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<ul><li><p>The Second Thing You Should Think About at Every DeliveryThink About at Every Delivery</p><p>T dd R L MD FACOGTodd R Lovgren, MD FACOGMethodist Perinatal Center</p><p>Methodist Womens HospitalMethodist Women s Hospital6/14/2013</p></li><li><p>DisclosuresDisclosures</p><p>N l t fi i lNo relevant financial relationships.relationships.</p></li><li><p>ObjectivesObjectives</p><p>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 </p><p>l ShDresolve a ShD. Discuss appropriate documentation and follow-up </p><p>when ShD is encounteredwhen ShD is encountered.</p></li><li><p>Shoulder DystociaShoulder Dystocia Background</p><p> 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.</p><p> Rates of occurrence: All deliveries: 0.6% to 3.0% BW&gt;4500g: 9.2-24% BW&gt;4500g + DM: 20-50%</p><p> Majority occur in infants of normal BW. </p></li><li><p>Shoulder DystociaNeonatal Complications</p><p> 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</p></li><li><p>Can Shoulder DystociaCan Shoulder Dystocia Be Predicted Accurately?</p><p> Risk FactorsAntepartum Antepartum</p><p> Intrapartum Ult d Ultrasound Estimated Fetal Weight (EFW) Biometric ratios</p></li><li><p>Shoulder DystociaRisk Factors - Antepartum</p><p> Macrosomia Macrosomia Maternal obesity</p><p> BW increases with maternal BMI. More likely to be diabetic Excessive pregnancy weight gain</p><p>Previous macrosomic infant Previous macrosomic infant Postdates MultiparityMultiparity Diabetes</p><p> Diabetes - pregestational &amp; gestationalabe es p eges a o a &amp; ges a o a Prior shoulder dystocia</p></li><li><p>Excessive Fetal Growth </p><p>LGA M iLGA vs Macrosomia LGA: BW 90th percentile for GA</p><p> Pediatric diagnosis Macrosomia: Ultrasound estimated weight </p><p>greater than cut-off 4000g vs 4250g vs 4500g vs 5000g</p></li><li><p>What estimated fetal weight cut off do you use definecut-off do you use define </p><p>macrosomia?</p><p>A 4000gA. 4000gB. 4250ggC. 4500gD 5000D. 5000g</p></li><li><p>MacrosomiaD fi i iDefinition</p><p> Growth beyond a specific weight regardless of y g ggestational age: &gt;4000g or &gt;4500g Morbidity of infants and mothers</p><p> 4000 4500g: greater than general ob population 4000 4500g: greater than general ob population &gt;4500g: sharply increased</p><p> Parallel increase in birth injuriesUsher 1988Usher, 1988</p><p> 10-20% incidence of BW &gt;4000g 3% incidence of BW &gt;4500g</p><p>P ll k 1992 Ed 1987Pollack, 1992; Eden, 1987</p><p> ACOG suggested definition: &gt;4500g</p><p> Important: Be consistent in your own definition and p ythis is not/should not be the same threshold to recommend primary CD</p></li><li><p>BW Percentiles for GA</p><p>Birth WeightGA 50th 90th 95th</p><p>37 3117 3755 395638 3263 3867 402739 3400 3980 410740 3495 4060 418541 3527 4094 421741 3527 4094 421742 3522 4098 4213</p><p>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</p></li><li><p>Antepartum Risk FactorsPostdates - Outcomes</p><p>Complication40 weeksN=8135</p><p>Post term (&gt;42wks)Complication N=8135 ( 42wks)N=3457</p><p>Meconium 19% 27%Meconium 19% 27%Meconium aspiration 0.6% 1.6%</p><p>M i 0 8% 2 8%Macrosomia 0.8% 2.8%Shoulder dystocia 8% 18%P</p></li><li><p>Other IntrapartumOther Intrapartum Considerations</p><p> Abnormal 1 hour normal 3 hour Excessive weight gainExcessive weight gain Obese patient</p><p>P i i i f t Prior macrosomic infant</p></li><li><p>Shoulder DystociaShoulder DystociaRisk Factors - Intrapartum</p><p>Reported Risk FactorsReported Risk Factors</p><p> Epidural anesthesia No!p</p><p> Labor dystocia</p><p> Operative vaginal delivery</p></li><li><p>Do LaborDo Labor Abnormalities Predict S ?Shoulder Dystocia?</p><p> Three studies have specifically addressed labor patterns in patients who develop shoulder dystocia.