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Shoulder dystociaH. Gordon

Online Publication Date: 01 May 2008

To cite this Article Gordon, H.(2008)'Shoulder dystocia',Journal of Obstetrics and Gynaecology,28:4,371 372To link to this Article: DOI: 10.1080/01443610802141068URL: http://dx.doi.org/10.1080/01443610802141068

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EDITORIAL

Shoulder dystocia

H. GORDON

Present Editor of Journal of Obstetrics and Gynaecology

The continued interest in the management of shoulder

dystocia is demonstrated by the number of papers on the

subject in recent issues of the Journal of Obstetrics and

Gynaecology. It is timely that attention has been drawn, yet

again, to the inadequate diagnostic criteria used in many

series. Mahran et al. (2008) noted that in the past, the

diagnosis of shoulder dystocia only relied on the birth

attendants opinion. Now, the most common definition

used specifies that shoulder dystocia has only occurred if

special manoeuvres were required. However, it is quite

possible for an inexperienced accoucher to utilise, for

example, McRoberts manoeuvre unnecessarily and a false

diagnosis is then recorded albeit with a satisfactory

outcome. Mahran and his co-workers (2008) also noted an

increase in the diagnosis of shoulder dystocia, but a marked

reduction in those with a poor outcome. They suggest that

this is more likely due to an over-diagnosis of the conditionrather than an improvement in management. They go on to

suggest that pre-existing risk factors should be included in

the diagnostic criteria.

Solcymani Majd et al. (2008) in their series of cases of

shoulder dystocia from a district general hospital empha-

sised the need for meticulous documentation (as stressed in

the RCOG 2005 guidelines), as they found in their series of

96 cases documentation was suboptimal in most of the

18% of their babies who needed admission to the special

care baby unit, about one-quarter had brachial plexus

injuries or factures. The authors also made a strong plea for

universal postnatal debriefing, and were disappointed to

find that it only occurred in 16% of their cases. In 4% of

cases, episiotomy was the only intervention needed to

facilitate delivery, perhaps suggesting overdiagnosis.

Perhaps the most important recent paper is that of

Sandmire et al. (2008). They review existing theories for

the aetiology of brachial plexus injuries (BPI) noting that

excessive lateral traction by the obstetrician as a major

cause of BPI has little convincing evidence to support it.

They then advance the attractive hypothesis that the major

cause is the twisting and extension of the fetal head, which

can occur as a result of the natural forces of labour. This

paper also contains a clear and concise description of

the mechanism of normal labour in the delivery of the

shoulders. This has become a neglected area in the

teaching of practical obstetrics to medical studentsand few of the junior staff now really understand the

mechanism of normal labour, and the abnormalities that

may develop.

The medico legal importance of their paper is clear, there

is a logical and convincing explanation for the brachial

plexus injury which does not involve the excessive use of

force by the birth attendants. While it must be accepted

that some cases of brachial plexus trauma do involve

excessive force (especially with lateral traction and lateral

flexion of the head), it is reasonable to suspect that BPI is

due to the normal forces of labour where there has been

prolonged labour, persistent occipitoposterior position,

instrumental delivery or maternal diabetes. Damage to

the posterior shoulder is unlikely to be caused by excess

force and strongly suggests that it is the result of forces of

labour. In cases of litigation, defence against malpractice

depends to a large extend on immaculate and detailed case

records (Noble 2006). Documentation is so often inade-quate, it may be of help to use the reporting form suggested

in the RCOG guidelines (2005).

A controversial area that still exists is the need for

episiotomy. The pneumonic HELPERR is widely used and

understood. The E has conventionally been used to indicate

episiotomy. The recent RCOG and Advanced Life Support

in Obstetrics (ALSO) suddenly changed this to Episiotomy

should be considered but is not mandatory Hinshaw

(2003). It is true that in many cases, an episiotomy has

been carried out for delivery of the head, especially if there

was an instrumental delivery. In some cases, the perineum

will already be torn. However, if the perineum is intact and

the head delivered, what are the criteria to suggest that an

episiotomy should or should not be done? I know of none.

The guidelines also stress the difficulty in performing an

episiotomy in these circumstances but this has not been

my experience nor is it mentioned in any previous papers

on the subject when episiotomy was advocated.

