newton, Mass

Labor and delivery nurses should know when and how to perform the McRoberts maneuver and apply suprapubic pressure. These meas- ® ures often resolve the dystocia by flat- Dowden Health Media tening the sacrum and altering the angle between the pubic bone and the baby’s anterior shoulder. Family Copyright members can assist, contrary to For personal use only plaintiff attorneys’ contentions. IN THIS ARTICLE : What is ❙ Is your team prepared? the legal standard of care? 4 standards of care Page 61 It’s your job to educate the jury that, even in the best of hands, permanent brachial plexus injuries can occur ❙ The traction reaction: Why plaintiffs focus on “force” o matter how excellent the care you textbook perfection. Lawsuits involving Page 62 provide, you have good reason to brachial plexus injuries following shoulder Nworry about shoulder dystocia. It is dystocia are now the second most common Visit our Web site for: one of the most difficult and frightening com- type of lawsuit in obstetrics, exceeded only ❙ Shoulder dystocia plications, and is essentially unpredictable by those due to neurologic damage from and unpreventable. It can happen even in birth asphyxia.1 is documentation form apparently routine deliveries, and can cause often difficult to defend in court and results www.obgmanagement.com permanent injury to the child despite the best in scores of millions of dollars in damages possible care by experienced obstetricians. each year. The plaintiff is usually a lovely IMAGE:

If permanent injury occurs after shoul- child with an obvious and permanent injury, RICH

der dystocia, it can also trigger a lawsuit and the defense is typically an undocument- LaROCCO that can last for years and end in a large jury ed claim that the obstetrician applied no verdict—even if you handled the case with undue force at delivery.

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Given the difficulties of knowing when TABLE shoulder dystocia will occur, how best to How fetal weight affects the rate of dystocia resolve it, and whether a claim is likely, how can we prepare for this event? What is ESTIMATED RATE OF SHOULDER DYSTOCIA (%) FETAL WEIGHT NONDIABETIC MOTHERS DIABETIC MOTHERS the accepted standard of care? This article <4,000 g answers these questions by surveying the 1.1 3.7 evidence on these aspects of management: 4,000–4,499 g 10 23.1 • risk factors for shoulder dystocia >5,000 g 22.6 50 • how to choose mode of delivery Source: Acker D et al2 • specific labor-management practices • the 4 most widely used maneuvers to resolve shoulder dystocia to the due date to prevent a baby from • what information the documentation becoming “too big” has been shown in should include. many studies to be ineffective in lowering the shoulder dystocia rate.16–18 No single “standard of care” In many states, the term “standard of care” Risk factors are not clinically useful has a specific legal meaning, but in most of The American College of Obstetricians and the United States—and to most physi- Gynecologists (ACOG) and Williams cians—the term means care that would be Obstetrics concur that risk factors for rendered by the majority of well-trained shoulder dystocia cannot be applied in a individuals. Complicating this definition is clinically useful way to prevent brachial the fact that medicine often offers no single plexus injury. As the ACOG practice bul- “right way.” Thus, it may be more appro- letin on shoulder dystocia19 observes: priate to speak of “standards of care”: the • “Shoulder dystocia cannot be predicted range of therapeutic choices a reasonable or prevented because accurate methods practitioner might decide to use. for identifying which will expe- rience this do not exist.” • “Elective induction of labor or elec- FAST TRACK ❚ Why dystocia cannot tive cesarean delivery for all women Women suspected of carrying a with be predicted macrosomia is not appropriate.” with gestational …despite known risk factors and/or The risk of shoulder dystocia is higher in Identify highest risk a macrosomic 2–5 women with diabetes, a macrosomic Nevertheless, there are generally accepted fetus are at highest fetus,2,6–8 ,5,8 or a previous shoulder guidelines for attempting to ascertain dystocia.9–11 The problem: The predictive which patients are at the absolute highest risk for shoulder value of these factors is so low and their risk for shoulder dystocia: dystocia false-positive rate so high they cannot be • Any woman with . used reliably in clinical decision-making.11–13 For any given week of gestation in the third trimester, the ratio of thorax and Prevention is impossible shoulder size to head volume is larger in Even if prediction were possible, the only babies of diabetic mothers.20 Thus, in preventive option is elective cesarean sec- these women, it is important to estimate tion. After all, this is the only intervention fetal weight near term to determine that might potentially avoid the infrequent whether a trial of makes but dreaded outcomes of asphyxia and per- sense. manent brachial plexus injury. But as the • If, for any reason, the fetus appears to be literature shows, even this is not an larger than average. Indications of size absolute guarantee.14,15 Moreover, the strat- may come from palpation of the maternal egy of inducing labor several weeks prior abdomen, fundal height measurements

