Optimizing shoulder dystocia management to prevent birth injury

Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial

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.

Improving the Quality of Maternity Care: Learning From Malpractice

OBJECTIVE

This study aimed to depict the characteristics, injury outcomes, and payment of obstetric malpractice lawsuits to better understand the medicolegal burden in obstetrics and categorize the causes of obstetric malpractice lawsuits using The National Health Service Litigation Authority coding taxonomy for further quality improvement in maternity care.

METHODS

We reviewed and retrieved key information on court records of legal trials from China Judgment Online between 2013 and 2021.

RESULTS

A total of 3441 obstetric malpractice lawsuits successfully claimed were reviewed in this study, with a total indemnity payment of $139,875,375. After peaking in 2017, the number of obstetric malpractice claims begins to decline. Of the 2424 hospitals that were sued, 8.3% (201/2424) were referred to as "repeat defendant" because they were involved in multiple lawsuits. Death and injury were the outcomes in 53.4% and 46.6% of the cases, respectively. The most common outcome type was neonatal death, which made up 29.8% of all cases. The median indemnity payment for death was higher compared with injury (P < 0.05). In terms of detailed injury outcomes, the major neonatal injury had higher median indemnity payments than neonatal death and fetal death (P < 0.05). The median indemnity payment of the major maternal injury was higher than that of maternal death (P < 0.05). The leading causes of obstetric malpractice were the management of birth complications and adverse events (23.3%), management of labor (14.4%), career decision making (13.7%), fetal surveillance (11.0%), and cesarean section management (9.5%). The cause for 8.7% of cases was high payment (≥$100, 000). As indicated by the results of the multivariate analysis, the hospitals in the midland of China (odds ratio [OR], 0.476; 95% confidence interval [CI], 0.348-0.651), the hospitals in the west of China (OR, 0.523; 95% CI, 0.357-0.767), and the secondary hospitals (OR, 0.587; 95% CI, 0.356-0.967) had lower risks of high payment. Hospitals with ultimate liability (OR, 9.695; 95% CI, 4.072-23.803), full liability (OR, 16.442; 95% CI, 6.231-43.391), major neonatal injury (OR, 12.326; 95% CI, 5.836-26.033), major maternal injury (OR, 20.885; 95% CI, 7.929-55.011), maternal death (OR, 18.783; 95% CI, 8.887-39.697), maternal death with child injury (OR, 54.682; 95% CI, 10.900-274.319), maternal injury with child death (OR, 6.935; 95% CI, 2.773-17.344), and deaths of both mother and child (OR, 12.770; 95% CI, 5.136-31.754) had higher risks of high payment. In the causative domain, only anesthetics had a higher risk of high payment (OR, 5.605; 95% CI, 1.347-23.320), but anesthetic-related lawsuits made up just 1.4% of all cases.

CONCLUSIONS

The healthcare systems had to pay a significant amount as a result of obstetric malpractice lawsuits. Greater efforts are required to minimize serious injury outcomes and improve obstetric quality in the risky domains.

Overview of techniques to manage shoulder dystocia during vaginal birth

Shoulder dystocia is an obstetric emergency which is unpredictable and complicates approximately 0.5-1% of vaginal births. This article discusses the risk factors and the associated fetal and maternal complications, while it is also an overview of techniques and algorithms to handle shoulder dystocia.

Obstetric Paralysis: Who is to blame? A systematic literature review

Obstetric palsy is classically defined as the brachial plexus injury due to shoulder dystocia or to maneuvers performed on difficult childbirths. In the last 2 decades, several studies have shown that half of the cases of Obstetric palsy are not associated with shoulder dystocia and have raised other possible etiologies for Obstetric palsy. The purpose of the present study is to collect data from literature reviews, classic articles, sentries, and evidence-based medicine to better understand the events involved in the occurrence of Obstetric palsy. A literature review was conducted in the search engine PubMed (MeSH - Medical Subject Headings) with the following keywords: shoulder dystocia and obstetric palsy , completely open, boundless regarding language or date. Later, the inclusion criterion was defined as revisions. A total of 21 review articles associated with the themes described were found until March 8, 2018. Faced with the best available evidence to date, it is well-demonstrated that Obstetric palsy occurs in uncomplicated deliveries and in cesarean deliveries, and there are multiple factors that can cause it, relativizing the responsibility of obstetricians, nurses, and midwives. The present study aims to break the paradigms that associate Obstetric palsy compulsorily with shoulder dystocia, and that its occurrence necessarily implies negligence, malpractice or recklessness of the team involved.

Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis

STATEMENT

Mastery of shoulder dystocia management skills acquired via simulation training can reduce neonatal brachial plexus injury by 66% to 90%. However, the correlation between simulation drills and reduction in clinical injuries has been inconsistently replicated, and establishing a causal relationship between simulation training and reduction of adverse clinical events from shoulder dystocia is infeasible due to ethical limitations. Nevertheless, professional liability insurance carriers increasingly are mandating simulation-based rehearsal and competency assessment of their covered obstetric providers' shoulder dystocia management skills-a high-stakes demand that will require rapid scaling up of access to quality shoulder dystocia simulation. However, questions remain about differing simulation training schemes and instructional content used among clinically effective and ineffective educational interventions. This review of original research compares curricular content of shoulder dystocia simulation and reveals several critical gaps: (1) prescriptive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus is inconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterally directed traction on the head or to observe a brief hands-off period before attempting traction is infrequently explicit. (3) Neither relative effectiveness nor potential interaction between prescriptive and proscriptive elements of instruction has been examined directly. (4) Reliability of high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competence is unknown. Further study is needed to address these gaps and inform efficient and effective implementation of clinically translatable shoulder dystocia simulation.

Accuracy of immediate antepartum ultrasound estimated fetal weight and its impact on mode of delivery and outcome - a cohort analysis

Background

The aim of the study was to investigate the accuracy of ultrasound-derived estimated fetal weight (EFW) and to determine its impact on management and outcome of delivery.

Methods

In this single-center cohort analysis, women with a singleton term pregnancy in the beginning stages of labor were included. Women with immediately antepartum EFW (N = 492) were compared to women without ultrasound (N = 515).

Results

EFW was correct (deviation from birth weight ≤ 10%) in 72.2% (355/492) of patients with fetal biometry; 19.7% (97/492) were underestimated, and 8.1% (40/492) were overestimated. Newborns with a lower birth weight were more frequently overestimated, and newborns with higher birth weight were more frequently underestimated. The mean difference between EFW and real birth weight was − 114.5 g (standard deviation ±313 g, 95% confidence interval 87.1–142.0). The rate of non-reassuring fetal heart tracing (9.8% vs. 1.9%, P < 0.001) and of caesarean delivery (9.1% vs. 5.0%, P = 0.013) was higher in women with EFW. Overestimation was associated with an increased risk for delivery by caesarean section (odds ratio 2.80; 95% confidence interval 1.2–6.5, P = 0.017). After adjustment, EFW remained associated with increased non-reassuring fetal heart tracing (odds ratio 4.73; 95% confidence interval 2.3–9.6) and caesarean delivery (odds ratio 1.86; 95% confidence interval 1.1–3.1). The incidence of perineal tears of grade 3/4, shoulder dystocia, postnatal depression and neonatal acidosis did not differ between groups.

Conclusions

Antepartum ultrasound-derived EFW does not improve maternal and fetal outcome and is therefore not recommended.

Normal Range of Head-to-body Delivery Interval by Two-step Delivery

Background:

The one-step method was routine practices in China, scientific evidence to support this intervention is scarce. The purpose of this study was to observe the natural process of head-to-body delivery interval by waiting for at least one contraction (two-step) after head delivered in normal birth.

Methods:

From March 1 to March 30 in 2015 at Haikou Maternal and Child Hospital in China, normal vaginal birth with normal baby condition were recorded by video. Videotapes were transferred to computer then replayed and observed.

Results:

Ninety-two cases were enrolled in this study. The average head-to-body delivery interval by two-step delivery was 71.04 ± 61.02 s, (mean + 2 standard deviation = 193.07 s, 95% confidence interval [15.65–229.15] s). Fifty-one patients (51/92, 55.43%) were <60 s, 41 patients (41/92, 44.57%) were over 60 s. Shoulders delivered at the first contraction were 96.74% (89/92), 3.26% (3/92) had delivered by the second contraction. Shoulders emerged from perineum were 71.73% (66/92), 15.21% (14/92) transversely, and 13.04% (12/92) emerged from under pubic arch. Babies cried before the shoulder were 31.52% (29/92), cried after birth 52.17% (48/92), and 16.30% (15/92) did not cry after birth. Baby activities included as making faces, sucking, and bubbled from mouth and noses, and the lighter blue color of skin with good perfusion.

