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Consider early delivery of posterior arm: approaches outlined for managing shoulder dystocia.

MAUI, HAWAII -- The different maneuvers to deliver a baby with shoulder dystocia fall into three categories: the good, the not bad, and the downright ugly.

Leading off the ugly category is traction with fundal pressure, which increased the neonatal death rate to 16% in one study, increased the rate of complications to 77% in another study, and increased complications by 28-fold compared with no fundal pressure in a third study, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

"Fundal pressure absolutely should not be used," he said.

To avoid litigation if a baby with shoulder dystocia has a bad outcome, train delivery room nurses to document suprapubic pressure if it is performed, but first to be sure that suprapubic pressure was actually used. "I frequently see situations where the nurse writes fundal pressure, and the doctor emphatically denies that fundal pressure was used," said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Instead, address shoulder dystocia by trying the McRoberts maneuver, suprapubic pressure, and early attempts to deliver the posterior arm, he advised. Exaggerated flexion of the mother's legs in the McRoberts maneuver will not change the diameter of the pelvis, but it decreases the angle of inclination and may allow the blocked shoulder to dislodge. Don't be too exuberant with this maneuver, though, he cautioned. Prolonged or overly forceful flexion of the patient's hips can damage maternal femoral nerves, ligaments, or other body parts.

A recent case report from Georgetown University in Washington suggested that physicians should make earlier attempts to deliver the posterior arm of a baby with shoulder dystocia.

Also called the Barnum maneuver, delivery of the posterior arm allowed the fetal trunk to follow easily after initial attempts at the McRoberts maneuver with traction had failed. A geometric analysis concluded that using posterior arm delivery reduces the shoulder obstruction by more than a factor of two relative to the McRoberts maneuver (Obstet. Gynecol. 101[5, pt. 2]: 1068-72, 2003).

The maneuver usually is not considered a first- or second-line strategy in algorithms of managing shoulder dystocia. "A lot of people leave it until late in the process before they start going for the posterior arm. At that point they may have damaged the maternal anatomy. They may have pushed or pulled the baby into a position where they can't get the posterior arm," Dr. Belfort commented at the meeting, sponsored by Boston University and the Center for Human Genetics.

Another maneuver to avoid is the Woods screw maneuver--applying pressure on the anterior portion of the posterior shoulder plus fundal pressure. Aside from the dangers of fundal pressure, the pressure on the anterior part of the shoulder can abduct the shoulder girdle, making it bigger and more difficult to get out.

Instead, Dr. Belfort uses the Rubin maneuver if the McRoberts maneuver, suprapubic pressure, and attempts to deliver the posterior arm have failed to deliver the baby. The Rubin maneuver involves transabdominal rocking of the fetal shoulders and transvaginal adduction of the most accessible shoulder (not necessarily the posterior one, as in the Woods maneuver) by pressing on the posterior aspect to collapse the shoulders inward.

If you're still stuck, try delivering the baby with the mother on her hands and knees, as recommended in some publications for nurse midwives. "I have done this once, and it worked for me," he said.

If all these maneuvers have failed but the baby's head is out and you have someone to help you, consider attempting an abdominal rescue as you're preparing the patient for surgical delivery. Open the abdomen and press behind the symphysis to get the shoulder out and allow a vaginal delivery. If that doesn't work, open the uterus as well to push the shoulder out, even if you have to break the clavicle and humerus.

Final options include C-section delivery, symphysiotomy, or the Zavanelli maneuver, which has been known to rupture cervical vertebrae and cause major intracranial damage.

Rate of Complications of Labor and/or Delivery, 2002

 Per 1,000 Live Births

Meconium, Moderate/Heavy 50.1
Fetal Distress 38.6
Breech/Malpresentation 38.1
Dysfunctional Labor 28.6
Premature Rupture of Membranes 23.1
Cephalopelvic Disproportion 15.8

Note: Based on all 4.02 million live births in 2002.
Source: Centers for Disease Control and Prevention

Note: Table made from bar graph.


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Title Annotation:Obstetrics
Author:Boschert, Sherry
Publication:OB GYN News
Date:Mar 1, 2004
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