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▲ Shoulder dystocia: What is the legal standard of care?

significantly greater than dates, ultrasound centage of even these high-risk patients estimation of large fetal weight, or mater- will have a shoulder dystocia that results in nal perception. In these cases, ultrasound a permanent brachial plexus injury? The imaging is advisable near term to estimate answer: Permanent injury is rare, even in fetal weight. This estimate can be factored highest-risk cases. into the selection of delivery mode. Only 10% to 20% of infants born after shoulder dystocia suffer brachial How big is “too big”? plexus injuries.16,21–23 Of these, only 10% There are 2 problems with using estimates to 15% are permanently injured.5,24,25 of fetal weight in determining mothers and Thus, even in women at highest risk, the babies at highest risk: odds of having an infant with permanent • How is “too big” defined? brachial plexus injury are roughly 1 in • What action should one take if a baby 450.14 In women at lower risk for shoulder is thought to be “too big”? dystocia, the odds of permanent brachial The rate of shoulder dystocia increases plexus injury are much lower: somewhere with the size of the fetus (TABLE). ACOG between 1 in 2,500 and 1 in 10,000. defines macrosomia in the context of shoulder dystocia as a fetal weight exceed- When is cesarean section ing 5,000 g in a nondiabetic woman and warranted? 4,500 g in a diabetic woman.19 In deciding the answer to this question, the As for what to do if a fetus is estimat- obstetrician must consider that cesarean ed to be in this size range, ACOG states: section is not without its own risks: exces- “Planned cesarean delivery to prevent sive bleeding, infection, injury to bowel or shoulder dystocia may be considered bladder, deep venous thrombosis, and the [emphasis added] for suspected fetal need for hysterectomy. macrosomia within the above weight These adverse events occur much more parameters.”19 The decision as to whether frequently than does permanent brachial to recommend or perform a cesarean sec- plexus injury.26 And the risks are higher yet FAST TRACK tion in these circumstances is intentionally for the very same patients at greatest risk Even in women left up to the physician and the patient. for shoulder dystocia—diabetic and obese The problem, of course, is that all our data women. at highest risk, are from measurements of babies after the odds of having delivery—information obstetricians do not Prevent “I didn’t know” accusations an infant with have at the time they must decide on the This is the point at which the patient’s permanent brachial mode of delivery. input becomes vital. It is important to con- vey to her in readily understandable terms plexus injury are the risks—to both her and her child—of roughly 1 in 450 ❚ Choosing a mode cesarean section versus attempted vaginal delivery. Plaintiff attorneys often claim of delivery: Not so simple that, had their client known there was a 1 The obstetrician must determine whether in 450 chance of her baby having a perma- the risk of shoulder dystocia is high enough nent injury, she would have opted for to outweigh the risks to a mother of elective cesarean section. The truth of this claim is, cesarean section. This is far from simple. of course, open to question. However, Although it is true that women at the high- from a medicolegal perspective, it is est risk for dystocia—those with gestation- extremely important that the woman be al diabetes and suspected macrosomia— informed of the degree of risk to herself have a risk for shoulder dystocia and her baby so that her decision is truly somewhere between 25% and 50%, this is informed—even if it is not the choice the not the main concern. obstetrician would have made. The main concern is this: What per- The consensus in surgery is that the

