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Prioritizing posterior arm delivery during severe shoulder dystocia
An extensive MEDLINE literature search from 1966 through March 2002 using the key words “ochronosis,” “vulva,” “vagina,” and “cervix” found no other cases. Cases of primary alkaptonuria may be suspected in infancy by the tendency for urine to darken on standing. If this is not seen, diagnosis is often delayed until discoloration of the sclera and/or ears becomes clinically apparent in early adulthood. Deposition of pigment may cause degenerative changes in cartilage, intervertebral discs, and other connective tissue leading to ochronotic arthritis. This typically involves the hips, knees, and shoulders. Limitation of motion and ankylosis of the lumbosacral spine are common late manifestations. Pigmented lesions in the vagina are rare, mandating biopsy to exclude highly lethal cases of vaginal melanoma, the second most common cause of primary vaginal cancer. Vaginal melanocytes and production of melanin pigmentation are both rare, occurring in one in 100 vaginectomy specimens and three in 100 autopsy cases, respectively.3,4 Benign blue nevi and melanosis are clinical manifestations of melanin pigmentation.5 Endometriosis may also cause bluish discoloration in the lower genital tract but is often suspected clinically based on gynecologic history and physical examination. This is the first documented case of vaginal ochronosis that
likely represents systemic deposition of benzoquinone acetic acid, as the patient has severe degenerative arthritis involving the hips, knees, and shoulders. Systemic diseases, like alkaptonuric ochronosis, that may cause pigmentation in the oral mucosa include Addison disease and Peutz-Jeghers syndrome. The pathophysiology that leads to oral mucosal pigmentation is unknown but may have implications for similar pigmentation in the genital tract mucosa. REFERENCES 1. Barnhill RL. Textbook of dermatopathology. New York: McGraw-Hill, 1998. 2. Gaines JJ. The pathology of alkaptonuric ochronosis. Hum Pathol 1989;20:40–6. 3. Batsakis JG, Dito WR. Primary malignant melanoma of the vagina. Obstet Gynecol 1962;20:109–11. 4. Nigogosyan G, De La Pava S, Pickren JW. Melanoblasts in vaginal mucosa: Origin for primary malignant melanoma. Cancer 1964;17:912–3. 5. Tobon H, Murphy AI. Benign blue nevus of the vagina. Cancer 1977;40:3174–6. Received January 31, 2002. Received in revised form June 15, 2002. Accepted June 27, 2002.
Prioritizing Posterior Arm Delivery During Severe Shoulder Dystocia
experienced a precipitous second stage of labor and severe shoulder dystocia. Attempts at the McRoberts maneuver with traction failed to deliver the fetus. In lieu of alternative maneuvers or continued attempts at traction, the posterior arm was delivered and the fetal trunk followed easily.
Sarah H. Poggi, MD, Catherine Y. Spong, MD, and Robert H. Allen, PhD
CONCLUSION: A geometric analysis reveals that using posterior arm delivery reduces the obstruction by more than a factor of two, relative to the McRoberts maneuver. We recommend earlier use of this maneuver during shoulder dystocia management. (Obstet Gynecol 2003;101: 1068 –72. © 2003 by The American College of Obstetricians and Gynecologists.)
Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC; Pregnancy and Perinatology Branch, Center for Research for Mothers and Children, National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland; and Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
BACKGROUND: Delivery of the posterior arm, or the Barnum maneuver, is at times used late in shoulder dystocia management algorithms, and is not often a first- or secondline management protocol. CASE: A multiparous, diabetic patient, who was morbidly obese and had a residual obstetric brachial plexus injury,
Address reprint requests to: Sarah H. Poggi, MD, Georgetown University Hospital, Department of Obstetrics and Gynecology, 3800 Reservoir Road, NW, 3PHC, Washington, DC 20007; E-mail: shp2 @gunet.georgetown.edu.
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Since Gonik et al1 popularized the McRoberts maneuver in the early 1980s, hip hyperflexion has become the de facto first maneuver for managing shoulder dystocia. The McRoberts maneuver is generally easy to perform with assistants and allows for atraumatic delivery about 40% of the time.2 Relative to the lithotomy position, the maneuver reduces the risk of mechanical injury for milder forms of shoulder dystocia.3 However, continued attempts at the McRoberts maneuver for more severe forms of shoulder dystocia are associated with increasing traction.3,4 Regardless of maternal delivery position, strong downward traction poses an increased risk of fetal
VOL. 101, NO. 5, PART 2, MAY 2003 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier.
