Vanderbilt High Risk Obstetrics Conference 2017 Shoulder Dystocia Vanderbilt High Risk Obstetrics Conference 2017

Outline Learning Objectives Background Management / Treatment Summary References

Learning Objectives Understand the risk factors for shoulder dystocia Be able to communicate the critical tasks that should be performed when a shoulder dystocia occurs Demonstrate the proper technique to relieve a shoulder dystocia Be able to communication effectively to the team and patient when a shoulder dystocia occurs

Background

Shoulder Dystocia Occurs in 0.2% - 3% of vaginal deliveries Variety of risk factors including fetal macrosomia, diabetes, history of shoulder dystocia and prolonged second stage Other factors that have been associated include post- term pregnancy, multiparity, obesity and operative vaginal delivery 50% of should dystocia have no risk factors identified

Definition Head successfully delivered Shoulder lodged behind pubic bone Posterior shoulder may be lodged behind sacral promontory Delivery arrested

Anterior Shoulder Impaction

Identification of Shoulder Dystocia Delivery of head with retraction of head against perineum (Turtle Sign) Delivery of head with arrest of shoulder delivery with usual delivery maneuver (axial traction of fetal head) Traction should be done in alignment with cervico-thoracic spine at an angle of 25-45 degree Should not be done at an angel – increases the risk of brachial plexus injury Delivery with or arrest of delivery of fetal head and chin

Risk Factors Antepartum Intrapartum Fetal macrosomia Obesity Maternal diabetes Prior shoulder dystocia Excessive weight gain Prior macrosomic infant Abnormal labor pattern Operative vaginal delivery

Prevention of Shoulder Dystocia Prevention of shoulder dystocia with Cesarean section prior to labor should only be considered in unusual circumstances: Estimated fetal weight in diabetic patient ≥ 4500 gms Estimated fetal weight in non diabetic patient ≥ 5000 gms Prior shoulder dystocia with injury to infant (brachial plexus, limb fracture or asphyxia)

# of CD needed to avoid permanent brachial plexus injury Elective CD for fetal macrosomia based on ultrasound – Effectiveness/Cost Non-Diabetic # of CD needed to avoid permanent brachial plexus injury Cost ($ millions) CD if ≥ 4000 gms 2345 $4.9 CD if ≥ 4500 gms 3695 $8.7 Rouse DJ, et al. JAMA 1996;276:1480–1486.

# of CD needed to avoid permanent brachial plexus injury Elective CD for fetal macrosomia based on ultrasound – Effectiveness/Cost Diabetic # of CD needed to avoid permanent brachial plexus injury Cost ($) CD if ≥ 4000 gms 489 $930,000 CD if ≥ 4500 gms 443 $880,000 Rouse DJ, et al. JAMA 1996;276:1480–1486.

Morbidity Maternal Neonatal Increased risk of postpartum hemorrhage Increased risk of higher degree perineal lacerations Brachial plexus injury – majority resolve Fractures of clavicle or humerus Hypoxemia Death

Management and Treatment

Shoulder Dystocia Algorithm Call for help: RN, Pediatrics, OB Brief team huddle (clearly state problem, assign roles) McRobert’s Maneuver (thighs to abdomen) Suprapubic pressure  routine delivery traction Episiotomy if necessary to do internal maneuvers Deliver posterior arm OR Internal rotational maneuvers Posterior Axilla Sling Traction (PAST) All fours position and delivery of posterior shoulder Cephalic replacement and Cesarean section

McRobert’s Maneuver - Before

McRobert’s Maneuver - After Flexion of maternal thighs Cephalad rotation of symphysis pubis Flattening of the lumbar lordosis

Suprapubic Pressure Pressure is directed downward and laterally (towards the fetus face and sternum) Assist in abduction and rotation of the anterior shoulder

Suprapubic Pressure

Delivery of the Posterior Arm Move the thumb to palm of hand prior to vaginal insertion

Delivery of the Posterior Arm

Delivery of Posterior Arm – View from inside

Delivery of Posterior Arm

Delivery of Posterior Arm

Delivery of Posterior Arm Delivery of posterior arm reduces obstruction from fetal shoulder

Rotational Maneuvers Rubin’s Maneuver Place pressure on fetal back rotating shoulder towards chest

Rotational Maneuvers Wood’s Screw Place pressure on the anterior portion of the shoulder to rotate it towards the back