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patient should be informed when the Oxytocin is OK threshold of risk for an adverse event In cases of arrest of labor and descent, the reaches 1% or higher. Although it is an use of oxytocin is appropriate. A laboring informal teaching, this threshold is docu- woman should be given adequate time to mented in the medical literature.27 deliver on her own, especially if a regional The option of cesarean section should be anesthetic has been used. discussed and possibly recommended for ... but prepare to act quickly. In high-risk all women whose infants are estimated to cases, be prepared to move more quickly weigh more than 5,000 g in the absence of than normal to cesarean section. diabetes and 4,500 g or more in women with diabetes. ❚ Is your team prepared? 4 standards of care ❚ Labor management Although it is true that an obstetrician Prolonged second stage must be prepared for the possibility of and instrumental delivery shoulder dystocia in any delivery, to act as Although the literature is not clear on this though it will occur in all deliveries is sim- point, there is a trend toward increased ply not reasonable, given that the rate of rates of shoulder dystocia with a pro- dystocia is 0.5% to 1.5%, or 1 in 67 to longed second stage of labor2,3,28 and with 200 deliveries.12,21,25,29 instrumental deliveries.6,12,29,30 Most experts Nevertheless, 4 specific standards believe this trend merely reflects the fact apply to all delivery facilities: that bigger babies—the known major risk 1. The entire labor and delivery staff factor for shoulder dystocia—encounter should know what to do and what these sorts of labor problems more fre- each person’s role is when shoulder quently than do smaller babies. Whatever dystocia is diagnosed. the reason, it warrants attention. An 2. Labor and delivery nurses should obstetrician’s care of any laboring woman know how and when to initiate FAST TRACK should follow standard practices regard- McRoberts maneuver and apply Discuss ing arrest of labor and descent or a pro- suprapubic pressure. longed second stage. 3. The team should immediately obtain and consider the assistance of another obstetrician, cesarean section a pediatrician, and an anesthesiolo- for all women Plaintiffs are quick to condemn gist, even though they are not likely to whose infants vacuum and forceps arrive before the dystocia is resolved. The same applies to intervention with for- 4. The obstetrician should be mentally are estimated to ceps or vacuum. Only in women at high- prepared for the possibility of shoul- weigh >5,000 g, or est risk for shoulder dystocia—those with der dystocia. This requires the ability >4,500 g in women diabetes or with suspected macrosomic to quickly recognize it, familiarity fetuses—should standard management be with the various techniques for resolv- with diabetes modified. ing it, and avoidance of unnecessary Given the potential for shoulder dysto- traction. It also is vital for the obstetri- cia in such high-risk circumstances, not to cian to remain composed and in mention our inability to predict dystocia, charge, as the obstetrician becomes prudence dictates that we avoid aggressive the leader of the medical team when management and the use of forceps or vac- this emergency arises. uum in these cases. These practices are often condemned in How to recognize shoulder dystocia court by plaintiff lawyers and their expert There are 2 ways to diagnose dystocia. witnesses. • “Turtle sign.” The first is recognizing the

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The traction reaction: Why plaintiffs focus on “force”

