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Follow the rules with shoulder dystocia: avoid fundal pressure.

ATLANTA -- "Never, never, never!" is Dr. Washington C. Hill's advice on when to apply fundal pressure for shoulder dystocia.

This can further impact the shoulder and is clearly associated with orthopedic and neurologic damage. It also is very hard to defend legally, Dr. Hill said at a conference on high-risk obstetrics sponsored by Symposia Medicus.

In most cases, gentle downward traction and McRoberts' maneuver, in which the mother's legs are flexed up and onto her abdomen, changing the position of her pelvis relative to her spine, will successfully disengage the shoulder.

"But despite our best efforts and the use of appropriate maneuvers injuries do occur," said Dr. Hill, chairman of the department of obstetrics and gynecology and director of maternal-fetal medicine at Sarasota (Fla.) Memorial Hospital.

Fortunately, most brachial plexus injuries improve within 18 months. And even if the injury is permanent, it does not necessarily mean malpractice, he said.

Central to defense against malpractice for shoulder dystocia-related injury is a detailed delivery note in which the estimated fetal weight, length of first and second stages of labor, method of delivery, and maneuvers performed are specified. Apgar score, cord gas values, and signs of trauma also should be noted, he said.

In most instances, shoulder dystocia cannot be predicted or prevented, and a risk factor profile is of limited clinical value. Certain factors such as macrosomia, diabetes, and obesity do correlate, but not strongly enough to be of predictive value. In fact, risk factors miss 85% of cases, said Dr. Hill, also of the University of South Florida, Tampa.

Elective induction of labor or cesarean section for suspected macrosomia is not appropriate, except for the patient who has a history of shoulder dystocia. In such a case, the risks and benefits of cesarean delivery should be discussed, he said. Planned cesarean delivery is reasonable if the patient is diabetic and the estimated fetal weight exceeds 4,250 grams.

"If you have done everything correctly your liability is reduced or absent and you are more defensible," Dr. Hill said.
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Title Annotation:Obstetrics
Author:Walsh, Nancy
Publication:OB GYN News
Date:Nov 1, 2003
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