The Second Thing You Should Think About at Every ...· Think About at Every DeliveryThink About at

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  • The Second Thing You Should Think About at Every DeliveryThink About at Every Delivery

    T dd R L MD FACOGTodd R Lovgren, MD FACOGMethodist Perinatal Center

    Methodist Womens HospitalMethodist Women s Hospital6/14/2013

  • DisclosuresDisclosures

    N l t fi i lNo relevant financial relationships.relationships.

  • ObjectivesObjectives

    U l i f thi t ti thUpon conclusion of this presentation, the participants should be able to: Identify patients at risk for shoulder dystocia (ShD). Discuss the use of ultrasound in macrosomia and ShD. Discuss the impact of diabetes on ShD. Describe the standard and alternative maneuvers to

    l ShDresolve a ShD. Discuss appropriate documentation and follow-up

    when ShD is encounteredwhen ShD is encountered.

  • Shoulder DystociaShoulder Dystocia Background

    Difficult vaginal delivery of the fetal shoulder.A delivery requiring additional obstetric maneuvers A delivery requiring additional obstetric maneuvers following the failure of gentle downward traction on the fetal head to effect delivery of the shoulders.

    Rates of occurrence: All deliveries: 0.6% to 3.0% BW>4500g: 9.2-24% BW>4500g + DM: 20-50%

    Majority occur in infants of normal BW.

  • Shoulder DystociaNeonatal Complications

    Brachial Plexus Injuries (4 40% of all ShD) Brachial Plexus Injuries (4-40% of all ShD) Most resolve w/o permanent disability by 1 year

  • Can Shoulder DystociaCan Shoulder Dystocia Be Predicted Accurately?

    Risk FactorsAntepartum Antepartum

    Intrapartum Ult d Ultrasound Estimated Fetal Weight (EFW) Biometric ratios

  • Shoulder DystociaRisk Factors - Antepartum

    Macrosomia Macrosomia Maternal obesity

    BW increases with maternal BMI. More likely to be diabetic Excessive pregnancy weight gain

    Previous macrosomic infant Previous macrosomic infant Postdates MultiparityMultiparity Diabetes

    Diabetes - pregestational & gestationalabe es p eges a o a & ges a o a Prior shoulder dystocia

  • Excessive Fetal Growth

    LGA M iLGA vs Macrosomia LGA: BW 90th percentile for GA

    Pediatric diagnosis Macrosomia: Ultrasound estimated weight

    greater than cut-off 4000g vs 4250g vs 4500g vs 5000g

  • What estimated fetal weight cut off do you use definecut-off do you use define


    A 4000gA. 4000gB. 4250ggC. 4500gD 5000D. 5000g

  • MacrosomiaD fi i iDefinition

    Growth beyond a specific weight regardless of y g ggestational age: >4000g or >4500g Morbidity of infants and mothers

    4000 4500g: greater than general ob population 4000 4500g: greater than general ob population >4500g: sharply increased

    Parallel increase in birth injuriesUsher 1988Usher, 1988

    10-20% incidence of BW >4000g 3% incidence of BW >4500g

    P ll k 1992 Ed 1987Pollack, 1992; Eden, 1987

    ACOG suggested definition: >4500g

    Important: Be consistent in your own definition and p ythis is not/should not be the same threshold to recommend primary CD

  • BW Percentiles for GA

    Birth WeightGA 50th 90th 95th

    37 3117 3755 395638 3263 3867 402739 3400 3980 410740 3495 4060 418541 3527 4094 421741 3527 4094 421742 3522 4098 4213

    Alexander GR et al. A United States national reference for fetal growth. (Live Birth File of the National Center for Health Statistics) Obsetet Gyencol 1996;87:163-168

  • Antepartum Risk FactorsPostdates - Outcomes

    Complication40 weeksN=8135

    Post term (>42wks)Complication N=8135 ( 42wks)N=3457

    Meconium 19% 27%Meconium 19% 27%Meconium aspiration 0.6% 1.6%

    M i 0 8% 2 8%Macrosomia 0.8% 2.8%Shoulder dystocia 8% 18%P

  • Other IntrapartumOther Intrapartum Considerations

    Abnormal 1 hour normal 3 hour Excessive weight gainExcessive weight gain Obese patient

    P i i i f t Prior macrosomic infant

  • Shoulder DystociaShoulder DystociaRisk Factors - Intrapartum

    Reported Risk FactorsReported Risk Factors

    Epidural anesthesia No!p

    Labor dystocia

    Operative vaginal delivery

  • Do LaborDo Labor Abnormalities Predict S ?Shoulder Dystocia?

    Three studies have specifically addressed labor patterns in patients who develop shoulder dystocia.