raction is the most used and abused of terms in to resolve dystocia. The reality is simple: An obstetri- Tshoulder dystocia lawsuits. Many plaintiff expert cian cannot determine whether a maneuver has witnesses claim that traction should never be applied released the anterior shoulder unless moderate trac- to a baby’s head during delivery. Other “experts” claim tion is applied after the maneuver to see if the baby only “gentle” traction is warranted. These statements can be delivered. Although extreme force at this or are designed to support the most frequent contention any point is not appropriate, moderate traction is against obstetricians when permanent brachial plexus entirely appropriate. injury occurs: As there is an injury, it must have been “Excessive traction” is an oxymoron, although plaintiff caused by a doctor or midwife who used “excessive lawyers often use the term. An obstetrician uses a given traction” to deliver the baby. This statement is usually amount of force in attempting to free a stuck shoulder. made without defining “excessive” and without evidence Once the shoulder is freed, no more force is applied. that more force than necessary was used. Thus, by definition, “excessive force”—more force than is necessary to deliver the baby—is never used. “Excessive” vs “minimum necessary” traction The proper term to describe the amount of force applied Routine or “moderate” traction is used in most deliver- by a physician to resolve shoulder dystocia is “minimum ies. The birth attendant almost always depresses the necessary traction.” fetal head and applies a moderate amount of traction to it to help the baby’s anterior shoulder slide beneath Injury can follow a traction-free delivery the mother’s pubic bone.38 The only time traction is For many years, obstetricians familiar with shoulder unnecessary is when the expulsive forces of the moth- dystocia have claimed that brachial plexus injuries can er are so strong or uncontrolled that she pushes the occur even in the absence of significant traction—either baby out entirely on her own. in utero or as a result of the natural forces of labor.Yet There is ambiguity—often contrived—about what plaintiff attorneys and expert witnesses have contended exactly constitutes mild, moderate, routine, and that all brachial plexus injuries are the result of some- “excessive” traction. No study has ever been pub- one pulling “too hard.” lished that accurately and unambiguously quantifies A recent case reported by Allen and Gurewitsch39 the amount of force used in actual deliveries. settled this question once and for all. They describe a Once shoulder dystocia is diagnosed, further attempts delivery in which a patient requested no intervention of at routine traction without the use of other maneuvers any kind. Despite no hand having touched the baby dur- should be avoided. At best these attempts are ing delivery—thus, no “excessive traction” having been unavailing. At worst they serve only to keep the anteri- applied —the baby suffered a brachial plexus injury. or shoulder lodged behind the maternal symphysis. This case proved that brachial plexus injuries can Much misinformation surrounds the role of trac- occur spontaneously and are not necessarily caused tion during the McRoberts maneuver and other efforts by traction.

pathognomonic “turtle sign,” in which, ❚ The 4 main maneuvers after delivery of the baby’s head, the The 4 maneuvers generally used by obste- head immediately retracts back up tricians to resolve shoulder dystocia are against the mother’s perineum, causing considered the standard of care: the baby’s cheeks to bulge. • McRoberts maneuver • The second diagnostic sign is when, after • Suprapubic pressure delivery of the head, the moderate • Woods screw maneuver amount of traction usually used does not • Delivery of the posterior arm suffice to deliver the anterior shoulder. Although the order in which the Cease attempts at routine traction as maneuvers are described below is the usual soon as shoulder dystocia is diagnosed. order in which they are performed, there is

