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Robert B. Gherman - One of the best experts on this subject based on the ideXlab platform.
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Shoulder Dystocia management and documentation
Seminars in Perinatology, 2014Co-Authors: Michael L Stitely, Robert B. GhermanAbstract:Shoulder Dystocia is an obstetric emergency that occurs when the fetal Shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing Shoulder Dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to Shoulder Dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency.
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Shoulder Dystocia the unpreventable obstetric emergency with empiric management guidelines
American Journal of Obstetrics and Gynecology, 2006Co-Authors: Robert B. Gherman, Suneet P. Chauhan, Joseph G. Ouzounian, Henry M Lerner, Bernard Gonik, Murphy T GoodwinAbstract:Objective Much of our understanding and knowledge of Shoulder Dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is Shoulder Dystocia predictable? (2) Can Shoulder dsytocia be prevented? (3) When Shoulder Dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of Shoulder Dystocia? Study design Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "Shoulder Dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion. Results There is a significantly increased risk of Shoulder Dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of Shoulder Dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of Shoulder Dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent Shoulder Dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of Shoulder Dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of Shoulder-Dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a Shoulder Dystocia event before any iatrogenic intervention may be associated with brachial plexus injury. Conclusion For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of Shoulder Dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by Shoulder Dystocia.
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Shoulder Dystocia: Prevention and Management
Obstetrics and Gynecology Clinics of North America, 2005Co-Authors: Robert B. GhermanAbstract:: Knowledge of the maneuvers used for the alleviation of Shoulder Dystocia is relevant not only for obstetric residents and attending house staff but also for family practitioners, nurses, and nurse midwives. The performance of Shoulder Dystocia "drills" can be helpful not only to coordinate a teamwork approach to this obstetric emergency but also to provide an opportunity to practice the maneuvers. Shoulder Dystocia continues to represent an immense area of clinical interest because it typically occurs without prediction. All patients in labor should be considered at risk for the development of Shoulder Dystocia.
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Shoulder Dystocia are historic risk factors reliable predictors
American Journal of Obstetrics and Gynecology, 2005Co-Authors: Joseph G. Ouzounian, Robert B. GhermanAbstract:Objective Our purpose was to determine the rate of associated risk factors for Shoulder Dystocia from a large cohort of patients delivered within our Southern California perinatal program. Study design A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without Shoulder Dystocia were identified from our computer-stored perinatal database and compared. Statistical methods used included: χ2 test, t test, calculation of odds ratios, and Fisher exact test, as indicated. Results Among the 267,228 vaginal births during the study period, there were 1,686 cases of Shoulder Dystocia (rate 0.6%). Rates for operative vaginal delivery, diabetes, epidural use, multiparity, and postdatism were similar among cases with and without Shoulder Dystocia. The clinical triad of oxytocin use, labor induction, and birth weight greater than 4,500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for Shoulder Dystocia, but its sensitivity and positive predictive value were only 12.4% and 3.4%, respectively. Conclusion Historic obstetric risk factors for Shoulder Dystocia are not useful predictors for the event. Furthermore, although Shoulder Dystocia was observed more frequently with increasing birth weight, current limitations in estimating birth weight antenatally with accuracy preclude its practical use as a reliable predictor.
Tim Draycott - One of the best experts on this subject based on the ideXlab platform.
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Shoulder Dystocia in Maternal Obesity
Maternal Obesity and Pregnancy, 2012Co-Authors: Polly Weston, Jo Crofts, Tim DraycottAbstract:Obesity increases all risks of adverse obstetric outcome including Shoulder Dystocia. Shoulder Dystocia is a serious complication of childbirth, defined as a vaginal cephalic delivery requiring additional obstetric manoeuvres to deliver the fetus after routine traction has failed. Case-control studies have demonstrated a higher prevalence of obesity in pregnancies affected by Shoulder Dystocia, but maternal obesity itself is not an independent risk factor for Shoulder Dystocia. There is a direct relationship between Shoulder Dystocia and birth weight once the fetal weight exceeds 4 kg. Maternal diabetes particularly with fetal macrosomia is one of the best available predictors of Shoulder Dystocia probably due to difference in the anthropomorphic makeup of the infant. When it does occur in the obese patient, the management of Shoulder Dystocia is far more challenging and manoeuvres may need to be adapted. Early results from the UK Obstetric Surveillance System (UKOSS) indicate elective Caesarean section for women with BMI exceeding 50 may prevent Shoulder Dystocia without affecting maternal outcomes.