</p><p>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</p></li><li><p>Shoulder DystociaShoulder DystociaLabor Abnormalities</p><p> Data are inadequate to answer this question: McFarland et al.; 276 ShD cases matched with 600 </p><p>controls; no association</p><p> Gemer et al.; 36 ShD; significant association</p><p> Lurie et al ; 52 ShD cases; no association Lurie et al.; 52 ShD cases; no association</p><p> Anecdotally still serve as a red flag</p></li><li><p>Is there a different definition for macrosomia in the diabeticfor macrosomia in the diabetic </p><p>patient?</p><p>A YesA. YesB. No</p></li><li><p>Diabetes &amp; Macrosomia</p><p>Maternal FetalPlacenta</p><p> Insulin release Insulin release</p><p> Glucose use</p><p> Lipid &amp; Glycogen</p><p> Insulin</p><p>Hyperglycemia</p><p> Insulin</p><p>Hyperglycemia</p></li><li><p>Diabetes &amp; Shoulder DystociaDiabetes &amp; Shoulder Dystocia</p><p>*</p></li><li><p>In the diabetic patient, what fetal weight cut off do you usefetal weight cut-off do you use </p><p>to offer cesarean delivery?y</p><p>A 4000gA. 4000gB. 4250ggC. 4500gD 5000</p><p>ACOG</p><p>D. 5000g</p></li><li><p>Shoulder DystociaShoulder DystociaDiabetes</p><p> 3-9% in diabetics compared with 0.2-2.8% in non diabeticsnon-diabetics</p><p> &gt; 4000 gms 18-23%</p><p> &gt; 4500 gms ~50% (14-25% in non-diabetics)</p><p> Brachial plexus injury (Erbs palsy) clavicular Brachial plexus injury (Erb s palsy), clavicular fracture, hypoxia, low Apgar scores</p><p>Uvena-Celebrezze and Catalano Clin Ob Gyn 2000; 43:127-139</p></li><li><p>Frequency in Non-DM and DM as well as OVD</p><p> 1992 1992 175,000 </p><p>d li ideliveriesNesbitt et al. AJOG 1998;179:476</p></li><li><p>Can Ultrasound PredictCan Ultrasound Predict Shoulder Dystocia?</p></li><li><p>Macrosomia &amp; UltrasoundMacrosomia &amp; UltrasoundEFW EFW &gt;50 formulas</p><p> ideally 3 parameters</p><p> Sheppard Formula (AC &amp; BPD)pp ( ) 50% time-- 5% of true fetal weight</p><p> 80% time-- 10% of true fetal weight80% time 10% of true fetal weight</p><p> 20% time-- &gt;10% discrepancy from weight</p><p>Ultrasound overestimates the FW/BW Ultrasound overestimates the FW/BW</p></li><li><p>Macrosomia and Ultrasound</p><p> 2002 Best et al Retrospective 1690 controls, 133 Diabetics</p><p> EFW at 34-37 weeks is extrapolated pusing Alexander growth curve</p><p> Mean absolute error 7.4% +/- 6.3%</p><p>US EFW* [Mean BW at delivery/Mean BW at current EGA] = EFW at delivery</p></li><li><p>U/S, Macrosomia, &amp; ShDU/S, Macrosomia, &amp; 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</p><p>TC th i i f t l l f 4 h b h t</p><p>AD = abdominal diameter = AC divided by 3.14</p><p>TC = thoracic circumference at level of 4-chamber heart</p><p>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</p></li><li><p>Truncal Asymmetry415 diabetic patients; 50% EFW 3800 4200g</p><p>Truncal Asymmetry415 diabetic patients; 50% EFW 3800 4200g</p><p>31 ShD cases</p><p>AD BPDAD - BPD (A.D. = AC divided by 3.14)</p><p>if &gt; 2.6 cm then 30% ShD rateif &lt; 2.6 cm then 0% ShD.</p><p>(p=.05)</p><p>Cohen B et al, Obstet Gynecol 1996;88:10-13</p></li><li><p>Cohen Index</p><p> Follow up study in 1999 Diabetics Only</p><p> Normalized for GA Determined residual AD-BPD</p><p> Unpublished nomogram for residual AD-BPD</p><p> Three categories10 20 and 34% risk of ShD 10, 20 and 34% risk of ShD </p><p> Third group was associated with necessity for advanced maneuvers</p><p> Req post arm or Woods maneuver</p></li><li><p>Shoulder DystociaWhat to tell patients?</p><p> X:100, (x%) risk of shoulder dystocia 1:10 (10%) risk of BPI 1:10 (10%) risk of permanent injury</p><p>3% risk of ShD=Roughly 1/3333 chance of permanent BPIRoughly 1/3333 chance of permanent BPI</p><p>*This is based on extrapolation from multiple studies</p></li><li><p>Where Do I get the X</p><p>I give patients 3 estimates and provide a range. i.e. 9-34% chanceg</p><p> California population data Nesbitt et al AJOG 1998;179:476 Nesbitt et al. AJOG 1998;179:476</p><p> EFW based on Best calculationT l A t Truncal Asymmetry</p></li><li><p>Does labor induction for suspected fetal macrosomiasuspected fetal macrosomia </p><p>affect the risk of ShD or brachial l i j ?plexus injury?