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no evidence that any one is more effective mented next.32 In this maneuver, the obstetri- than another or that the order in which cian inserts a hand into the posterior they are implemented makes any differ- and pushes the front of the baby’s posterior ence. (Other maneuvers have been shoulder in a spiral direction (clockwise or described, but are not widely used.) counterclockwise). The goal is to “unjam” the anterior shoulder from its trapped posi- McRoberts maneuver tion behind the symphysis pubis. is often the only one needed The Woods screw maneuver is very In this maneuver, the laboring woman’s effective. After it has been used, it is thighs are hyperflexed against her appropriate to apply moderate traction abdomen.31 This hyperflexion does not to the baby’s head to determine whether increase the diameter of the , as is the baby can be delivered. sometimes claimed. Rather, it flattens the Variant: Rubens maneuver. In this maneu- sacrum and changes the angle of the symph- ver, the obstetrician pushes on the posteri- ysis pubis in relation to the baby’s anterior or aspect of the posterior shoulder. In addi- shoulder, often freeing it. It is an extremely tion to spinning the shoulders, as in the effective way to resolve shoulder dystocia Woods screw maneuver, the Rubens and is often the only maneuver necessary. maneuver causes shoulder abduction, thus Family members can assist—contrary to decreasing the biacromial diameter that plaintiff attorney contentions. This maneu- has to pass through the pelvic outlet. ver can be performed by nurses or family members if they are properly instructed. Attempts to deliver the posterior arm Plaintiff attorneys will sometimes argue If shoulder dystocia still persists, the next that the use of family members in this situ- strategy is usually an attempt to deliver the ation is inappropriate, but they are wrong. baby’s posterior arm. This is done by plac- Family members are sometimes instructed ing a hand deep into the posterior aspect of to hold a mother’s legs in a certain position the vagina, grabbing the baby’s posterior while she is pushing; they can certainly be arm, sweeping that arm across the baby’s instructed to hold the legs against the chest, and delivering it. Once the posterior FAST TRACK maternal abdomen during attempts to arm and shoulder are delivered, it is almost We lack evidence resolve a shoulder dystocia. always possible to deliver the baby direct- ly from this position or to move the baby that any of the 4 Suprapubic pressure in a spiral direction (clockwise or counter- main maneuvers with or without McRoberts clockwise) to free the anterior shoulder. is superior—or that In this maneuver, a nurse or other attendant they should be places direct pressure with an open hand or Other maneuvers fist just above the mother’s symphysis Two other maneuvers are occasionally used, used in a specific pubis. The pressure can be directed straight though neither is considered mainstream. sequence down or to the left or right. Wherever it is Gaskin or “all fours” maneuver. This tech- directed, the aim of the pressure is to push nique is frequently advocated by the mid- the baby’s anterior shoulder out of its posi- wife community.33 It involves moving the tion behind the mother’s pubic bone. laboring woman from the standard The combination of McRoberts maneu- lithotomy pushing position to her hands ver and suprapubic pressure can resolve shoul- and knees to free the stuck anterior shoul- der dystocia in as many as 58% of cases.22 der. However, many have questioned the practicality of turning a fatigued, laboring Woods screw maneuver woman rapidly enough to deliver a baby attempts to “spin” the baby within the 4 to 6 minutes available, partic- If the McRoberts maneuver and suprapubic ularly when an epidural has been given or pressure do not resolve the shoulder dystocia, other maneuvers have already used up the Woods screw maneuver is usually imple- much of the allotted time.

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after each one to see if the shoulder has Do not ignore maternal concerns been freed. Often a mother will voice concern about whether she will be able to deliver her baby safely vaginally. She may feel that her Fundal pressure infant is too big, that she is too small, or that her obesity will Do not apply fundal pressure. It never helps make her delivery more difficult. Do not blithely ignore such resolve shoulder dystocia, but only further concerns or provide blanket reassurances that everything will jams the stuck shoulder against the mater- be OK. nal pubic bone. It also can cause injury to Instead, review with her any risk factors she may have for the fetus or even rupture the . shoulder dystocia and discuss the specific odds of injury to her Fundal pressure is often cited in court baby should dystocia arise. Then discuss the risks to her and the as a definite standard of care violation. discomfort she will experience if she elects a cesarean section.

Patients have a right to know the risks Although it is appropriate to be reassuring when there are no ❚ Theory vs evidence significant risk factors, patients deserve to know what risks A 3-member team is adequate they run and to have these risks put into perspective. For Shoulder dystocia occurs unexpectedly. example, if the mother has diabetes and her baby is estimated Once it does occur, the obstetrician has 4 to weigh over 4,500 g, the risk of permanent brachial plexus to 6 minutes to resolve it before the threat injury approaches 1 in 450. The same is true if she is nondia- of central neurologic damage to the baby betic but has an estimated fetal weight of 5,000 g or more. becomes significant. Although it would be In high-risk cases such as these, you should discuss the very helpful for additional personnel to be risks with the patient and have her participate in the decision- available, it is not always possible to making. You should also clearly document this discussion in assemble this team quickly enough. the medical record. In reality, the only personnel truly nec- essary to resolve a shoulder dystocia are: 1. The delivering doctor or midwife if all else fails. This 2. A medically trained assistant familiar FAST TRACK maneuver should be attempted only when with McRoberts maneuver and supra- The obstetrician all other efforts have failed.34 It involves pubic pressure flexing the fetal head and attempting to 3. Any other available person, including has 4 to 6 minutes push the baby’s head back into the vagina, a family member, who can be drafted to resolve shoulder followed by emergency cesarean section. to help and instructed to participate in dystocia before Although case reports have described the McRoberts maneuver by flexing the threat of successful use of this maneuver, there also one of the mother’s thighs have been reports of fetal death, fractured The McRoberts maneuver and supra- central neurologic spines, and other severe fetal damage. pubic pressure can be and often are per- injury is significant Thus, this maneuver should be the absolute formed simultaneously by the same nurse last resort in desperate emergencies.35 or other assistant.

