SHOULDER DYSTOCIA ACOG Simulation Committee

Outline Learning Objectives Background Management / Treatment Summary References ACOG Simulation Committee

ACOG Simulation Committee Learning Objectives At the end of this presentation, participants should be able to: Identify factors for shoulder dystocia Communicate critical tasks that should be performed when this complication occurs Demonstrate proper technique for basic maneuvers to relieve shoulder dystocia Communicate effectively with delivery team during a shoulder dystocia ACOG Simulation Committee

BACKGROUND ACOG Simulation Committee

ACOG Simulation Committee Definition ACOG Simulation Committee

Shoulder Dystocia Head successfully delivered Add question regarding immediate delivery vs watchful waiting Head successfully delivered Shoulder lodged behind pubic bone Posterior shoulder may be lodged behind sacral promontory Delivery arrested

Anterior Shoulder Impaction Symphysis ACOG Simulation Committee

ACOG Simulation Committee Diagnosis ACOG Simulation Committee

Identification of Shoulder Dystocia Delivery of head with retraction against maternal perineum (Turtle Sign) Delivery of head with arrest of shoulder delivery with usual delivery maneuver (axial traction on fetal head) Difficulty with or arrest of delivery of fetal head and chin

Risk Factors Shoulder Dystocia Antepartum: High fetal weight (actual vs. estimated) Obesity Diabetes Prior shoulder dystocia Excessive weight gain Prior macrosomic infant Intrapartum: 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 (EFW) in diabetic of ≥4250 gms – EFW in non diabetic of ≥5000 gms – Prior shoulder dystocia with injury to infant (brachial plexus, limb fracture or asphyxia)

Effectiveness/Costs of Elective C/S for Fetal Macrosomia Diagnosed by U/S per Million Non-Diabetic Women Cesarean, Permanent Cost Non-Diabetic BPP Avoided (Millions) Standard Care — — U/S: C/S if ≥4000 g 2345 $4.9 U/S: C/S if ≥4500 g 3695 $8.7

Effectiveness/Costs of Elective C/S for Fetal Macrosomia Diagnosed by U/S per Million Diabetic Women Cesarean, Permanent Cost Diabetic BPP Avoided (Millions) Standard Care — — U/S: C/S if ≥4000 g 489 $0.93 U/S: C/S if ≥4500 g 443 $0.88 Rouse DJ, et al. JAMA 1996;276:1480–1486.

Complications with Shoulder Dystocia Neonatal: • Brachial plexus injury, fracture (humerus, clavicle) • Hypoxemia • Stillbirth Maternal: • Perineal laceration • Uterine rupture • Hemorrhage • PTSD

One Presumed Mechanism Brachial Plexus Injury Natural Position Forcibly Separated “The author, by numerous dissections on infantile cadavers, has shown that traction and forcible separation of the head and shoulder puts the upper cords, the 5th and 6th roots of the brachial plexus, under dangerous tension. This tension is so great that the two upper cords stand out like violin strings.” Sever JW. Am J Diseases of Children Dec 1916;12(6):541–78.

Mollberg M et al. Jour Child Neurology Dec 2008;23(12):1424–32. Correlation Between Degrees of Force Used in Downward Traction on Fetal Head and Number of Nerve Roots Affected in Brachial Plexus Palsy at Birth Mollberg M et al. Jour Child Neurology Dec 2008;23(12):1424–32.

Mollberg M et al. Jour Child Neurology Dec 2008;23(12):1424–32.

Obstetric Brachial Plexus Palsy Natural History The 2 studies (out of 7) which come closest to an ideal study show a tendency towards a 20–30% residual deficit, in contrast to the optimistic view of over 90% complete or almost complete recovery Physicians should exercise caution in predicting excellent recovery shortly after birth Pondaag 2004. Develop Med and Child Neurology. Vol 46.

Allen RH et al. AJOG Oct 2002;187(4):839–42. 5-Min Apgars vs Head-to-Body Delivery Intervals 36 Neonates Who Sustained PBPI Allen RH et al. AJOG Oct 2002;187(4):839–42.