</p></li><li><p>Does Labor Induction for suspected fetal macrosomia affect the risk of </p><p>ShD or brachial plexus injury?ShD or brachial plexus injury?</p><p>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 </p><p>macrosomia in DM</p></li><li><p>Shoulder DystociaShoulder DystociaLabor Induction for Macrosomia (non-DM)</p><p> Management of suspected macrosomia is t i lcontroversial</p><p> Elective C/S and labor inductions have been proposed interventions to prevent maternal and fetal M&amp;M.</p><p> 3600 C/S required to prevent 1 permanent neonatal injury. </p><p>Rouse et al. JAMA 1996;276:1480-6</p></li><li><p>Shoulder DystociaLabor Induction for Macrosomia (non-DM)</p><p> Expectant Management Versus Labor Induction for Suspected Fetal Macrosomia in non-diabetics</p><p> 11/29 studies met inclusion criteria 9 observational studies</p><p> 2 randomized clinical studies</p><p> 3751 patients (2700 Exp Mgmt; 1051 Indxn)p ( p g )</p><p> Metanalysis; OR &amp; 95% CI </p><p> Primary outcomes: delivery mode &amp; perinatal outcomePrimary outcomes: delivery mode &amp; perinatal outcomeRamos et al. Obstet Gynecol 2002;100:997-1002</p></li><li><p>Shoulder DystociaLabor Induction for Macrosomia (non-DM)</p><p>Expectant Induction OR (95% CI)</p><p>C/S 214/2540 (8.4) 149/898 (16.6) 0.39 (0.30, 0.50)C/S</p><p>SVD 1987/2400 (82.8) 620/852 (72.8) 2.07 (1.34, 3.19)</p><p>OVD 213/2400 (8.9) 88/852 (10.3) 0.89 (0.68, 1.17)</p><p>ShD 73/1213 (6.0) 26/365 (7.1) 0.81 (0.50, 1.31)ShD ( ) ( ) ( , )</p><p> 5m AS 28/1553 (1.8) 8/445 (1.7) 0.65 (0.3, 1.42)</p><p>Ramos et al. Obstet Gynecol 2002;100:997-1002</p></li><li><p>Labor Induction for Macrosomia Diabetic Patient</p><p>L b i d ti t 38 39 k f Labor induction at 38-39 weeks for: Macrosomia or LGA to prevent injury Prevention of macrosomia</p><p> Reduction in: BW without a significant in C/S LGA &amp; macrosomia without a significant in C/Sg ShD without at significant in C/S</p><p>Conway and Langer AJOG 1998; 178:922 5</p><p>Kjos SL et al, AJOG 1993; 169: 611-15Lurie et al. Am J Perinatology 1996; 13:293-6Conway and Langer. AJOG 1998; 178:922-5</p></li><li><p>Strategies for prevention of shoulder dystocia in diabetics</p><p> Induction of labor when LGA fetus is suspectedInduction of labor when LGA fetus is suspected, especially if cervix favorable</p><p>I l i t l t d i Improve glycemic control to reduce macrosomia</p><p> Improve prediction of shoulder dystocia reevaluate use of Cohen and Elliott criteria</p><p> Avoid operative vaginal deliveryp g y</p><p> Elective C/S: DM: &gt;4250 or &gt;4500 </p><p>(Non DM: &gt;5000g)(Non-DM: &gt;5000g)</p></li><li><p>H h ld ithHow should a woman with a previous shoulder dystocia beprevious shoulder dystocia be </p><p>counseled regarding ?subsequent deliveries?</p></li><li><p>Shoulder DystociayThe next pregnancy</p><p> Rate of recurrence: 1-16%, BUT, difficult to determine</p><p> Most subsequent deliveries free of ShDBenefit of universal elective C/S? Benefit of universal elective C/S?</p><p> Other factors to dictate mode of delivery EFW; gestational age; DM; severity of prior injury</p><p> Discuss and review of prior deliveryp y Either method of delivery is appropriate</p></li><li><p>What Do I Do When A Sh ld D t i IShoulder Dystocia Is </p><p>Encountered?Encountered?</p></li><li><p>Shoulder DystociaManeuversManeuvers</p><p> Be prepared and be able to recognize! Be prepared and be able to recognize! Take a deep breath &amp; note the time Marshall your resources GET HELP Marshall your resources GET HELP Episiotomy if necessary to access pelvis!! McRoberts maneuver &amp; suprapubic pressure McRobert s maneuver &amp; suprapubic pressure Woods screw &amp; Rubin maneuvers Delivery of posterior arm Delivery of posterior arm Zavanelli </p><p>(Fracture Clavicle) (Fracture Clavicle) (Symphysiotomy)</p></li><li><p>McRoberts Maneuver(Gonik et al. AJOG 1983;145:882)</p></li><li><p>Suprapubic PressureSuprapubic Pressure </p></li><li><p>Know Your References</p></li><li><p>Woods Screw ManeuverWood s Screw Maneuver </p></li><li><p>dWilliams Obstetrics 23rd Ed.