Drills are not an absolute necessity It is sometimes claimed that formal shoul- ❚ What not to do der dystocia drills should be conducted in Traction labor and delivery units at fixed intervals. Do not continue to apply traction to the Although this may be a useful and reason- fetal head if the shoulder does not come. able educational practice, it is more impor- Once shoulder dystocia is diagnosed, cease tant that each individual on the labor and all attempts to deliver the baby by contin- delivery team know what his or her role is ued pulling. Carefully but expeditiously during such an emergency. Whether this is use the various maneuvers you were achieved through a practice drill or didac- trained to do, applying moderate traction tic instruction does not matter.

CONTINUED

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In short, there is nothing about the Given that the most frequent criticism concept of a drill that is “standard of care.” of obstetricians in the courtroom in What is standard of care is that every team brachial plexus injury lawsuits is that they member knows what to do, how to do it, pulled too hard, the best defense consists of when to do it, and how to document it. careful, complete, and contemporaneous documentation of one’s actions at delivery. is often superfluous Multiple studies have shown that episiotomy is not necessary to resolve shoulder dystocia, although many textbooks and other pub- ❚ Lawsuits happen lished protocols still recommend it.36 The Even when everything is done correctly, obstructing factor in shoulder dystocia is not there is a very high likelihood that a lawsuit the soft tissue of the perineum but the symph- will be filed when there is a permanent ysis pubis. The only time episiotomy helps is brachial plexus injury. when more room is needed for the obstetri- The 2 claims generally made against cian’s hand to enter the posterior aspect of the obstetricians are: vagina to perform a shoulder dystocia maneu- • The obstetrician should have known or ver. If you can perform all necessary maneu- predicted that the risk of shoulder dys- vers without episiotomy, it is superfluous. tocia was high, and should have per- formed a cesarean section or at least offered the mother that choice. • As the baby has a permanent brachial ❚ Document early and always plexus injury, the obstetrician must Because shoulder dystocia often leads to lit- have pulled too hard at delivery. igation, it is extremely important to docu- ment what happened during delivery as The best defense soon as feasible and in as much detail as The best defense is, as always, to have prac- possible. Standardized forms are now avail- ticed good medicine and to have document- able. (Visit WWW.OBGMANAGEMENT.COM for ed it. You must be able to demonstrate from FAST TRACK the form accompanying this article.) your records—years after a delivery that You must be able At minimum, you should record: you no longer remember—that you: • how shoulder dystocia was diagnosed • made appropriate prenatal judgments to show—years • which shoulder was anterior and and were aware of risk factors later—that you: which was posterior • informed the mother of such risk fac- ❙ • quantification of the force applied tors when they are significant made appropriate initially and in subsequent traction • provided proper obstetrical care prenatal judgments attempts, using terms such as “mild,” • documented in the medical record that ❙ “moderate,” or “significant” you knew what you were doing and did informed the mother • duration of attempts to resolve the it correctly of her risk factors dystocia It is then your job, along with the • maneuvers performed defense team, to educate the jury that, even ❙ provided proper care • approximate length of time each in the best of hands and with perfectly ❙ knew what you maneuver was tried appropriate care, permanent brachial • condition of the baby at delivery, plexus injuries can occur. The plaintiff’s were doing including Apgar scores, a description contention that an injury proves the obste- of all injuries and bruises, and cord trician did something wrong must be shown Visit our Web site for: pH, if obtained for the unsubstantiated misstatement it is. ❙ Shoulder dystocia • time from delivery of the fetal head Some good news is on the horizon. Recent to delivery of the body research has produced a mathematical tool documentation form • documentation of the discussion with that appears to be able to predict 50% to www.obgmanagement.com the patient following delivery 75% of all women destined to have shoul-