Conclusions:

The average time of head-to-body delivery interval was longer than 60 s by two-step delivery. Majority shoulders were delivered at the first contraction. Majority shoulders emerged from perineum rather from under pubic arch. The routine one-step method of shoulder delivery where the downward force applied is not necessary and is not the right direction. Baby's breath, making faces, sucking, bubble from noses and mouth, and the light blue color of the faces, all those signs during shoulder delivery indicated a normal live birth.

Prevention of shoulder dystocia related birth injuries: Myths and facts

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.

Risk factors profile of shoulder dystocia in oman: a case control study

OBJECTIVE

This study aimed to assess the risk factor profile of shoulder dystocia and associated neonatal complications in Oman, a developing Arab country.

METHODS

A retrospective case-control study was conducted among 111 cases with dystocia and 111 controls, identified during 1994-2006 period in a tertiary care hospital in Oman. Controls were randomly selected among women who did not have dystocia, and were matched to cases on the day of delivery. Data related to potential risk factors, delivery, and obstetric complications were collected.

RESULTS

Dystocia was significantly associated with older maternal age, higher parity, larger BMI, diabetes, and previous record of dystocia. In addition, dystocia was associated more with vacuum and forceps deliveries. Routine traction (51%) was the most used manoeuvre. Among dystocia cases, 13% were associated with fetal complications of which Erb's Palsy was the most prevalent (79%).

CONCLUSION

Our finding of significant associations with risk factors lays out the ground to develop a predictability index for shoulder dystocia, which would help in making it preventable. Further p rospective studies are required to confirm the obtained results.

Reducing the risk of shoulder dystocia and associated brachial plexus injury

Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.

Shoulder dystocia: a qualitative exploration of what works

OBJECTIVE

to explore expert practitioners' methods of managing shoulder dystocia.

DESIGN AND SETTING

a qualitative interpretive study enabled a descriptive, hermeneutic analysis of data collected. Data were collected via tape recorded interviews, transcribed and analysed to explore themes and meanings.

PARTICIPANTS

five clinicians (four midwives and one obstetrician) who have significant experience in the management of shoulder dystocia and work in high risk maternity practice.

KEY FINDINGS

IMPLICATIONS FOR PRACTICE

the results of this study demonstrate that the actions to be taken in the event of shoulder dystocia should be further examined and possibly reviewed. The three simple steps of McRoberts Manoeuvre - Suprapubic Pressure - Axillary Traction could revolutionise the way in which shoulder dystocia is managed.

Effects of shoulder dystocia training on the incidence of brachial plexus injury

OBJECTIVE

We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI).

STUDY DESIGN

After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia.

RESULTS

The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining (P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining (P < .01). Maternal body mass index (P < .01) and neonatal weight (P = .02) decreased and head-to-body delivery interval increased in the posttraining period (P = .03). Only shoulder dystocia training remained associated with reduced OBPI (P = .02) after logistic regression analysis. OBPI remained less in the posttraining period (P = .01), even after excluding all neonates with birthweights >2 SD above the mean.

CONCLUSION

Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.

Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis

BACKGROUND

Obstetric brachial plexus palsy is rare, but the limb impairments are manifold and often long-lasting. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed with success. The role of conservative and operative treatment options should be regularly reviewed.

METHODS

Selective literature review (evidence levels 3 and 4) and analysis of personal clinical operative and scientific experience over the past 15 years.

RESULTS

Children with upper and total plexus palsy displaying nerve root avulsions and/or -ruptures are treated today by early primary nerve reconstruction in the first few months of life followed by secondary corrections, with good functional results. The late complications, with muscle weakness, impaired motion patterns, and joint dysplasia, are often underrated.

CONCLUSIONS

The potential for scientific analysis is limited, due to the rarity and interindividual variability of the lesions and the varying effects on function and growth. Expectations and compliance are different in every patient. Surgical techniques are not yet standardized. Knowledge of the consequences for joint growth and congruence is inadequate. Today, functional improvement can be achieved by surgery in most clinical manifestations of obstetric brachial plexus palsy, within the framework of an interdisciplinary treatment concept.

Lyme disease--current state of knowledge

BACKGROUND

Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease.

METHOD

The authors conducted a selective review of the literature, including various national and international guidelines.

RESULTS

The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins.

CONCLUSIONS

After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.