</p><p>Woods maneuver. The hand is placed behind the posterior shoulder of the fetus. The shoulder is then rotated progressively 180 degrees in a corkscrew manner so that the impacted anterior shoulder is released impacted anterior shoulder is released.</p><p>A i fi d t t ADd tiAccompanying figure demonstrates ADduction of the posterior shoulder.</p></li><li><p>Woods Manuever</p><p> Woods was the physicians name. He described using the physics of a screw to affect delivery.</p><p>Woods, CE, Am J Obstet Gynecol 45:796, 1943 A principle of physics is applicable to shoulder delivery.</p><p> Description per Dr. Woods (1943) Demonstration with mannequins/models. ABduction of the q</p><p>shoulders which become the threads. Coccyx and pubic symphisis serve as counter threads.</p></li><li><p>Rubin Maneuver </p></li><li><p>Rubin ManeuverTwo-Maneuver Program First</p><p> Rock shoulders side to side by pushing on maternal Rock shoulders side to side by pushing on maternal abdomen</p><p> Repeat Fundal Pressure and gentle traction Rock shoulders again and repeat with considerable Rock shoulders again and repeat with considerable</p><p>fundal pressure Second</p><p> Place fingers behind whichever shoulder is readily Place fingers behind whichever shoulder is readily accessible and push toward the fetal chest</p><p> Finger can be placed in opposite axilla to assist descent More fundal pressure after the shoulder is disimpacted More fundal pressure after the shoulder is disimpacted</p></li><li><p>Dont Use EponymsDont Use Eponyms-Describe what you did and be sure to identify which shoulder was anterior and posterior. This can be difficult to recall even 15-20 pminutes after a difficult delivery let alone 10years later at trial.</p></li><li><p>Posterior Arm Maneuver </p><p>A CC</p><p>B</p></li><li><p>Posterior Arm Maneuver </p><p>D</p><p>E</p></li><li><p>Posterior Arm Maneuver with C/S assistassist</p></li><li><p>Menticoglou The head is gently held upward by an </p><p>assistant. The operator has the 4th and 5th fingers of each hand flexed and pressedfingers of each hand flexed and pressed against the womans perineal area. The middle fingers are both placed into the fetuss posterior axilla one from the fetuss front andposterior axilla, one from the fetus s front and the other from the fetuss back. The fingers overlap each other. By using both fingers, traction is used to pull the posterior shouldertraction is used to pull the posterior shoulder downward and outward along the curve of the sacrum.</p><p>Menticoglou, S A Modified Technique to Deliver the Posterior Arm in Severe Shoulder Dystocia Ob Gyn 108, No 3. Part 2, p. 755-7. </p></li><li><p>Menticoglou</p></li><li><p>Zavanelli ManeuverZavanelli Maneuver </p><p> Cardinal Movements Reversed &amp; C/S Cardinal Movements ----- Reversed &amp; C/SEngagementD tDescentFlexionInternal RotationExtensionExternal Rotation (restitution)Expulsion</p><p> Preferable to intentional clavicle fx.</p></li><li><p>How many providers have done a Zavanelli maneuver?done a Zavanelli maneuver?</p></li><li><p>Shoulder DystociaShoulder DystociaOther Maneuvers</p><p> Lubrication tough to do when you cant put your hand past the fetal headBl dd D i Bl dd D t i id thi Bladder Drainage Bladder Dystocia avoid this by draining the bladder in the second stage prior to deliveryespecially with an epidural. Cant put adelivery especially with an epidural. Can t put a foley in after ShD present. </p><p> Gaskin Maneuver SP pressure + Fundal pressure- Frowned upon in </p><p>the US but common elsewhere.S hi Symphisotomy </p></li><li><p>How many providers know the Gaskin maneuver?Gaskin maneuver?</p></li><li><p>Shoulder DystociayGaskin Maneuver</p><p> Retros...</p></li></ul>