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Delivering Shoulders and Dealing With Shoulder Dystocia: Should the Standard of Care Change?
COMMENTARY
Delivering Shoulders and Dealing With Shoulder Dystocia: Should the Standard of Care Change? Savas Menticoglou, MDCM, FRCSC Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Manitoba, Winnipeg MB
Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;38(7):655-658
F
or a normal delivery, standard textbooks advise that after delivery of the baby’s head, gentle downward traction should be applied, with the head depressed towards the rectum to allow the anterior shoulder to deliver under the symphysis pubis.1e3
Authoritative national committees4,5 define shoulder dystocia as a cephalic delivery that requires additional obstetric manoeuvres to deliver the body after gentle downward traction on the baby’s head has failed to effect delivery of the shoulders. When shoulder dystocia is diagnosed, the standard management is similar to that proposed in the ALARM course manual6: A Ask for help L
Lift/hyperflex legs (McRoberts manoeuvre)
A Anterior shoulder disimpaction (suprapubic pressure and/or Rubin manoeuvre) R Rotation of the posterior shoulder M Manual removal of the posterior arm E Episiotomy R Roll over on to “all fours” Key Words: Brachial plexus injury, shoulder dystocia, posterior axillary traction, McRoberts manoeuvre Competing interests: None declared. Received on February 17, 2016 Accepted on March 29, 2016 http://dx.doi.org/10.1016/j.jogc.2016.03.012
I contend in this commentary that (1) the way doctors have been taught to deliver the shoulders is wrong, (2) the definition of shoulder dystocia should be changed, and (3) the standard management of shoulder dystocia should be reconsidered. The practice of any traction on the baby’s headdgentle or not, axial or downwarddis unnecessary and potentially harmful. There should never be any traction on the baby’s head. There are two contentious issues with respect to obstetrical brachial plexus injury: first, many cases occur in the absence of described shoulder dystocia, and second, even when shoulder dystocia is described, the delivering obstetrician or midwife often asserts that no undue traction was used to deliver the shoulders. If the brachial plexus injury is permanent, the imputation is often made that shoulder dystocia must have been present, but was not reported, and that more-than-gentle downward traction must have been used. Many brachial plexus injuries occur without the recognition of shoulder dystocia. In one series of 1611 brachial plexus injuries in California, half occurred in the absence of recognized shoulder dystocia.7 In a series from Saudi Arabia, one third of 751 cases occurred in the absence of shoulder dystocia or perceived difficulty.8 It is possible that sometimes not mentioning suspected shoulder dystocia is a deliberate omission of documentation by the obstetrician in order to have the defense that it was perhaps a non-iatrogenic injury. However, more often, it is likely a case in which the usual method of delivery of the shoulders was successful and shoulder dystocia was not appreciated. For example, if one requires (as the standard definitions do4,5) that the diagnosis of shoulder dystocia be made only after the use of gentle downward traction has failed to deliver the anterior shoulder, then the diagnosis will not be made if the anterior shoulder is delivered JULY JOGC JUILLET 2016
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with perceived gentle downward traction, but the brachial plexus could nevertheless be injured. This has happened in my practice. When shoulder dystocia is recognized because the use of gentle downward traction has failed to deliver the shoulders and other manoeuvres have been necessary to complete the delivery, the obstetrician will be accused of not using “gentle traction” if a subsequent brachial plexus injury is noted. What I believe is happening in some cases is that the usual downward traction used in the course of non-shoulder dystocia cases may, in cases of true shoulder dystocia, be enough to damage the nerves. After the baby’s head is delivered and external restitution has taken place, the standard textbook teaching is to place one’s hands on either side of the head and ask the woman to push and to guide the anterior shoulder under the symphysis while she pushes.1e3 There is always an element of traction in this. If there is no shoulder dystocia (i.e., no impediment to the anterior shoulder sliding under the symphysis), then “usual” traction will not cause stretching