The RCOG guidelines do not produce any solid

evidence to back up their statement, only evidence

obtained from expert committee reports or opinions of

respected authorities (Level IV evidence). The statement

of Sriemevan et al. (2000) seems more logical: A large

episiotomy should be cut. This makes more space for

the upper trunk to move posteriorly, takes much of the

pressure off the fetal neck, helps to diminish fetal cerebral

engorgement and also creates more room if intravaginalmanipulation is required.

Correspondence: H. Gordon, 26 Kent Gardens, Ealing, London W13 8BU. E-mail: z.whitlock@imperial.ac.uk

Journal of Obstetrics and Gynaecology, May 2008; 28(4): 371372

ISSN 0144-3615 print/ISSN 1364-6893 online 2008 Informa UK Ltd.

DOI: 10.1080/01443610802141068

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There is also the protection of the mothers perineum

from major trauma. In the largest published series on the

value of episiotomy (284,783 vaginal deliveries) de Leeuw

et al. (2001) concluded that mediolateral episiotomy

protects strongly against the occurrence of 3rd- and 4th-

degree tears. Their series included 1,180 cases where there

was intervention for shoulder dystocia with 46 (3.89%)cases of 3rd-degree tears. As they point out, all types of

assisted vaginal delivery were associated with an increase in

the risk of 3rd-degree ruptures. When discussing medico-

legal aspects of episiotomy, Johnson (2005) advocated a

large episiotomy. This statement was criticised by the

chairman of the audit committee because RCOG guide-

lines did not recommend episiotomy as first-line or indeed

a necessary part of shoulder dystocia management. No

further evidence was offered. It does suggest that it is so

because I say it is so! She goes even further to say we are

long past the point where an individuals personal opinion

should either dictate clinical practice or the outcome of the

medico-legal process. Perhaps the time is ripe for the

College to reconsider this aspect of their guidelines. One

final comment on this subject, from a PACE review

by Neill and Thornton (2000) although shoulder dystocia

is a bony problem rather than a soft tissue obstruction

an episiotomy may create more space. This procedure

increases the chances of delivering the anterior shoulder

under the symphysis. Moreover, it provides greater access

to the pelvis if additional manoeuvres are required, and it

protects the pelvic floor (Coates 1997).

One final neglected area in relation to shoulder dystocia

is uterine activity. It must be remembered that the

mechanism of labour is driven by uterine contractions.

These may be weak and irregular if labour has been

prolonged. Attempts to pull out the baby in the absence of

contractions invites both fetal trauma and postpartum

haemorrhage.

References

Coates T. 1997. Manoeuvers for the relief of shoulder dystocia.

Modern Midwife 7:1519.de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HCS. 2001.

Risk factors for the third degree perineal ruptures during

delivery. British Journal of Obstetrics and Gynaecology

108:383387.

Hinshaw K. 2003. Shoulder dystocia. In: Johnson R, Cox C,

Grady K, Howell C, editors Managing obstetric emergencies

and trauma. The MOET course manual. London: RCOG Press.

pp 165174.

Johnson A. 2005. Obstetric brachial plexus palsy: the medico-legal

view. Obstetrician and Gynaecologist 7:257265.

Mahran MA, Sayed AT, Imoh-Ita F. 2008. Avoiding over

diagnosis of shoulder dystocia. Journal of Obstetrics and

Gynaecology 28:173176.

Murphy DJ. 2006. Obstetric brachial plexus palsy (letter).

Obstetrician and Gynaecologist 8:5960.Neill AMC, Thornton S. 2000. Shoulder dystocia. The Obste-

trician & Gynaecologist 2:4547.

Noble A. 2006. Litigation concerningobstetric brachial plexus palsy.

An alternative view. Obstetrician and Gynaecologist 8:4549.

Royal College of Obstetricians and Gynaecologists. 2005.

Shoulder dystocia, guideline No. 42. London: RCOG.

Sandmire H, Morrison J, Racinet C, Pecorari D, Hawkings G,

Gherman R. 2008. Newborn brachial plexus injuries: The

twisting and extension of the fetal head as contributing causes.

Journal of Obstetrics and Gynaecology 28:170172.

Soleymani Majd H, Ismail L, Iqbal R. 2008. Experience of

shoulder dystocia in a district general hospital: What have we

learnt? Journal of Obstetrics and Gynaecology 28:386389.

Sriemevan A, Neill A, Overton TG. 2000. Shoulder dystocia.

Journal of Obstetrics and Gynaecology 20:579583.

372 Editorial