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Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Shoulder dystocia and neonatal brachial plexus palsy: Eliminating the nightmare Clinicians involved with childbirth have heard or recited, recalled or perpetuated the cliché: Shoulder dystocia is an obstetrician's nightmare.1–6 By definition, shoulder dystocia is the requirement of “additional obstetric maneuvers” when “gentle downward traction” has “failed” to affect the delivery of the shoulders. The maternal complications linked with impacted shoulder include postpartum hemorrhage and fourth-degree laceration.7 However, these morbidities are not the reason clinicians fear the uncommon and unpredictable occurrence. It is the potential neonatal sequela of brachial plexuses palsy, hypoxic ischemic injury, or death, which causes consternation to clinicians. The possibility of litigation8 with permanent palsy or death is disquieting and a reason to brandish shoulder dystocia as a “nightmare.” Several facts, however, should obviate the nightmare. First, the likelihood of lasting injury with shoulder dystocia is exceedingly rare. Two recent multi-center reports with combined experience of over 178,000 births and 3195 shoulder dystocia were notable for the following: the likelihood of neonatal brachial plexus palsy (NBPP) was 1 per 1000 births, the rate of hypoxic ischemic encephalopathy was 3 per 100,000 births, and there were no neonatal deaths secondary to impacted shoulders.9,10 Second, permanent NBPP occurs in approximately 1 in 10,000 births and a litigation for palsy, 1 in 45,000 births.11 Third, there is emerging evidence that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve outcomes with the nightmare.12 To further assist the clinicians, we invited seasoned investigators to write on the topic and provide an up-to-date understanding of this obstetric emergency. Though it is not feasible to eliminate shoulder dystocia, an enhanced understanding should avert unnecessary interventions, like induction or cesarean delivery, help formulate evidence-based guidelines, and plan prospective multi-center studies that would optimize outcomes when there is an impacted shoulder.
2. Bassaw B, Roopnarinesingh S, Mohammed N, Ali A, Persad H. Shoulder dystocia: an obstetrical nightmare. West Indian Med J. 1992;41:158–159. 3. Gherman RB. Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol. 2002;45:345–362. 4. Niederhauser A, Magann EF, Mullin PM, Morrison JC. Resolution of infant shoulder dystocia with maternal spontaneous symphyseal separation: a case report. J Reprod Med. 2008;53:62–64. 5. Politi S, D emidio L, Cignini P, Giorlandino M, Giorlandino C. Shoulder dystocia: an evidence-based approach. J Prenat Med. 2010;4:35–42. 6. Ahmed S, Romejko-Wolniewicz E, Zare˛ba-Szczudlik J, Czajkowski K. Fetal macrosomia—an obstetrician's nightmare? Neuro Endocrinol Lett. 2012;33(2):149–155. 7. American College of Obstetricians and Gynecologists. Shoulder Dystocia. ACOG Practice Pattern No. 40. Washington, DC: ACOG;2002. 8. Chauhan SP, Chauhan VB, Cowan BD, Hendrix NW, Magann EF, Morrison JC. Professional liability claims and Central Association of Obstetricians and Gynecologists members: myth versus reality. Am J Obstet Gynecol. 2005;192:1820–1826; discussion 1826-1828. 9. Hoffman MK, Bailit JL, Branch DW, et al. Consortium on safe labor. A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol. 2011;117:1272–1278. 10. Chauhan SP, Laye MR, LutgendorfM, et al., A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned. Am J Perinatol. 2013; [Epub ahead of print]. 11. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC. Brachial plexus injury: a 23-year experience from a tertiary center. Am J Obstet Gynecol. 2005;192:1795–1800 [discussion 1800-2]. 12. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205:513–517.
Suneet P. Chauhan, MD Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology UT Health Science Center at Houston Houston, TX
re fe r en ces http://dx.doi.org/10.1053/j.semperi.2014.04.001 0146-0005/& 2014 Published by Elsevier Inc. 1. Blickstein I, Lancet M. Shoulder dystocia—the obstetricianʼs nightmare. Harefuah. 1987;113:357–361.