of the brachial plexus. The obstetrician becomes accustomed to applying downward traction for all deliveries as a matter of course, and in most cases in which there is no mechanical impediment, no harm is done. However, in cases in which the anterior shoulder is or could potentially be caught behind the symphysis pubis, a degree of downward traction that does not seem unusual for the obstetrician may transiently stretch the neck and damage the nerves. I think this is one explanation in cases of brachial plexus injury in which the obstetrician truthfully declares that he or she did not apply any more traction than in numerous previous deliveries without shoulder dystocia. The other possible explanation is that in cases in which shoulder dystocia is recognized, the sense of urgency that is created may lead the obstetrician to apply more traction than he or she thinks is applied. It has been well documented that obstetricians have difficulty gauging the force with which they pull.9,10 If these speculations are correct, what are the implications for practice? One is that obstetricians have been delivering babies the wrong way for many years. After a mother has pushed the head out, the idea that the obstetrician or the midwife must put their hands on the head to help guide the shoulders out is wrong. If the mother has been able to push the head out spontaneously or with the aid of a vacuum, and if there is no shoulder dystocia, then almost invariably she can push the shoulders out as well. I have now adopted the practice of waiting, after the head has been delivered, until the next contraction, and when that contraction comes, exhorting the mother to push the
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shoulders out by herself. This usually takes one good push, but it may sometimes take three or four pushes during the contraction for the anterior shoulder to emerge under the symphysis. Waiting for two or three minutes with the head already delivered is unnerving for observers who are not used to it, but it causes no harm if the baby has been in good condition before delivery of the head.11,12 If an operative vaginal delivery for profound bradycardia has lasted several minutes or if there has been an umbilical cord prolapse or major placental abruption, then waiting another two or three minutes would be detrimental; however, such cases would be exceptional. In these cases the mother should be encouraged to continue pushing to expel the shoulders, and if this is unsuccessful, the obstetrician should immediately deliver the posterior arm. The concept of waiting for shoulders to deliver with maternal effort alone has been espoused for some time by some midwives11,13,14 and by some obstetricians.15 If neither shoulder delivers after two or three minutes despite good maternal pushing efforts during the next contraction, then the diagnosis of shoulder dystocia can be made. Standard practice in this setting is to ask for help and to use the McRoberts manoeuvre and try to disimpact the anterior shoulder. In the McRoberts manoeuvre the patient’s thighs are flexed against the abdomen, supposedly allowing the symphysis pubis to slide over the anterior shoulder or the posterior shoulder to descend farther in the sacral concavity. Unfortunately, the McRoberts manoeuvre is usually followed (after flexion of the hips) by another attempt at traction on the head, again with the potential to damage the brachial plexus. The McRoberts positiond flexing the hips without tractiondis often useful; the McRoberts manoeuvre, with added downward traction on the head, may not be. It is the same with disimpacting the anterior shoulder, either with suprapubic pressure or with a Rubin’s manoeuvre. More downward traction is invariably applied during or after the manoeuvre. Once shoulder dystocia is diagnosed, the approach that I believe is best is to proceed with delivery of the posterior arm or shoulder. I believe that the best course is to insert one’s dominant hand into the hollow of the sacrum, either along the back or the chest of the baby, and feel for the posterior axilla. Then, using one’s fingers, possibly with the assistance of the fingers of the other hand, the posterior shoulder is pulled along the sacral concavity and gradually brought out. The usual advice (to insert one’s hand along the ventral surface of the baby, find the posterior forearm, and then pull the arm out6) often fails because the posterior arm may be extended or lying under the baby’s body.
Delivering Shoulders and Dealing With Shoulder Dystocia: Should the Standard of Care Change?