0029-7844/03/$30.00 doi:10.1016/S0029-7844(02)02332-3
clavicular fracture and brachial plexus injury.5 When the McRoberts maneuver fails, management algorithms call for a number of alternative maneuvers, usually with a lower priority assigned to delivery of the posterior arm, especially in the United States. The purpose of this case report is to highlight the use of this maneuver early in the management of shoulder dystocia. CASE The patient was a 26-year-old multipara who presented at 394⁄7 weeks in early labor with ruptured membranes. The patient’s prenatal care was complicated by dietcontrolled gestational diabetes and morbid obesity (her weight at admission was 176 kg [388 lb]). Her obstetric history was remarkable for three uncomplicated spontaneous vaginal deliveries, with her largest infant weighing 3430 g (7 lb 9 oz). Notably, the patient had compromised function of her left arm secondary to a shoulder dystocia at the time of her own birth. The patient requested and received epidural anesthesia shortly after admission. The patient’s labor was short, such that her first stage lasted just over 2 hours and her second stage was precipitous, lasting less than 20 minutes. The head delivered spontaneously over an intact perineum and restituted to right occiput anterior. Three attempts at increasing traction on the fetal head failed to deliver the anterior shoulder. The second and third attempts were performed with the McRoberts maneuver employed. However, true hyperflexion of the hips could not be achieved because of soft tissue dystocia. A severe shoulder dystocia was diagnosed. Because of the patient’s size and soft tissue dystocia, suprapubic pressure was deemed impractical. The decision was made to deliver the posterior (right) arm. This was accomplished by inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest. The posterior shoulder delivered as a consequence, and the rest of the neonate was delivered easily after this maneuver. The total time on the perineum was about 60 seconds. The neonate weighed 3760 g (8 lb 1 oz) and had Apgar scores of 6 and 8 at 1 and 5 minutes, respectively. The baby was noted to have crepitus of the left clavicle, and a clavicular fracture was diagnosed. In addition, the infant initially had decreased movements of its left shoulder, but this resolved spontaneously within an hour. There were no other obstetric complications. COMMENT Shoulder dystocia is an underreported6 obstetric emergency when the bisacromial diameter aligns with and is obstructed by the anteroposterior diameter of the pelvic
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inlet. Although there are well-known risk factors for shoulder dystocia (such as the maternal obesity and diabetes in this case), these are not predictive; more importantly, their absence does not eliminate the risk of shoulder dystocia. As a result, every practicing clinician needs to be prepared with an algorithm for shoulder dystocia management. Although no one maneuver has been shown to be better than another, the McRoberts maneuver and traction are generally employed first. Although the maneuver does not change the dimensions of the pelvis, it does straighten the sacrum relative to the lumbar spine, with consequent cephalad rotation of 16° of the symphysis pubis.1 As shown in Figure 1, this rotation ideally raises the symphysis pubis 8.6% (or 0.9 cm for a 10.5-cm pelvic inlet) and moves the symphysis pubis in a cephalad direction 26.5% (or 2.8 cm for a 10.5-cm pelvic inlet). The degree of hyperflexion achieved is patient specific; obese patients, for example, will not be able to achieve ideal values. In many deliveries, this change in pelvic orientation enables the impacted shoulder to slip under the symphysis pubis. However, where the bisacromial diameter is more than 8.6% larger than the pelvic inlet, the McRoberts maneuver will not free the impacted shoulder, and may push the anterior shoulder back with the symphysis pubis. Continued attempts at the McRoberts maneuver during severe shoulder dystocia are often associated with increasing traction, which can lead to iatrogenic brachial plexus injury.3–5 First popularized by Barnum over half a century ago,7 posterior arm delivery is not generally used as a first-line maneuver today for several reasons. The maneuver is generally not practiced during routine deliveries used for shoulder dystocia drills (unlike the McRoberts maneuver or suprapubic pressure), posterior arm delivery has been associated with humeral fracture, and the Barnum maneuver involves fetal manipulation, which is thought to be more difficult to perform than maneuvers involving maternal manipulation. Because the maneuver is often used deep into a shoulder dystocia management plan, others have assumed that posterior arm delivery is associated with a higher rate of birth injury.2,8 In contrast, Baskett and Allen5 reported no neonatal injuries associated with posterior arm delivery when it was used as the sole shoulder dystocia maneuver. In addition, Adler and Patterson9 observed a 400% reduction in brachial plexus injuries during the 1940s and 1950s, when the Woods and Barnum maneuvers were the prevailing standard of care for shoulder dystocia management. The morbidity attributed to posterior arm delivery may in fact be due to the multiple failed attempts at delivery before its use (using other maneuvers) rather than the maneuver itself.