Annual Shoulder Dystocia Training Neonatal Injury§ 1996–2000 2001–2004 Births 15,908 13,117 Shoulder Dystocia 324 (2.04%) 262 (2.0%) Injuries 30 (9.3%) 6 (2.3%)* §RR = 0.25 (0.11–5.7) *p< 0.001 Crofts & Draycott. Ob Gyn 2008;112:14–20.

Simulation & Outcomes Shoulder dystocia management protocol introduced All providers trained Didactics Simulations & Debriefing Evaluated fetal outcomes for three time periods 6 months before 6 months during implementation 6 months after (Grobman 2011)

Neonatal Outcomes

MANAGEMENT / TREATMENT ACOG Simulation Committee

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 All fours position and delivery of posterior shoulder Cephalic replacement and Cesarean section

McRobert’s Maneuver (Before) Shoulder Dystocia ACOG Simulation Committee

McRobert’s Maneuver (After) Shoulder Dystocia ACOG Simulation Committee

Suprapubic Pressure Shoulder Dystocia ACOG Simulation Committee

ACOG Simulation Committee Suprapubic Pressure ACOG Simulation Committee

Posterior Rubin’s Maneuver Shoulder Dystocia ACOG Simulation Committee

Avoid Fundal Pressure Shoulder Dystocia ACOG Simulation Committee

Anterior Rubin’s Maneuver Shoulder Dystocia ACOG Simulation Committee

ACOG Simulation Committee Move Thumb to Palm of Hand Prior to Vaginal Insertion Shoulder Dystocia ACOG Simulation Committee

Delivery of Posterior Arm (1 of 3) Shoulder Dystocia ACOG Simulation Committee

Posterior Arm Delivery Shoulder Dystocia ACOG Simulation Committee

Delivery of Posterior Arm (2 of 3) Shoulder Dystocia ACOG Simulation Committee

Delivery of Posterior Arm (3 of 3) Shoulder Dystocia ACOG Simulation Committee

ACOG Simulation Committee Effect of Posterior Arm Delivery (reducing obstructing part of fetal shoulder) ACOG Simulation Committee

Cephalic Replacement (1 of 2) Shoulder Dystocia ACOG Simulation Committee

Cephalic Replacement (2 of 2) Shoulder Dystocia ACOG Simulation Committee

Hands and Knees Position Shoulder Dystocia ACOG Simulation Committee

Hands and Knees Position Shoulder Dystocia ACOG Simulation Committee

Delivery of Shoulder in Hands and Knees Position ACOG Simulation Committee

Documentation After Shoulder Dystocia Implementation of a standard checklist may be necessary to achieve complete documentation: 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

Documentation Three important items uncommonly completed, even after simulation training: – Quantification of traction – Neonatal evaluation for Moro reflex – Discussion of delivery events with mother Specific documentation components more likely to be present if checkboxes or headings to be completed: – Position of fetal head – Head-to-shoulder delivery time – Classification as shoulder dystocia

What We Do Not Know How to determine exact cause and timing of brachial plexus injury Correct delivery techniques to avoid injury – Spontaneous delivery maneuvers – Shoulder dystocia maneuvers How to estimate fetal weight in a manner that will enhance clinical decision making Force characteristics to injure the brachial plexus How to use antenatal and intrapartum risk factors in a manner that will enhance clinical decision making

Optimal Management Suspected Fetal Macrosomia, Shoulder Dystocia and Brachial Plexus Injury Discussion Diagnosis Documentation Disclosure

SUMMARY ACOG Simulation Committee

ACOG Simulation Committee 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 ACOG Simulation Committee

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. 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.

Disclaimer Every effort has been made to ensure that the instruction and materials contained within this course are based on current evidence-based practice, but new recommendations may become available and inadvertent errors are always possible. In every case all variables must be taken into consideration and clinical judgment must be used. ACOG do not accept any liability for medical care rendered by those who take this course. All materials are copyrighted and provided for educational use and may not be modified, altered, or otherwise distributed without prior authorization. ACOG Simulation Committee