M I N A R S I N
P
E R I N A T O L O G Y
38 (2014) 183
Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Shoulder dystocia and neonatal brachial plexus palsy: Eliminating the nightmare Clinicians involved with childbirth have heard or recited, recalled or perpetuated the cliché: Shoulder dystocia is an obstetrician's nightmare.1–6 By definition, shoulder dystocia is the requirement of “additional obstetric maneuvers” when “gentle downward traction” has “failed” to affect the delivery of the shoulders. The maternal complications linked with impacted shoulder include postpartum hemorrhage and fourth-degree laceration.7 However, these morbidities are not the reason clinicians fear the uncommon and unpredictable occurrence. It is the potential neonatal sequela of brachial plexuses palsy, hypoxic ischemic injury, or death, which causes consternation to clinicians. The possibility of litigation8 with permanent palsy or death is disquieting and a reason to brandish shoulder dystocia as a “nightmare.” Several facts, however, should obviate the nightmare. First, the likelihood of lasting injury with shoulder dystocia is exceedingly rare. Two recent multi-center reports with combined experience of over 178,000 births and 3195 shoulder dystocia were notable for the following: the likelihood of neonatal brachial plexus palsy (NBPP) was 1 per 1000 births, the rate of hypoxic ischemic encephalopathy was 3 per 100,000 births, and there were no neonatal deaths secondary to impacted shoulders.9,10 Second, permanent NBPP occurs in approximately 1 in 10,000 births and a litigation for palsy, 1 in 45,000 births.11 Third, there is emerging evidence that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve outcomes with the nightmare.12 To further assist the clinicians, we invited seasoned investigators to write on the topic and provide an up-to-date understanding of this obstetric emergency. Though it is not feasible to eliminate shoulder dystocia, an enhanced understanding should avert unnecessary interventions, like induction or cesarean delivery, help formulate evidence-based guidelines, and plan prospective multi-center studies that would optimize outcomes when there is an impacted shoulder.
2. Bassaw B, Roopnarinesingh S, Mohammed N, Ali A, Persad H. Shoulder dystocia: an obstetrical nightmare. West Indian Med J. 1992;41:158–159. 3. Gherman RB. Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol. 2002;45:345–362. 4. Niederhauser A, Magann EF, Mullin PM, Morrison JC. Resolution of infant shoulder dystocia with maternal spontaneous symphyseal separation: a case report. J Reprod Med. 2008;53:62–64. 5. Politi S, D emidio L, Cignini P, Giorlandino M, Giorlandino C. Shoulder dystocia: an evidence-based approach. J Prenat Med. 2010;4:35–42. 6. Ahmed S, Romejko-Wolniewicz E, Zare˛ba-Szczudlik J, Czajkowski K. Fetal macrosomia—an obstetrician's nightmare? Neuro Endocrinol Lett. 2012;33(2):149–155. 7. American College of Obstetricians and Gynecologists. Shoulder Dystocia. ACOG Practice Pattern No. 40. Washington, DC: ACOG;2002. 8. Chauhan SP, Chauhan VB, Cowan BD, Hendrix NW, Magann EF, Morrison JC. Professional liability claims and Central Association of Obstetricians and Gynecologists members: myth versus reality. Am J Obstet Gynecol. 2005;192:1820–1826; discussion 1826-1828. 9. Hoffman MK, Bailit JL, Branch DW, et al. Consortium on safe labor. A comparison of obstetric maneuvers for the acute management of shoulder dystocia. Obstet Gynecol. 2011;117:1272–1278. 10. Chauhan SP, Laye MR, LutgendorfM, et al., A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned. Am J Perinatol. 2013; [Epub ahead of print]. 11. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC. Brachial plexus injury: a 23-year experience from a tertiary center. Am J Obstet Gynecol. 2005;192:1795–1800 [discussion 1800-2]. 12. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205:513–517.
Suneet P. Chauhan, MD Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology UT Health Science Center at Houston Houston, TX
re fe r en ces http://dx.doi.org/10.1053/j.semperi.2014.04.001 0146-0005/& 2014 Published by Elsevier Inc. 1. Blickstein I, Lancet M. Shoulder dystocia—the obstetricianʼs nightmare. Harefuah. 1987;113:357–361.