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Figure 1. Effect of McRoberts positioning relative to lithotomy. The patient’s legs have been hyperflexed by assistants. The 16° rotation for a 10.5-cm obstetric conjugate (ideally) moves the symphisis pubis 9 mm anteriorly and 28 mm in a cephalad direction. Poggi. Posterior Arm Delivery. Obstet Gynecol 2003. 1070
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OBSTETRICS & GYNECOLOGY
Figure 2. The effect of the Barnum maneuver in reducing the obstructing part of the fetal shoulder. The operator has already inserted a hand into the vagina and delivered the posterior arm by sweeping it across the fetal chest, and thus delivered the posterior shoulder as well. A 13-cm bisacromial diameter becomes an 11-cm axillo-acromial diameter upon delivery of the arm. Poggi. Posterior Arm Delivery. Obstet Gynecol 2003.
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As shown in Figure 2, posterior arm delivery effectively replaces the bisacromial diameter with the axilloacromial diameter. This change results in a reduction equivalent to the diameter of a term bicep (or about 2 cm for a 3.5-kg neonate). The maneuver will be effective in deliveries where the bisacromial diameter is up to 12.5 cm or more. The maneuver also provides access to the fetal arm, which can be used instead of the head for rotation and ultimate delivery.7 By using the arm rather than the head to manipulate the fetus, the risk of brachial plexus injury is reduced. Although easier to perform than posterior arm delivery, the McRoberts maneuver does require two assistants to achieve optimal hip hyperflexion, and it does rely on traction. Beyond that, its effectiveness for obese patients is limited because of soft tissue dystocia. The Barnum maneuver has the advantage of not requiring assistants, allowing for a near 20% reduction in shoulder diameter, and permitting better assessment of the degree of shoulder dystocia. If the arm delivers and the trunk still will not deliver or rotate, emergent techniques such as intentional clavicular fracture or excessive traction, cephalic replacement, and symphysiotomy become the only practical management options. Although humeral fracture has been associated with posterior arm delivery,2,8 this is usually after multiple maneuvers have failed, and may reflect the severity of the dystocia. When a primary maneuver is used, posterior arm delivery has not been associated with humeral fractures (or other trauma).5 Schwartz and Dixon10 describe better neonatal outcome with the Barnum maneuver, and O’Shaughnessy11 reports success with posterior arm delivery during severe dystocia when all other maneuvers have failed. The perception that the Barnum maneuver is associated with high neonatal morbidity2,8 needs to be reconsidered. Because of the reduced risk of brachial plexus injury and the dramatic benefit in reducing the shoulder diameter, we recommend prioritizing posterior
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arm delivery in dystocia management algorithms. Using the maneuver even as a first choice should not be considered unorthodox. REFERENCES 1. Gonik B, Stringer C, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol 1983;145:882–4. 2. McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynecol Obstet 1996;55:219–24. 3. Gonik B, Allen R, Sorab J. Objective evaluation of the shoulder dystocia phenomenon: Effect of pelvic orientation on force reduction. Obstet Gynecol 1989;74:44–8. 4. Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: An engineering study of clinician-applied forces. Obstet Gynecol 1991;77:352–5. 5. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol 1995;86:14–7. 6. Beall MH, Spong C, McKay J, Ross M. Objective definition of shoulder dystocia: A prospective evaluation. Am J Obstet Gynecol 1998;179:934–7. 7. Barnum CG. Dystocia due to the shoulders. Am J Obstet Gynecol 1945;50:439–42. 8. Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178:1126–30. 9. Adler J, Patterson RL. Erb’s palsy: Long term results of treatment in eighty-eight cases. J Bone Joint Surg 1967;49A:1052–74. 10. Schwartz B, Dixon D. Shoulder dystocia. Obstet Gynecol 1958;11:468–71. 11. O’Shaughnessy MJ. Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia. Obstet Gynecol 1997;89:139–41. Received April 16, 2002. Received in revised form June 14, 2002. Accepted June 27, 2002.