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observations from 450 Shoulder Dystocia simulations lessons for skills training
Obstetrics & Gynecology, 2008Co-Authors: Joanna F Crofts, Denise Ellis, Catherine Winter, Kim Hinshaw, Tim DraycottAbstract:Poor neonatal outcomes after Shoulder Dystocia have been associated with inappropriate management. Until there are significant developments in the prediction and subsequent prevention of Shoulder Dystocia, improving Shoulder Dystocia management through practical training may be the most effective me
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improving neonatal outcome through practical Shoulder Dystocia training
Obstetrics & Gynecology, 2008Co-Authors: Tim Draycott, J F Crofts, Louise V Wilson, Elaine Yard, Thabani Sibanda, Andrew WhitelawAbstract:RESULTS: There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The Shoulder Dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P.813). After training was introduced, clinical management improved: McRoberts’ position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P.010). There was a significant reduction in neonatal injury at birth after Shoulder Dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11–0.57]). CONCLUSION: The introduction of Shoulder Dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by Shoulder Dystocia. (Obstet Gynecol 2008;112:14–20) LEVEL OF EVIDENCE: II
Robert J Sokol - One of the best experts on this subject based on the ideXlab platform.
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Shoulder Dystocia risk factors predictability and preventability
Seminars in Perinatology, 2014Co-Authors: Shobha H Mehta, Robert J SokolAbstract:Shoulder Dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe Shoulder Dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a Shoulder Dystocia, whose attendant morbidities are estimated to be at a rate as high as 16–48%. The study of Shoulder Dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of Shoulder Dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the Shoulder Dystocia itself, it is in the presence of an identified Shoulder Dystocia that occurrence of injury is most common. The majority of Shoulder Dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder Dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.
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Shoulder Dystocia and the next delivery outcomes and management
Journal of Maternal-fetal & Neonatal Medicine, 2007Co-Authors: Shobha H Mehta, Sean C Blackwell, Rati Chadha, Robert J SokolAbstract:Objective. To evaluate delivery mode management decisions and the rate of Shoulder Dystocia recurrence for women with a prior delivery complicated by Shoulder Dystocia.Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by Shoulder Dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of Shoulder Dystocia was calculated and the characteristics of these cases further described.Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 Shoulder Dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial Shoulder Dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subseque...
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is abnormal labor associated with Shoulder Dystocia in nulliparous women
American Journal of Obstetrics and Gynecology, 2004Co-Authors: Shobha H Mehta, Sean C Blackwell, Emmanuel Bujold, Yoram Sorokin, Robert J SokolAbstract:OBJECTIVE: This study was undertaken to examine the relationship between labor abnormalities and Shoulder Dystocia in nulliparous women. STUDY DESIGN: Nulliparous women whose delivery was complicated by Shoulder Dystocia were studied and compared with a control group selected based on the best possible match for race, labor type (spontaneous or induced), and birth weight. The duration of first and second stage of labor, as well as the rates of labor progress, were calculated and compared between groups. RESULTS: During this 4-year study period, there were 8010 nulliparous singleton deliveries of which 65 (0.8%) were complicated by Shoulder Dystocia. Compared with controls, there was no difference in the rate of cervical dilation in the active phase of the first stage of labor. In the Shoulder Dystocia group, more patients had a second stage of labor greater than 2 hours (22% vs 3%; P <.05) and had operative vaginal deliveries (26% vs 1.5%; P <.001). In Shoulder Dystocia cases with birth weight greater than 4000 g, 33% had a second stage of labor greater than 2 hours. CONCLUSION: In our population, the combination of fetal macrosomia, second stage of labor longer than 2 hours and the use of operative vaginal delivery were associated with Shoulder Dystocia in nulliparous women.
Joseph G. Ouzounian - One of the best experts on this subject based on the ideXlab platform.
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Shoulder Dystocia: Incidence and Risk Factors.
Clinical Obstetrics and Gynecology, 2016Co-Authors: Joseph G. OuzounianAbstract:: Shoulder Dystocia complicates ∼1% of vaginal births. Although fetal macrosomia and maternal diabetes are risk factors for Shoulder Dystocia, for the most part its occurrence remains largely unpredictable and unpreventable.