Instead, the posterior shoulder is delivered first, not the posterior arm. This was the teaching of Louise Bourgeois, a 17th century French midwife.16 Posterior axillary traction17,18 almost always works and has been the preferred method at my hospital for approximately a decade. In extreme cases, one team has described looping a plastic catheter in the axilla and using it to pull out the posterior shoulder.19 In my experience, posterior axillary traction leads to an approximately one in four chance of fracturing the humerus, but humeral fractures always heal without permanent injury. In my experience, again, many cases of permanent brachial plexus injury go to litigation, but I have never been aware of a lawsuit for a broken humerus. Third- and fourth-degree tears are also common, but these can be repaired. An avulsion of the baby’s cervical nerve roots cannot be fixed satisfactorily; a permanent handicap results. Parents can forgive a broken humerus, but it is much more difficult to forgive a useless arm. Posterior axillary traction will only be effective if the posterior shoulder is accessible and is not held up by the sacral promontory. If neither shoulder has entered the pelvis, I usually resort to the Jacquemier manoeuvre20 or symphysiotomy.21 I do not believe that the head should be touched at all after it has delivered. At most, one could place the index and middle fingers on the baby’s anterior jaw to direct the head downwards in the axis of the pelvis while the woman pushes. The temptation to place one’s hands on the sides of the head must be absolutely resisted to prevent the head from being pulled down unconsciously. One should patiently wait for the next contraction while, metaphorically, sitting on one’s hands. 22
Many years ago Crothers and Putnam wrote : .traction upon a part of the foetus already delivered against the resistance of the part still within the birth canal is an entirely unphysiological procedure.. The most fragile and least elastic structures are the spinal cord, the membranes protecting it and the nerves issuing from it. As the force imposed is entirely under the control of the operator, it is incumbent upon him to realize that he is exerting it upon the nervous system and the membranes covering it.. If no adequate warning is given by teachers that traction is dangerous, the individual practitioner cannot be blamed if he uses it to the detriment of the babies he delivers.
My views can be summarized as follows: 1. After the head delivers, do not touch the head at all. This avoids the possibility of inadvertently pulling it down. There should be no traction on the baby’s head. 2. Wait for the next contraction, then ask the mother to push the shoulders out herself. There should be no traction on the baby’s head. 3. If the mother cannot push the shoulders out herself, then shoulder dystocia is diagnosed. 4. McRoberts position (flexed hips without traction) is acceptable; McRoberts manoeuvre (flexed hips with traction) is not. 5. The first manoeuvre to resolve shoulder dystocia is delivery of the posterior arm or shoulder. 6. If one cannot reach the posterior forearm, use posterior axillary traction to deliver the posterior shoulder. 7. If the posterior shoulder is inaccessible (in other words, if neither shoulder is in the pelvis), proceed immediately to Jacquemier’s manoeuvre or symphysiotomy. 8. The standard of care,1e3 which permits “gentle downward traction” to deliver the baby’s head and which considers shoulder dystocia to be present only after the use of such traction has failed to deliver the head,4,5 should be changed. There should not be any traction at all applied to the baby’s head.
REFERENCES 1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams obstetrics. ed 23. New York: McGraw-Hill; 2010. p. 396. 2. Marshall JE, Raynor MD, editors. Myles textbook for midwives. ed 16. Edinburgh, Scotland: Churchill Livingstone; 2014. p. 378e80. 3. Posner GD, Dy J, Black A, Jones GD. Oxorn-Foote human labor & birth. ed 6. New York: McGraw-Hill; 2013. p. 279e80. 4. Sokol RJ, Blackwell SC, American College of Obstetricians and Gynecologists, Committee on Practice Bulletins-Gynecology. ACOG practice bulletin: shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). Int J Gynaecol Obstet 2003;80:87e92. 5. Royal College of Obstetricians and Gynaecologists. Shoulder dystocia. Green-top guideline No. 42. ed 2. Royal College of Obstetricians and Gynaecologists; 2012. Available at:. https://www.rcog.org.uk/globalassets/ documents/guidelines/gtg42_25112013.pdf. Accessed on April 28, 2016. 6. Society of Obstetricians and Gynaecologists of Canada. ALARM manual, ed 22. 7. Gilbert WM, Nesbitt TS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 1999;93:536e40. 8. El-Sayed AA. Obstetric brachial plexus palsy following routine versus difficult deliveries. J Child Neurol 2013;29:920e3. 9. Allen RH, Bankoski BR, Butzin CA, Nagey DA. Comparing clinicianapplied loads for routine, difficult, and shoulder dystocia deliveries. Am J Obstet Gynecol 1994;171:1621e7.