OBSTETRICS & GYNECOLOGY
likely represents systemic deposition of benzoquinone acetic acid, as the patient has severe degenerative arthritis involving the hips, knees, and shoulders. Systemic diseases, like alkaptonuric ochronosis, that may cause pigmentation in the oral mucosa include Addison disease and Peutz-Jeghers syndrome. The pathophysiology that leads to oral mucosal pigmentation is unknown but may have implications for similar pigmentation in the genital tract mucosa. REFERENCES 1. Barnhill RL. Textbook of dermatopathology. New York: McGraw-Hill, 1998. 2. Gaines JJ. The pathology of alkaptonuric ochronosis. Hum Pathol 1989;20:40–6. 3. Batsakis JG, Dito WR. Primary malignant melanoma of the vagina. Obstet Gynecol 1962;20:109–11. 4. Nigogosyan G, De La Pava S, Pickren JW. Melanoblasts in vaginal mucosa: Origin for primary malignant melanoma. Cancer 1964;17:912–3. 5. Tobon H, Murphy AI. Benign blue nevus of the vagina. Cancer 1977;40:3174–6. Received January 31, 2002. Received in revised form June 15, 2002. Accepted June 27, 2002.
Prioritizing Posterior Arm Delivery During Severe Shoulder Dystocia
experienced a precipitous second stage of labor and severe shoulder dystocia. Attempts at the McRoberts maneuver with traction failed to deliver the fetus. In lieu of alternative maneuvers or continued attempts at traction, the posterior arm was delivered and the fetal trunk followed easily.
Sarah H. Poggi, MD, Catherine Y. Spong, MD, and Robert H. Allen, PhD
CONCLUSION: A geometric analysis reveals that using posterior arm delivery reduces the obstruction by more than a factor of two, relative to the McRoberts maneuver. We recommend earlier use of this maneuver during shoulder dystocia management. (Obstet Gynecol 2003;101: 1068 –72. © 2003 by The American College of Obstetricians and Gynecologists.)
Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC; Pregnancy and Perinatology Branch, Center for Research for Mothers and Children, National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland; and Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
BACKGROUND: Delivery of the posterior arm, or the Barnum maneuver, is at times used late in shoulder dystocia management algorithms, and is not often a first- or secondline management protocol. CASE: A multiparous, diabetic patient, who was morbidly obese and had a residual obstetric brachial plexus injury,
Address reprint requests to: Sarah H. Poggi, MD, Georgetown University Hospital, Department of Obstetrics and Gynecology, 3800 Reservoir Road, NW, 3PHC, Washington, DC 20007; E-mail: shp2 @gunet.georgetown.edu.
1068
Since Gonik et al1 popularized the McRoberts maneuver in the early 1980s, hip hyperflexion has become the de facto first maneuver for managing shoulder dystocia. The McRoberts maneuver is generally easy to perform with assistants and allows for atraumatic delivery about 40% of the time.2 Relative to the lithotomy position, the maneuver reduces the risk of mechanical injury for milder forms of shoulder dystocia.3 However, continued attempts at the McRoberts maneuver for more severe forms of shoulder dystocia are associated with increasing traction.3,4 Regardless of maternal delivery position, strong downward traction poses an increased risk of fetal
VOL. 101, NO. 5, PART 2, MAY 2003 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier.
