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morbidity
Robert B. Gherman, LCDR, MC, USNR, Joseph G. Ouzounian, MD,
and T. Murphy Goodwin, MD
Los Angeles, California
OBJECTIVE: We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery.
STUDY DESIGN: A retrospective review of 285 cases of shoulder dystocia that occurred between January
1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers
used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1)
those resolved with McRoberts maneuver, suprapubic pressure, or proctoepisiotomy or a combination of
these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm,
or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral
fracture, or fetal death caused by asphyxial complications.
RESULTS: The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%)
clavicular fractures, and 12 (4.2%) humeral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal
death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of
bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of
158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs
21/158, p = 0.1).
CONCLUSIONS: Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated
with an increased rate of bone fracture or brachial plexus injury. (Am J Obstet Gynecol 1998;178:1126-30.)
The anticipation of shoulder dystocia mandates a thorough prospective evaluation for fetal macrosomia, maternal diabetes mellitus, postterm pregnancy, prior shoulder
dystocia, and avoidance of prolonged second stage of
labor coupled with midpelvic operative delivery.1-5
Unfortunately, these associated risk factors lack both sensitivity and specificity.6 Shoulder dystocia remains an unpredictable occurrence, occurring in 0.2% to 2.1% of all
deliveries.7, 8
Because shoulder dystocia is an infrequent event, obstetricians have little opportunity to become comfortable
1126
(9.5%) clavicular fractures, and 12 (4.2%) humeral fractures. There were 46 cases of unilateral Erbs palsy, one
case of bilateral Erbs palsy, and one case of Klumpkes
palsy. Nearly two thirds of the nerve injuries (31 of 48,
64.6%) occurred in the right brachial plexus. None of
the neonates displayed evidence of other peripheral
nerve injury. One infant, delivered with use of a symphysiotomy after a failed Zavanelli maneuver, had evidence of hypoxic ischemic encephalopathy and a
markedly abnormal-appearing electroencephalogram
and died at age 3 months.
Sixteen cases of brachial plexus palsy had a concomitant bone fracture, with the clavicle (15/16, 94%) being
most commonly injured. A statistically significant increase in bone fracture was seen with increasing birth
weight (Table II), with 7 of 112 (6.3%) fetuses weighing
<4000 gm and 32 of 173 (18.5%) fetuses weighing >4000
gm (p = 0.003, odds ratio 0.29, 95% confidence interval
0.11 to 0.73) having bone fracture. When birth weight
rose above 4000 gm, statistically significant increases in
both clavicular and humeral fracture occurred (p = 0.02
and 0.05, respectively). However, no statistically significant increase in brachial plexus injury was noted with increasing birth weight. Nerve injury occurred in 14 of 112
(12.5%) fetuses weighing <4000 gm and in 34 of 173
(19.7%) weighing >4000 gm (p = 0.15).
Slightly more than 50% (158/285) of the shoulder dystocia cases were resolved with McRoberts maneuver, either alone or in combination with either suprapubic
pressure or proctoepisiotomy or both. In the remaining
cases (127/285, 44.6%), Woods maneuver, posterior
arm extraction, or Zavanelli maneuver was added to accomplish delivery. All maneuvers were associated with
fetal injury (Table III).
The overall incidence of fetal bone fracture was not increased with the addition of fetal manipulation: 21 of 127
June 1998
Am J Obstet Gynecol
Table II. Relationship of birth injury to birth weight in shoulder dystocia cases (n = 285)
Birth weight
No. of cases
Brachial plexus
Bone fracture
Clavicle
Humerus
<3000 gm
3000-3499 gm
3500-3999 gm
4000-4499 gm
4500 gm
3 (1.0%)
0
0
23 (8.1%)
3 (13.0%)
0
86 (30.2%)
11 (12.8%)
7 (8.1%)
6
1
118 (41.4%)
26 (22.0%)
17 (14.4%)
12
5
55 (19.3%)
8 (14.5%)
15 (27.3%)
9
6
Table III. Relationship of fetal injury to maneuver(s) used during alleviation of shoulder dystocia
Maneuver
No.
McRoberts*
112
McRoberts plus suprapubic pressure*
31
McRoberts plus suprapubic pressure plus proctoepisiotomy*
7
8
McRoberts plus proctoepisiotomy*
McRoberts plus Woods*
30
McRoberts plus Woods* plus proctoepisiotomy
8
McRoberts plus Woods plus posterior arm extraction*
27
McRoberts plus Woods plus posterior arm extraction*
16
plus proctoepisiotomy
McRoberts plus Woods plus posterior arm extraction
2
plus other*,
McRoberts plus posterior arm extraction*
31
McRoberts plus posterior arm extraction*
13
plus proctoepisiotomy
*Maneuver noted to have effect on delivery.
Includes one case of Zavanelli maneuver and one
Includes one neonatal death at age 3 months.
No.
injured
20 (17.9%)
7 (22.6%)
1 (14.3%)
0 (0%)
3 (10%)
3 (37.5%)
10 (37.0%)
8 (50%)
2 (100%)
14 (45.2%)
7 (53.9%)
Brachial
plexus
13 (11.6%)
7 (22.6%)
1 (14.3%)
0 (0%)
2 (6.7%)
2 (25%)
4 (14.8%)
5 (31.3%)
Clavicular
fracture
Humeral
fracture
12 (10.7%)
4 (12.9%)
1 (14.3%)
0 (0%)
2 (6.7%)
2 (25%)
1 (3.7%)
2 (12.5%)
1 (0.89%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
4 (14.8%)
2 (12.5%)
0 (0%)
0 (0%)
1 (50%)
9 (29%)
5 (38.5%)
1 (3.2%)
2 (15.4%)
2 (6.5%)
2 (15.4%)
No.
Estimated gestational age (wk)
Birth weight (gm)
Maternal weight (lb)
Epidural anesthetic
Diabetes
Instrumental delivery
Oxytocin use
Active phase (min)
Second stage (min)
Bone injury
Clavicle
Humerus
Persistence at 1 yr follow-up
No fetal manipulation
Fetal manipulation
21
38.5 5.7
4089.8 94.1
179.8 7.5
7
8
4
18
356.31 56.7
80.1 15.9
27
39.1 4.3
4198.3 70.8
181.4 6.5
6
9
4
12
344.5 49.9
88.6 17.5
9
1
1 (3.7%)
5
1
3 (14.3%)
Statistical significance
p = 0.64
p = 0.35
p = 0.87
p = 0.84
p = 0.34
p = 0.70
p = 0.56
p = 0.71
p = 0.73
p = 0.13
p = 0.4
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