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10. Crofts JF, Ellis D, James M, Hunt LP, Fox R, Draycott TJ. Pattern and degree of forces applied during simulation of shoulder dystocia. Am J Obstet Gynecol 2007;197:156.e1e6. 11. Kotaska A, Campbell K. Two-step delivery may avoid shoulder dystocia: head-to-body delivery interval is less important than we think. J Obstet Gynecol Can 2014;36:716e20. 12. Locatelli A, Incerti M, Ghidini A, Longoni A, Casarico G, Ferrini S, et al. Head-to-body delivery interval using ‘two-step’ approach in vaginal deliveries: effect on umbilical artery pH. J Matern Fetal Neonatal Med 2011;24:799e803. 13. Hart G. Waiting for shoulders. Midwifery Today Childbirth Educ 1997;42:32e4. 14. Mortimore VR, McNabb M. A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders. Midwifery 1998;14:162e73.
naiz [Various observations on sterility, childloss, fertility, childbirth, and diseases of women, infants, and newborns]. Paris: A Sougrain; 1617. p. 90. 17. Schramm M. Impacted shouldersda personal experience. Aust N Z J Obstet Gynaecol 1983;23:28e31. 18. Menticoglou SM. A modified technique to deliver the posterior arm in severe shoulder dystocia. Obstet Gynecol 2006;108(3 Pt 2):755e7. 19. 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 Obset Gynecol 2015;212:784.e1e7. 20. Schaal JP, Riethmuller D, Maillet R, Uzan M. Mécanique et techniques obstétricales [Obstetrical mechanisms and techniques]. ed 3. Montpellier, France: Sauramps Médical; 2007. p. 523e4.
15. Iffy L, Ganesh V, Gittens L. Obstetric maneuvers for shoulder dystocia. Am J Obstet Gynecol 1998;179:1379e80.
21. Reid PC, Osuagwu FI. Symphysiotomy in shoulder dystocia. J Obstet Gynaecol 1999;19:664e6.
16. Bourgeois L. Observations diverses, sur la sterilité, perte de fruict, foecondité, accouchements, et maladies des femmes, et infants nouveaux
22. Crothers B, Putnam MC. Obstetrical injuries of the spinal cord. Medicine 1927;6:41e126.
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Delivering Shoulders and Dealing With Shoulder Dystocia: Should the Standard of Care Change? Savas Menticoglou, MDCM, FRCSC Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Manitoba, Winnipeg MB
Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;38(7):655-658
F
or a normal delivery, standard textbooks advise that after delivery of the baby’s head, gentle downward traction should be applied, with the head depressed towards the rectum to allow the anterior shoulder to deliver under the symphysis pubis.1e3
Authoritative national committees4,5 define shoulder dystocia as a cephalic delivery that requires additional obstetric manoeuvres to deliver the body after gentle downward traction on the baby’s head has failed to effect delivery of the shoulders. When shoulder dystocia is diagnosed, the standard management is similar to that proposed in the ALARM course manual6: A Ask for help L
Lift/hyperflex legs (McRoberts manoeuvre)
A Anterior shoulder disimpaction (suprapubic pressure and/or Rubin manoeuvre) R Rotation of the posterior shoulder M Manual removal of the posterior arm E Episiotomy R Roll over on to “all fours” Key Words: Brachial plexus injury, shoulder dystocia, posterior axillary traction, McRoberts manoeuvre Competing interests: None declared. Received on February 17, 2016 Accepted on March 29, 2016 http://dx.doi.org/10.1016/j.jogc.2016.03.012
I contend in this commentary that (1) the way doctors have been taught to deliver the shoulders is wrong, (2) the definition of shoulder dystocia should be changed, and (3) the standard management of shoulder dystocia should be reconsidered. The practice of any traction on the baby’s headdgentle or not, axial or downwarddis unnecessary and potentially harmful. There should never be any traction on the baby’s head. There are two contentious issues with respect to obstetrical brachial plexus injury: first, many cases occur in the absence of described shoulder dystocia, and second, even when shoulder dystocia is described, the delivering obstetrician or midwife often asserts that no undue traction was used to deliver the shoulders. If the brachial plexus injury is permanent, the imputation is often made that shoulder dystocia must have been present, but was not reported, and that more-than-gentle downward traction must have been used. Many brachial plexus injuries occur without the recognition of shoulder dystocia. In one series of 1611 brachial plexus injuries in California, half occurred in the absence of recognized shoulder dystocia.7 In a series from Saudi Arabia, one third of 751 cases occurred in the absence of shoulder dystocia or perceived difficulty.8 It is possible that sometimes not mentioning suspected shoulder dystocia is a deliberate omission of documentation by the obstetrician in order to have the defense that it was perhaps a non-iatrogenic injury. However, more often, it is likely a case in which the usual method of delivery of the shoulders was successful and shoulder dystocia was not appreciated. For example, if one requires (as the standard definitions do4,5) that the diagnosis of shoulder dystocia be made only after the use of gentle downward traction has failed to deliver the anterior shoulder, then the diagnosis will not be made if the anterior shoulder is delivered JULY JOGC JUILLET 2016