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Shoulder Dystocia the unpreventable obstetric emergency with empiric management guidelines
American Journal of Obstetrics and Gynecology, 2006Co-Authors: Robert B. Gherman, Suneet P. Chauhan, Joseph G. Ouzounian, Henry M Lerner, Bernard Gonik, Murphy T GoodwinAbstract:Objective Much of our understanding and knowledge of Shoulder Dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is Shoulder Dystocia predictable? (2) Can Shoulder dsytocia be prevented? (3) When Shoulder Dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of Shoulder Dystocia? Study design Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "Shoulder Dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion. Results There is a significantly increased risk of Shoulder Dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of Shoulder Dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of Shoulder Dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent Shoulder Dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of Shoulder Dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of Shoulder-Dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a Shoulder Dystocia event before any iatrogenic intervention may be associated with brachial plexus injury. Conclusion For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of Shoulder Dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by Shoulder Dystocia.
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Shoulder Dystocia are historic risk factors reliable predictors
American Journal of Obstetrics and Gynecology, 2005Co-Authors: Joseph G. Ouzounian, Robert B. GhermanAbstract:Objective Our purpose was to determine the rate of associated risk factors for Shoulder Dystocia from a large cohort of patients delivered within our Southern California perinatal program. Study design A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without Shoulder Dystocia were identified from our computer-stored perinatal database and compared. Statistical methods used included: χ2 test, t test, calculation of odds ratios, and Fisher exact test, as indicated. Results Among the 267,228 vaginal births during the study period, there were 1,686 cases of Shoulder Dystocia (rate 0.6%). Rates for operative vaginal delivery, diabetes, epidural use, multiparity, and postdatism were similar among cases with and without Shoulder Dystocia. The clinical triad of oxytocin use, labor induction, and birth weight greater than 4,500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0) for Shoulder Dystocia, but its sensitivity and positive predictive value were only 12.4% and 3.4%, respectively. Conclusion Historic obstetric risk factors for Shoulder Dystocia are not useful predictors for the event. Furthermore, although Shoulder Dystocia was observed more frequently with increasing birth weight, current limitations in estimating birth weight antenatally with accuracy preclude its practical use as a reliable predictor.
Shobha H Mehta - One of the best experts on this subject based on the ideXlab platform.
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Shoulder Dystocia risk factors predictability and preventability
Seminars in Perinatology, 2014Co-Authors: Shobha H Mehta, Robert J SokolAbstract:Shoulder Dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe Shoulder Dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a Shoulder Dystocia, whose attendant morbidities are estimated to be at a rate as high as 16–48%. The study of Shoulder Dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of Shoulder Dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the Shoulder Dystocia itself, it is in the presence of an identified Shoulder Dystocia that occurrence of injury is most common. The majority of Shoulder Dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder Dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.
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Shoulder Dystocia and the next delivery outcomes and management
Journal of Maternal-fetal & Neonatal Medicine, 2007Co-Authors: Shobha H Mehta, Sean C Blackwell, Rati Chadha, Robert J SokolAbstract:Objective. To evaluate delivery mode management decisions and the rate of Shoulder Dystocia recurrence for women with a prior delivery complicated by Shoulder Dystocia.Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by Shoulder Dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of Shoulder Dystocia was calculated and the characteristics of these cases further described.Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 Shoulder Dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial Shoulder Dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subseque...
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is abnormal labor associated with Shoulder Dystocia in nulliparous women
American Journal of Obstetrics and Gynecology, 2004Co-Authors: Shobha H Mehta, Sean C Blackwell, Emmanuel Bujold, Yoram Sorokin, Robert J SokolAbstract:OBJECTIVE: This study was undertaken to examine the relationship between labor abnormalities and Shoulder Dystocia in nulliparous women. STUDY DESIGN: Nulliparous women whose delivery was complicated by Shoulder Dystocia were studied and compared with a control group selected based on the best possible match for race, labor type (spontaneous or induced), and birth weight. The duration of first and second stage of labor, as well as the rates of labor progress, were calculated and compared between groups. RESULTS: During this 4-year study period, there were 8010 nulliparous singleton deliveries of which 65 (0.8%) were complicated by Shoulder Dystocia. Compared with controls, there was no difference in the rate of cervical dilation in the active phase of the first stage of labor. In the Shoulder Dystocia group, more patients had a second stage of labor greater than 2 hours (22% vs 3%; P <.05) and had operative vaginal deliveries (26% vs 1.5%; P <.001). In Shoulder Dystocia cases with birth weight greater than 4000 g, 33% had a second stage of labor greater than 2 hours. CONCLUSION: In our population, the combination of fetal macrosomia, second stage of labor longer than 2 hours and the use of operative vaginal delivery were associated with Shoulder Dystocia in nulliparous women.