0029-7844/03/$30.00 doi:10.1016/S0029-7844(02)02332-3
clavicular fracture and brachial plexus injury.5 When the McRoberts maneuver fails, management algorithms call for a number of alternative maneuvers, usually with a lower priority assigned to delivery of the posterior arm, especially in the United States. The purpose of this case report is to highlight the use of this maneuver early in the management of shoulder dystocia. CASE The patient was a 26-year-old multipara who presented at 394⁄7 weeks in early labor with ruptured membranes. The patient’s prenatal care was complicated by dietcontrolled gestational diabetes and morbid obesity (her weight at admission was 176 kg [388 lb]). Her obstetric history was remarkable for three uncomplicated spontaneous vaginal deliveries, with her largest infant weighing 3430 g (7 lb 9 oz). Notably, the patient had compromised function of her left arm secondary to a shoulder dystocia at the time of her own birth. The patient requested and received epidural anesthesia shortly after admission. The patient’s labor was short, such that her first stage lasted just over 2 hours and her second stage was precipitous, lasting less than 20 minutes. The head delivered spontaneously over an intact perineum and restituted to right occiput anterior. Three attempts at increasing traction on the fetal head failed to deliver the anterior shoulder. The second and third attempts were performed with the McRoberts maneuver employed. However, true hyperflexion of the hips could not be achieved because of soft tissue dystocia. A severe shoulder dystocia was diagnosed. Because of the patient’s size and soft tissue dystocia, suprapubic pressure was deemed impractical. The decision was made to deliver the posterior (right) arm. This was accomplished by inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest. The posterior shoulder delivered as a consequence, and the rest of the neonate was delivered easily after this maneuver. The total time on the perineum was about 60 seconds. The neonate weighed 3760 g (8 lb 1 oz) and had Apgar scores of 6 and 8 at 1 and 5 minutes, respectively. The baby was noted to have crepitus of the left clavicle, and a clavicular fracture was diagnosed. In addition, the infant initially had decreased movements of its left shoulder, but this resolved spontaneously within an hour. There were no other obstetric complications. COMMENT Shoulder dystocia is an underreported6 obstetric emergency when the bisacromial diameter aligns with and is obstructed by the anteroposterior diameter of the pelvic
VOL. 101, NO. 5, PART 2, MAY 2003
inlet. Although there are well-known risk factors for shoulder dystocia (such as the maternal obesity and diabetes in this case), these are not predictive; more importantly, their absence does not eliminate the risk of shoulder dystocia. As a result, every practicing clinician needs to be prepared with an algorithm for shoulder dystocia management. Although no one maneuver has been shown to be better than another, the McRoberts maneuver and traction are generally employed first. Although the maneuver does not change the dimensions of the pelvis, it does straighten the sacrum relative to the lumbar spine, with consequent cephalad rotation of 16° of the symphysis pubis.1 As shown in Figure 1, this rotation ideally raises the symphysis pubis 8.6% (or 0.9 cm for a 10.5-cm pelvic inlet) and moves the symphysis pubis in a cephalad direction 26.5% (or 2.8 cm for a 10.5-cm pelvic inlet). The degree of hyperflexion achieved is patient specific; obese patients, for example, will not be able to achieve ideal values. In many deliveries, this change in pelvic orientation enables the impacted shoulder to slip under the symphysis pubis. However, where the bisacromial diameter is more than 8.6% larger than the pelvic inlet, the McRoberts maneuver will not free the impacted shoulder, and may push the anterior shoulder back with the symphysis pubis. Continued attempts at the McRoberts maneuver during severe shoulder dystocia are often associated with increasing traction, which can lead to iatrogenic brachial plexus injury.3–5 First popularized by Barnum over half a century ago,7 posterior arm delivery is not generally used as a first-line maneuver today for several reasons. The maneuver is generally not practiced during routine deliveries used for shoulder dystocia drills (unlike the McRoberts maneuver or suprapubic pressure), posterior arm delivery has been associated with humeral fracture, and the Barnum maneuver involves fetal manipulation, which is thought to be more difficult to perform than maneuvers involving maternal manipulation. Because the maneuver is often used deep into a shoulder dystocia management plan, others have assumed that posterior arm delivery is associated with a higher rate of birth injury.2,8 In contrast, Baskett and Allen5 reported no neonatal injuries associated with posterior arm delivery when it was used as the sole shoulder dystocia maneuver. In addition, Adler and Patterson9 observed a 400% reduction in brachial plexus injuries during the 1940s and 1950s, when the Woods and Barnum maneuvers were the prevailing standard of care for shoulder dystocia management. The morbidity attributed to posterior arm delivery may in fact be due to the multiple failed attempts at delivery before its use (using other maneuvers) rather than the maneuver itself.