l
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COMMENTARY
with perceived gentle downward traction, but the brachial plexus could nevertheless be injured. This has happened in my practice. When shoulder dystocia is recognized because the use of gentle downward traction has failed to deliver the shoulders and other manoeuvres have been necessary to complete the delivery, the obstetrician will be accused of not using “gentle traction” if a subsequent brachial plexus injury is noted. What I believe is happening in some cases is that the usual downward traction used in the course of non-shoulder dystocia cases may, in cases of true shoulder dystocia, be enough to damage the nerves. After the baby’s head is delivered and external restitution has taken place, the standard textbook teaching is to place one’s hands on either side of the head and ask the woman to push and to guide the anterior shoulder under the symphysis while she pushes.1e3 There is always an element of traction in this. If there is no shoulder dystocia (i.e., no impediment to the anterior shoulder sliding under the symphysis), then “usual” traction will not cause stretching of the brachial plexus. The obstetrician becomes accustomed to applying downward traction for all deliveries as a matter of course, and in most cases in which there is no mechanical impediment, no harm is done. However, in cases in which the anterior shoulder is or could potentially be caught behind the symphysis pubis, a degree of downward traction that does not seem unusual for the obstetrician may transiently stretch the neck and damage the nerves. I think this is one explanation in cases of brachial plexus injury in which the obstetrician truthfully declares that he or she did not apply any more traction than in numerous previous deliveries without shoulder dystocia. The other possible explanation is that in cases in which shoulder dystocia is recognized, the sense of urgency that is created may lead the obstetrician to apply more traction than he or she thinks is applied. It has been well documented that obstetricians have difficulty gauging the force with which they pull.9,10 If these speculations are correct, what are the implications for practice? One is that obstetricians have been delivering babies the wrong way for many years. After a mother has pushed the head out, the idea that the obstetrician or the midwife must put their hands on the head to help guide the shoulders out is wrong. If the mother has been able to push the head out spontaneously or with the aid of a vacuum, and if there is no shoulder dystocia, then almost invariably she can push the shoulders out as well. I have now adopted the practice of waiting, after the head has been delivered, until the next contraction, and when that contraction comes, exhorting the mother to push the
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shoulders out by herself. This usually takes one good push, but it may sometimes take three or four pushes during the contraction for the anterior shoulder to emerge under the symphysis. Waiting for two or three minutes with the head already delivered is unnerving for observers who are not used to it, but it causes no harm if the baby has been in good condition before delivery of the head.11,12 If an operative vaginal delivery for profound bradycardia has lasted several minutes or if there has been an umbilical cord prolapse or major placental abruption, then waiting another two or three minutes would be detrimental; however, such cases would be exceptional. In these cases the mother should be encouraged to continue pushing to expel the shoulders, and if this is unsuccessful, the obstetrician should immediately deliver the posterior arm. The concept of waiting for shoulders to deliver with maternal effort alone has been espoused for some time by some midwives11,13,14 and by some obstetricians.15 If neither shoulder delivers after two or three minutes despite good maternal pushing efforts during the next contraction, then the diagnosis of shoulder dystocia can be made. Standard practice in this setting is to ask for help and to use the McRoberts manoeuvre and try to disimpact the anterior shoulder. In the McRoberts manoeuvre the patient’s thighs are flexed against the abdomen, supposedly allowing the symphysis pubis to slide over the anterior shoulder or the posterior shoulder to descend farther in the sacral concavity. Unfortunately, the McRoberts manoeuvre is usually followed (after flexion of the hips) by another