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der dystocia, with a false-positive rate of 16. Delpapa DH, Mueller-Heubach E. outcome fol- 37 lowing ultrasound diagnosis of macrosomia. Obstet only 2% to 3%. If this model holds up Gynecol. 1991;78:340–343. under further investigation, it may become 17. Gonen O, Rosen DJ, Dolfin Z, et al. Induction of labor versus possible to avoid most shoulder dystocia expectant management in macrosomia: a randomized study. Obstet Gynecol. 1997;89:913–917. deliveries and, with them, permanent 18. Leaphart WL, Meyer MC, Capeless EL. with brachial plexus injuries. a prenatal diagnosis of fetal macrosomia. J Matern Fetal Meanwhile, what is an obstetrician to Med. 1997;6:99–102. 19. American College of Obstetricians and Gynecologists. do about shoulder dystocia? As always, give ACOG Practice Bulletin #40: Shoulder Dystocia. the best care you can. Know the risk factors. Washington, DC: ACOG; November 2002. 20. Elliott JP, Garite TJ, Freeman RK, McQuown DS, Patel JM. When possible, consider alternatives to Ultrasonic prediction of fetal macrosomia in diabetic vaginal delivery and be less aggressive in the patients. Obstet Gynecol. 1982;60:159–162. management of labor. Know the techniques 21. Gherman RB. Persistent brachial plexus injury: the outcome of concern among patients with suspected fetal macroso- for resolving shoulder dystocia and have a mia. Am J Obstet Gynecol. 1998;178:195. preestablished plan for what to do. 22. McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoul- Document, document, document. You can give der dystocia. Int J Obstet Gynaecol. 1996;55:219–224. the best care in the world, but if you cannot 23. Bofill JA, Rust OA, Devidas M, et al. Shoulder dystocia and demonstrate on paper years down the road operative vaginal delivery. J Matern Fetal Med. 1997;6:220–224. that you did so, our current liability system 24. Johnson NR. Shoulder dystocia: a study of 47 cases. Aust will make it seem as if you did not. ■ N Z J Obstet Gynaecol. 1979;19:28–31. 25. Nocon JJ, Weisbrod L. Shoulder dystocia. Chapter 14. In: O’Grady JP, Gimovsky M, eds. Operative Obstetrics. REFERENCES Philadelphia: Williams & Wilkins; 1995:339–353. 1. Professional Insurance Association of America risk man- 26. Creasy RK, Resnik R. Maternal–Fetal Medicine. 5th ed. agement data, 2005. Philadelphia: Saunders; 2004:690–691. 2. Acker D, Sachs B, Friedman E. Risk factors for shoulder 27. Nichols DH, DeLancey JO, eds. Clinical Problems, Injuries dystocia. Obstet Gynecol. 1985;66:762–768. and Complications of Gynecologic and Obstetric Surgery. 3. Al-Najashi S, Al-Suleiman S, El-Yahia A, Rahman M, Baltimore: Williams & Wilkins; 1995:447. Rahman J. Shoulder dystocia—a clinical study of 56 cases. 28. Hopewood HG. Shoulder dystocia: fifteen years’ experi- Aust N Z J Obstet Gynaecol. 1989;29:129. ence in a community hospital. Am J Obstet Gynecol. 4. Casey BM, Lucas MJ, McIntire DD, Leveno KJ. Pregnancy 1982;144:162–166. outcomes in women with gestational diabetes compared 29. Benedetti TJ, Gabbe SG. Shoulder dystocia: a complication with the general obstetric population. Obstet Gynecol. 1997; of fetal macrosomia and prolonged second stage of labor FAST TRACK 90:869–873. with midpelvic delivery. Obstet Gynecol. 