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Figure 1. Effect of McRoberts positioning relative to lithotomy. The patient’s legs have been hyperflexed by assistants. The 16° rotation for a 10.5-cm obstetric conjugate (ideally) moves the symphisis pubis 9 mm anteriorly and 28 mm in a cephalad direction. Poggi. Posterior Arm Delivery. Obstet Gynecol 2003. 1070
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OBSTETRICS & GYNECOLOGY
Figure 2. The effect of the Barnum maneuver in reducing the obstructing part of the fetal shoulder. The operator has already inserted a hand into the vagina and delivered the posterior arm by sweeping it across the fetal chest, and thus delivered the posterior shoulder as well. A 13-cm bisacromial diameter becomes an 11-cm axillo-acromial diameter upon delivery of the arm. Poggi. Posterior Arm Delivery. Obstet Gynecol 2003.
VOL. 101, NO. 5, PART 2, MAY 2003
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As shown in Figure 2, posterior arm delivery effectively replaces the bisacromial diameter with the axilloacromial diameter. This change results in a reduction equivalent to the diameter of a term bicep (or about 2 cm for a 3.5-kg neonate). The maneuver will be effective in deliveries where the bisacromial diameter is up to 12.5 cm or more. The maneuver also provides access to the fetal arm, which can be used instead of the head for rotation and ultimate delivery.7 By using the arm rather than the head to manipulate the fetus, the risk of brachial plexus injury is reduced. Although easier to perform than posterior arm delivery, the McRoberts maneuver does require two assistants to achieve optimal hip hyperflexion, and it does rely on traction. Beyond that, its effectiveness for obese patients is limited because of soft tissue dystocia. The Barnum maneuver has the advantage of not requiring assistants, allowing for a near 20% reduction in shoulder diameter, and permitting better assessment of the degree of shoulder dystocia. If the arm delivers and the trunk still will not deliver or rotate, emergent techniques such as intentional clavicular fracture or excessive traction, cephalic replacement, and symphysiotomy become the only practical management options. Although humeral fracture has been associated with posterior arm delivery,2,8 this is usually after multiple maneuvers have failed, and may reflect the severity of the dystocia. When a primary maneuver is used, posterior arm delivery has not been associated with humeral fractures (or other trauma).5 Schwartz and Dixon10 describe better neonatal outcome with the Barnum maneuver, and O’Shaughnessy11 reports success with posterior arm delivery during severe dystocia when all other maneuvers have failed. The perception that the Barnum maneuver is associated with high neonatal morbidity2,8 needs to be reconsidered. Because of the reduced risk of brachial plexus injury and the dramatic benefit in reducing the shoulder diameter, we recommend prioritizing posterior
1072
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arm delivery in dystocia management algorithms. Using the maneuver even as a first choice should not be considered unorthodox. REFERENCES 1. Gonik B, Stringer C, Held B. An alternate maneuver for management of shoulder dystocia. Am J Obstet Gynecol 1983;145:882–4. 2. McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynecol Obstet 1996;55:219–24. 3. Gonik B, Allen R, Sorab J. Objective evaluation of the shoulder dystocia phenomenon: Effect of pelvic orientation on force reduction. Obstet Gynecol 1989;74:44–8. 4. Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: An engineering study of clinician-applied forces. Obstet Gynecol 1991;77:352–5. 5. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol 1995;86:14–7. 6. Beall MH, Spong C, McKay J, Ross M. Objective definition of shoulder dystocia: A prospective evaluation. Am J Obstet Gynecol 1998;179:934–7. 7. Barnum CG. Dystocia due to the shoulders. Am J Obstet Gynecol 1945;50:439–42. 8. Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178:1126–30. 9. Adler J, Patterson RL. Erb’s palsy: Long term results of treatment in eighty-eight cases. J Bone Joint Surg 1967;49A:1052–74. 10. Schwartz B, Dixon D. Shoulder dystocia. Obstet Gynecol 1958;11:468–71. 11. O’Shaughnessy MJ. Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia. Obstet Gynecol 1997;89:139–41. Received April 16, 2002. Received in revised form June 14, 2002. Accepted June 27, 2002.
OBSTETRICS & GYNECOLOGY