attempt at traction on the head, again with the potential to damage the brachial plexus. The McRoberts positiond flexing the hips without tractiondis often useful; the McRoberts manoeuvre, with added downward traction on the head, may not be. It is the same with disimpacting the anterior shoulder, either with suprapubic pressure or with a Rubin’s manoeuvre. More downward traction is invariably applied during or after the manoeuvre. Once shoulder dystocia is diagnosed, the approach that I believe is best is to proceed with delivery of the posterior arm or shoulder. I believe that the best course is to insert one’s dominant hand into the hollow of the sacrum, either along the back or the chest of the baby, and feel for the posterior axilla. Then, using one’s fingers, possibly with the assistance of the fingers of the other hand, the posterior shoulder is pulled along the sacral concavity and gradually brought out. The usual advice (to insert one’s hand along the ventral surface of the baby, find the posterior forearm, and then pull the arm out6) often fails because the posterior arm may be extended or lying under the baby’s body.
Delivering Shoulders and Dealing With Shoulder Dystocia: Should the Standard of Care Change?
Instead, the posterior shoulder is delivered first, not the posterior arm. This was the teaching of Louise Bourgeois, a 17th century French midwife.16 Posterior axillary traction17,18 almost always works and has been the preferred method at my hospital for approximately a decade. In extreme cases, one team has described looping a plastic catheter in the axilla and using it to pull out the posterior shoulder.19 In my experience, posterior axillary traction leads to an approximately one in four chance of fracturing the humerus, but humeral fractures always heal without permanent injury. In my experience, again, many cases of permanent brachial plexus injury go to litigation, but I have never been aware of a lawsuit for a broken humerus. Third- and fourth-degree tears are also common, but these can be repaired. An avulsion of the baby’s cervical nerve roots cannot be fixed satisfactorily; a permanent handicap results. Parents can forgive a broken humerus, but it is much more difficult to forgive a useless arm. Posterior axillary traction will only be effective if the posterior shoulder is accessible and is not held up by the sacral promontory. If neither shoulder has entered the pelvis, I usually resort to the Jacquemier manoeuvre20 or symphysiotomy.21 I do not believe that the head should be touched at all after it has delivered. At most, one could place the index and middle fingers on the baby’s anterior jaw to direct the head downwards in the axis of the pelvis while the woman pushes. The temptation to place one’s hands on the sides of the head must be absolutely resisted to prevent the head from being pulled down unconsciously. One should patiently wait for the next contraction while, metaphorically, sitting on one’s hands. 22
Many years ago Crothers and Putnam wrote : .traction upon a part of the foetus already delivered against the resistance of the part still within the birth canal is an entirely unphysiological procedure.. The most fragile and least elastic structures are the spinal cord, the membranes protecting it and the nerves issuing from it. As the force imposed is entirely under the control of the operator, it is incumbent upon him to realize that he is exerting it upon the nervous system and the membranes covering it.. If no adequate warning is given by teachers that traction is dangerous, the individual practitioner cannot be blamed if he uses it to the detriment of the babies he delivers.
My views can be summarized as follows: 1. After the head delivers, do not touch the head at all. This avoids the possibility of inadvertently pulling it down. There should be no traction on the baby’s head. 2. Wait for the next contraction, then ask the mother to push the shoulders out herself. There should be no traction on the baby’s head. 3. If the mother cannot push the shoulders out herself, then shoulder dystocia is diagnosed. 4. McRoberts position (flexed hips without traction) is acceptable; McRoberts manoeuvre (flexed hips with traction) is not. 5. The first manoeuvre to resolve shoulder dystocia is delivery of the posterior arm or shoulder. 6. If one cannot reach the posterior forearm, use posterior axillary traction to deliver the posterior shoulder. 7. If the posterior shoulder is inaccessible (in other words, if neither shoulder is in the pelvis), proceed immediately to Jacquemier’s manoeuvre or symphysiotomy. 8. The standard of care,1e3 which permits “gentle downward traction” to deliver the baby’s head and which considers shoulder dystocia to be present only after the use of such traction has failed to deliver the head,4,5 should be changed. There should not be any traction at all applied to the baby’s head.
