One of these studies retrospectively compared the management and neonatal outcomes of almost 20,000 births that were complicated by shoulder dystocia in the years before and after the introduction of shoulder dystocia training for all maternity staff in a hospital in the United Kingdom (Obstet. Gynecol. 2008;112:14-20). The rate of brachial plexus injury at birth was significantly reduced, from 7.4% to 2.3%, as was the rate of neonatal injury more broadly (from 9.3% to 2.3%).
In the other study – also a retrospective assessment – the rate of obstetric brachial plexus injury in cases of shoulder dystocia fell from 30% before a training protocol was implemented for maternity staff at Jamaica Hospital in New York, to 11% afterward (Am. J. Obstet. Gynecol. 2011;204:322.e1-6).
A recently published study from Ireland, however, failed to reveal any difference in the frequency of brachial plexus injury after the introduction of specific staff training in managing shoulder dystocia. In this single-hospital study, investigators assessed outcomes associated with more than 77,000 deliveries that occurred during two 5-year time periods, before and after training was instituted. The incidence of brachial plexus injury remained unchanged from 1.5 per 1,000 in 1994-1998 to 1.7 per 1,000 in 2004-2008 (Am. J. Obstet. Gynecol. 2011;204:324.e1-6).
Although the results of this latter study are disappointing, I believe they are unlikely to limit the enthusiasm for the simulation training and shoulder dystocia drills that have become fairly routine in many large maternity hospitals in the United States.
Regardless of the limited outcomes data we have available thus far, experience with simulation training has taught us that in order to retain necessary skills, repetitive participation in simulation training appears to be required. The relatively infrequent nature of severe shoulder dystocia cases makes the simulation model for learning very attractive.
The doctor inserts a hand (left), then he/she sweeps the arm across the baby's chest and over the mother's perineum.
Source Images: ©Elsevier, From Obstetrics: Normal and Problem Pregnancies, 5th Edition
Shoulder Dystocia
Routine vaginal deliveries can sometimes quickly become not-so-routine deliveries. When an otherwise normal labor process – and sometimes even a near-delivery – ends with a delayed or obstructed delivery of the fetal shoulder, the obstetrician and his or her team are challenged – physically and emotionally.
This complication is a nightmare for the family as well as the obstetrician who struggles to complete the process. What actually may be a matter of seconds or a minute can feel like an eternity.
We now know that diabetes and obesity are conditions that are increasing at a rapid pace in our society. With the rise in these two conditions (known collectively as diabesity), we can anticipate a rise in fetal macrosomia.
On the other hand, we know that not every macrosomic infant results in obstructed labor or shoulder dystocia. In addition, we currently do not have a very good biometric methodology by which we can precisely estimate fetal weight, or even the pelvic size. Thus, it is difficult to come to an objective conclusion regarding the probability of obstructed labor.
These are the variables that, together, create such a vexing and sometimes underappreciated conundrum.
To attempt to anticipate and to manage the problem, obstetrical specialists must rely on less-than-satisfactory biomedical parameters, historical experience, and their best judgment about medical condition.
Despite such imprecision and the lack of certainty we have for addressing the problem, there is some guidance that can be helpful in predicting the level of risk of shoulder dystocia, and in managing the complication should it occur. It is in this light that we have invited Dr. Mark B. Landon, a maternal-fetal medicine specialist, to discuss the problem of shoulder dystocia. Dr. Landon is the Richard L. Meiling Professor and chairman of the department of ob.gyn. at the Ohio State University, Columbus.
As Dr. Landon discusses, it is almost impossible to be absolutely perfect in preventing and managing shoulder dystocia. We can, however, improve our understanding of which scenarios call for the consideration of prophylactic cesarean section, and of how we can deliver affected infants as safely as possible. As Dr. Landon duly notes, it is critical for the obstetrician to be able to perform a repertoire of potentially effective maneuvers to manage shoulder dystocia.