1978:52:526–529. 5. Sandmire HF,O’Halloin TJ. Shoulder dystocia: its incidence 30. McFarland LV, Raskin M, Daling JR, Benedetti TJ. A new model may and associated risk factors. Int J Obstet Gynaecol. 1988; Erb/Duchenne’s palsy: a consequence of fetal macrosomia 26:65–73. and method of delivery. Obstet Gynecol. 1986;68:784–788. 6. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and predict 50% to 75% 31. Gonik B, Stringer CA, Held B. An alternate mechanism for associated risk factors with macrosomic infants born in management of shoulder dystocia. Am J Obstet Gynecol. California. Am J Obstet Gynecol. 1998;179:47–480. of all women 1983;145:882–884. 7. Kolderup LB, Laros RK Jr, Musci TJ. Incidence of persistent 32. Woods CE. A principle of physics as applicable to shoulder destined to have birth injury in macrosomic infants: association with mode of delivery.Am J Obstet Gynecol. 1943;45:796–804. delivery.Am J Obstet Gynecol. 1997;177:37–41. shoulder dystocia 33. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours 8. Emerson R. Obesity and its association with the complica- maneuver for reducing shoulder dystocia during labor. J tions of pregnancy. Br Med J. 1962;2:516–519. Reprod Med. 1998;43:439–443. 9. Smith RB, Lane C, Pearson JF. Shoulder dystocia: what happens at the next delivery? Br J Obstet Gynaecol. 34. Sandberg EC. The Zavanelli maneuver: a potentially revolu- 1994;101:713–715. tionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol. 1985;152:479. 10. Ginsberg NA, Moisidis C. How to predict recurrent shoulder dystocia. Am J Obstet Gynecol. 2001;184:1427–1430. 35. Sandberg EC. The Zavanelli maneuver: 12 years of record- ed experience. Obstet Gynecol. 1999;93:312–317. 11. Gherman RB. Shoulder dystocia: an evidence-based eval- uation of the obstetrical nightmare. Clin Obstet Gynecol. 36. Gurewitsch ED, Donithan M, Stalllings SP, et al. Episiotomy 2002;45:345–361. versus fetal manipulation in managing severe shoulder dys- tocia: a comparison of outcomes. Am J Obstet Gynecol. 12. Baskett TF,Allen AC. Perinatal implications of shoulder dys- 2004;191:911–916. tocia. Obstet Gynecol. 1995;86:14–17. 37. Dyachenko A, Ciampi A, Fahey J, et al. Prediction of risk for 13. Lewis DF,Edwards MS, Asrat T,et al. Can shoulder dystocia shoulder dystocia with neonatal injury. Am J Obstet be predicted? Preconceptual and prenatal factors. J Gynecol. 2006 Jul 14 [Epub ahead of print]. Reprod Med. 1998;43:654–658. 38. DeCherney AH, Pernoll ML, eds. Lange Obstetric and 14. Rouse DJ, Owen J, Goldenberg RL, Cliver SP. The effective- Gynecologic Diagnosis and Treatment. 8th ed. Norwalk, ness and costs of elective cesarean delivery for fetal Conn: Appleton & Lange; 1994:219. macrosomia diagnosed by ultrasound. JAMA. 1996;276:1480–1486. 39. Allen RH, Gurewitsch ED. Temporary Erb-Duchenne palsy without shoulder dystocia or traction to the fetal head. 15. Gherman RB, Ouzounian JG, Goodwin TM. Brachial plexus Obstet Gynecol. 2005;105:1210–1212. palsy: an in utero injury? Am J Obstet Gynecol. 1999;180:1303–1307. Dr. Lerner is a consultant for LMS Medical Services.

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