Posterior Axilla Sling Traction (PAST) Suction catheter or firm urinary catheter is formed into a loop Loop is fed behind the posterior shoulder The loop is grabbed and brought anterior to create a sling around the posterior axilla Traction applied to sling to deliver posterior shoulder

Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling  Catherine Anne Cluver, MD, G. Justus Hofmeyr, DSc American Journal of Obstetrics & Gynecology 2015 212, 784.e1-784.e7DOI: (10.1016/j.ajog.2015.02.025) Copyright © 2015 Elsevier Inc. Terms and Conditions

Gaskin Maneuver – Hands and Knees Woman placed on hands and knees Delivery is effected by downward traction on the posterior shoulder or upward traction on the anterior shoulder

Cephalic Replacement

Documentation Following a Shoulder Dystocia Identification of complication as shoulder dystocia Pediatrician called/present at delivery Identification of anterior shoulder Quantification of traction Duration of shoulder dystocia Maneuvers used to resolve dystocia Cord blood gases sent or values noted Moro reflex Communication with patient about events of delivery Implementation of a standardized checklist may be necessary to achieve complete documentation

Simulation Training and Shoulder Dystocia

Simulation Training Effective because high acuity and low frequency event Studies have demonstrated improved outcomes following simulation training Increase use of evidence based techniques Lower incidence of brachial plexus injury Simulation and team training is recommended to improve team communication and maneuver use leading to reduction in injuries

Fetal outcome before and after simulation training Crofts & Draycott. Ob Gyn 2008;112:14–20. Pre-training 15,908 Post-training 13,117 p value Shoulder Dystocia 324 (2.04%) 262 (2.00%) 0.813 Neonatal Injury 30 (9.3%) 6 (2.3%) RR 0.25 McRoberts 95 (29.3%) 229 (87.4%) <0.001 Suprapubic pressure 90 (27.8%) 119 (45.4%) Internal rotation 22 (6.8%) 29 (11.1%) 0.02 Delivery of posterior arm 24 (7.4%) 52 (19.8%)

Fetal outcome after sustained simulation training Pre-training 15,908 Early Post-training 13,117 Late Post-Training 17,037 Shoulder Dystocia 324 (2.04%) 262 (2.00%) 562 (3.03%) Neonatal Injury 30 (9.3%) 8 (3.1%) 8 (1.4%) Sustained Improvements were maintained overtime with training program Crofts JF et al. BJOG 2016;123:111–118

Summary Shoulder dystocia unpredictable and most occur in patients with no risk factors Permanent fetal injury may be prevented by limiting non-axial traction on fetal head simulation training Documentation and debriefing after shoulder dystocia essential part of good patient care

References Ouounian JG, Gherman RB. Shoulder dystocia: are historic risk factors reliable predictors? Am J Obstet Gynecol 2005; 192:1933-5. Smith RB, Lane C, Pearson JF, Should dystocia: what happens at the next delivery? Br J Obstet Gynaecol 1994; 101:713-5. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998; 179:476-80. Bahar AM. Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight. Br J Obstet Gynaecol 1996; 103:868-72. Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk. Am J Obstet Gynecol 1987; 156:1408-18. Rouse DJ, Owen J. Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography – A Faustian bargain? Am J Obstet Gynecol 1999; 181:332-8. Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage labor with midpelvic delivery. Obstet Gynecol 1978; 52:526-9. Sandmire HF, O’Halloin TJ. Shoulder dystocia: its incidence and associated risk factors. Int J Gynaecol Obstet 1988; 26:65-73. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005; 112:768-72. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998; 43:439-43.

References Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia. Am J Obstet Gynecol 1985; 152:479-84. Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008; 112:906-912. Draycott TJ, Crofts JF, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20.  Grobman WA, Miller D, Burke C, et al. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol 2011; 205:513-517. Crofts JF, Lenguerrand E, et al. Prevention of brachial plexus injury – 12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2015; doi: 10.1111/1471-0528.13302. Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011; 204:322.e1-6. Deering SH, Weeks L, Benedetti TJ. Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation. Am J Obstet Gynecol 2011; 204:234.e1-5. Cluver CA, Hofmeyr GJ. Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling. Am J Obstet Gynecol 2015; 212: 781-784 Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, Fox R, Draycott TJ. Prevention of brachial plexus injury—12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016;123:111–118 ACOG Emergency in Clinical Obstetrics Simulation Course. Shoulder Dystocia. 2015.