REFERENCES 1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams obstetrics. ed 23. New York: McGraw-Hill; 2010. p. 396. 2. Marshall JE, Raynor MD, editors. Myles textbook for midwives. ed 16. Edinburgh, Scotland: Churchill Livingstone; 2014. p. 378e80. 3. Posner GD, Dy J, Black A, Jones GD. Oxorn-Foote human labor & birth. ed 6. New York: McGraw-Hill; 2013. p. 279e80. 4. Sokol RJ, Blackwell SC, American College of Obstetricians and Gynecologists, Committee on Practice Bulletins-Gynecology. ACOG practice bulletin: shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). Int J Gynaecol Obstet 2003;80:87e92. 5. Royal College of Obstetricians and Gynaecologists. Shoulder dystocia. Green-top guideline No. 42. ed 2. Royal College of Obstetricians and Gynaecologists; 2012. Available at:. https://www.rcog.org.uk/globalassets/ documents/guidelines/gtg42_25112013.pdf. Accessed on April 28, 2016. 6. Society of Obstetricians and Gynaecologists of Canada. ALARM manual, ed 22. 7. Gilbert WM, Nesbitt TS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 1999;93:536e40. 8. El-Sayed AA. Obstetric brachial plexus palsy following routine versus difficult deliveries. J Child Neurol 2013;29:920e3. 9. Allen RH, Bankoski BR, Butzin CA, Nagey DA. Comparing clinicianapplied loads for routine, difficult, and shoulder dystocia deliveries. Am J Obstet Gynecol 1994;171:1621e7.
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10. Crofts JF, Ellis D, James M, Hunt LP, Fox R, Draycott TJ. Pattern and degree of forces applied during simulation of shoulder dystocia. Am J Obstet Gynecol 2007;197:156.e1e6. 11. Kotaska A, Campbell K. Two-step delivery may avoid shoulder dystocia: head-to-body delivery interval is less important than we think. J Obstet Gynecol Can 2014;36:716e20. 12. Locatelli A, Incerti M, Ghidini A, Longoni A, Casarico G, Ferrini S, et al. Head-to-body delivery interval using ‘two-step’ approach in vaginal deliveries: effect on umbilical artery pH. J Matern Fetal Neonatal Med 2011;24:799e803. 13. Hart G. Waiting for shoulders. Midwifery Today Childbirth Educ 1997;42:32e4. 14. Mortimore VR, McNabb M. A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders. Midwifery 1998;14:162e73.
naiz [Various observations on sterility, childloss, fertility, childbirth, and diseases of women, infants, and newborns]. Paris: A Sougrain; 1617. p. 90. 17. Schramm M. Impacted shouldersda personal experience. Aust N Z J Obstet Gynaecol 1983;23:28e31. 18. Menticoglou SM. A modified technique to deliver the posterior arm in severe shoulder dystocia. Obstet Gynecol 2006;108(3 Pt 2):755e7. 19. 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 Obset Gynecol 2015;212:784.e1e7. 20. Schaal JP, Riethmuller D, Maillet R, Uzan M. Mécanique et techniques obstétricales [Obstetrical mechanisms and techniques]. ed 3. Montpellier, France: Sauramps Médical; 2007. p. 523e4.
15. Iffy L, Ganesh V, Gittens L. Obstetric maneuvers for shoulder dystocia. Am J Obstet Gynecol 1998;179:1379e80.
21. Reid PC, Osuagwu FI. Symphysiotomy in shoulder dystocia. J Obstet Gynaecol 1999;19:664e6.
16. Bourgeois L. Observations diverses, sur la sterilité, perte de fruict, foecondité, accouchements, et maladies des femmes, et infants nouveaux
22. Crothers B, Putnam MC. Obstetrical injuries of the spinal cord. Medicine 1927;6:41e126.
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