    McFarland et al. AJOG 1995;173:1211-4Gemer et al. Acta Obstet Gynecol Scan 1999;78:735-6Gemer et al. Acta Obstet Gynecol Scan 1999;78:735 6Lurie et al. Am J Perinatol 1995;12:61-2

  • Shoulder DystociaShoulder DystociaLabor Abnormalities

    Data are inadequate to answer this question: McFarland et al.; 276 ShD cases matched with 600

    controls; no association

    Gemer et al.; 36 ShD; significant association

    Lurie et al ; 52 ShD cases; no association Lurie et al.; 52 ShD cases; no association

    Anecdotally still serve as a red flag

  • Is there a different definition for macrosomia in the diabeticfor macrosomia in the diabetic


    A YesA. YesB. No

  • Diabetes & Macrosomia

    Maternal FetalPlacenta

    Insulin release Insulin release

    Glucose use

    Lipid & Glycogen





  • Diabetes & Shoulder DystociaDiabetes & Shoulder Dystocia


  • In the diabetic patient, what fetal weight cut off do you usefetal weight cut-off do you use

    to offer cesarean delivery?y

    A 4000gA. 4000gB. 4250ggC. 4500gD 5000


    D. 5000g

  • Shoulder DystociaShoulder DystociaDiabetes

    3-9% in diabetics compared with 0.2-2.8% in non diabeticsnon-diabetics

    > 4000 gms 18-23%

    > 4500 gms ~50% (14-25% in non-diabetics)

    Brachial plexus injury (Erbs palsy) clavicular Brachial plexus injury (Erb s palsy), clavicular fracture, hypoxia, low Apgar scores

    Uvena-Celebrezze and Catalano Clin Ob Gyn 2000; 43:127-139

  • Frequency in Non-DM and DM as well as OVD

    1992 1992 175,000

    d li ideliveriesNesbitt et al. AJOG 1998;179:476

  • Can Ultrasound PredictCan Ultrasound Predict Shoulder Dystocia?

  • Macrosomia & UltrasoundMacrosomia & UltrasoundEFW EFW >50 formulas

    ideally 3 parameters

    Sheppard Formula (AC & BPD)pp ( ) 50% time-- 5% of true fetal weight

    80% time-- 10% of true fetal weight80% time 10% of true fetal weight

    20% time-- >10% discrepancy from weight

    Ultrasound overestimates the FW/BW Ultrasound overestimates the FW/BW

  • Macrosomia and Ultrasound

    2002 Best et al Retrospective 1690 controls, 133 Diabetics

    EFW at 34-37 weeks is extrapolated pusing Alexander growth curve

    Mean absolute error 7.4% +/- 6.3%

    US EFW* [Mean BW at delivery/Mean BW at current EGA] = EFW at delivery

  • U/S, Macrosomia, & ShDU/S, Macrosomia, & ShDTD - BPD 1.4 cm (Elliott)TD BPD 1.4 cm (Elliott)AD - BPD 2.6 cm (Cohen)Six parameters compared (Winn)Six parameters compared (Winn)-TC most predictive

    TC th i i f t l l f 4 h b h t

    AD = abdominal diameter = AC divided by 3.14

    TC = thoracic circumference at level of 4-chamber heart

    TD = thoracic diameter at level of fetal liver just below heartCohen et al Obstet Gynecol 1996; 88:10 3Cohen et. al. Obstet Gynecol 1996; 88:10-3Elliott JP, et al. Obstet Gynecol 1982; 60: 159Winn HN et. al. J Perinat Med 1997; 25:484-87

  • Truncal Asymmetry415 diabetic patients; 50% EFW 3800 4200g

    Truncal Asymmetry415 diabetic patients; 50% EFW 3800 4200g

    31 ShD cases

    AD BPDAD - BPD (A.D. = AC divided by 3.14)

    if > 2.6 cm then 30% ShD rateif < 2.6 cm then 0% ShD.


    Cohen B et al, Obstet Gynecol 1996;88:10-13

  • Cohen Index

    Follow up study in 1999 Diabetics Only

    Normalized for GA Determined residual AD-BPD

    Unpublished nomogram for residual AD-BPD

    Three categories10 20 and 34% risk of ShD 10, 20 and 34% risk of ShD

    Third group was associated with necessity for advanced maneuvers

    Req post arm or Woods maneuver

  • Shoulder DystociaWhat to tell patients?

    X:100, (x%) risk of shoulder dystocia 1:10 (10%) risk of BPI 1:10 (10%) risk of permanent injury

    3% risk of ShD=Roughly 1/3333 chance of permanent BPIRoughly 1/3333 chance of permanent BPI

    *This is based on extrapolation from multiple studies

  • Where Do I get the X

    I give patients 3 estimates and provide a range. i.e. 9-34% chanceg

    California population data Nesbitt et al AJOG 1998;179:476 Nesbitt et al. AJOG 1998;179:476

    EFW based on Best calculationT l A t Truncal Asymmetry

  • Does labor induction for suspected fetal macrosomiasuspected fetal macrosomia

    affect the risk of ShD or brachial l i j ?plexus injury?

  • Does Labor Induction for suspected fetal macrosomia affect the risk of

    ShD or brachial plexus injury?ShD or brachial plexus injury?

    St di di id d i t 3 t iStudies are divided into 3 categories:1. Induction for macrosomia in non-DM2. Induction for macrosomia in DM3 I d ti f ti f3. Induction for prevention of

    macrosomia in DM

  • Shoulder DystociaShoulder DystociaLabor Induction for Macrosomia (non-DM)

    Management of suspected macrosomia is t i lcontroversial

    Elective C/S and labor inductions have been proposed interventions to prevent maternal and fetal M&M.

    3600 C/S required to prevent 1 permanent neonatal injury.

    Rouse et al. JAMA 1996;276:1480-6

  • Shoulder DystociaLabor Induction for Macrosomia (non-DM)

    Expectant Management Versus Labor Induction for Suspected Fetal Macrosomia in non-diabetics

    11/29 stu