The Zavanelli manoeuvre revisited: A review of the literature and a guide to performing cephalic replacement for severe shoulder dystocia.

The Zavanelli manoeuvre is often the final resort of the clinician facing undeliverable shoulder dystocia and we present retrospective pooled data comprising 110 shoulder dystocia cases, 11 impacted breech and 11 locked twin deliveries assessed from ten case series and 38 individual case reports. Although recommended when other external and internal manipulations have failed, we suspect that many clinicians have not had formal training on how to conduct the manoeuvre and may be unfamiliar with the steps involved, leading to a reluctance and delay in initiating this. We describe original descriptions of the manoeuvre, examine its use in intractable shoulder dystocia and illustrate stepwise the cephalic replacement technique. For this review, we have concentrated mainly on the outcomes of the Zavanelli manoeuvre in shoulder dystocia but have also touched on its role in impacted breech and locked twin deliveries. Lastly, we discuss the cognitive load an obstetrician faces when having to make time critical decisions in severe shoulder dystocia and share how other disciplines train and prepare their personnel to manage similar rare and unexpected scenarios.

Prolonged brachial plexus neuropathy: a rare complication following protracted endometriosis surgery in Lloyd-Davies position.

Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Loss of motor and/or sensory innervation can have a significant impact on the patient's quality of life following otherwise successful surgery. A 38-year-old underwent elective laparoscopic management of severe endometriosis during which she was placed in steep head-down tilt Lloyd-Davies position for a prolonged period. On awakening from anaesthesia, the patient had no sensation or movement of her dominant right arm. A total plexus brachialis injury was suspected. As advised by a neurologist, an MRI brachial plexus, nerve conduction study and electromyography were requested. She was managed conservatively and made a gradual recovery with a degree of residual musculocutaneous nerve neuropathy. The incidence of brachial plexus injury following laparoscopy is unknown but the brachial plexus is particularly susceptible to injury as a result of patient positioning and prolonged operative time. Patient positioning in relation to applied clinical anatomy is explored and risk reduction strategies described.

Validation of the Omron MIT Elite blood pressure device in a pregnant population with large arm circumference.

OBJECTIVE: The aim of this study was to evaluate the accuracy of the Omron MIT Elite automated device in pregnant women with an arm circumference of or above 32 cm, using the British Hypertension Society validation protocol. METHODS: Blood pressure was measured sequentially in 46 women of any gestation requiring the use of a large cuff (arm circumference ≥32 cm) alternating between the mercury sphygmomanometer and the Omron MIT Elite device. RESULTS: The Omron MIT Elite achieved an overall D/D grade with a mean of the device-observer difference being 7.17±6.67 and 9.31±6.59 for systolic and diastolic blood pressure respectively. Interobserver accuracy was 94.6% for systolic and 95% for diastolic readings within 5 mmHg. CONCLUSION: The Omron MIT Elite overestimates blood pressure and has failed the British Hypertension Society protocol requirements. Therefore, it cannot be recommended for use in pregnant women with an arm circumference of or above 32 cm.

Validation of the Withings BP-800 in pregnancy and impact of maternal characteristics on the accuracy of blood pressure measurement.

OBJECTIVE: Firstly, to validate the Withings BP-800 automated device for use in pregnancy and, secondly, to assess the impact of maternal somatometric and demographic variables on the accuracy of the device. DESIGN: Prospective observational study. SETTING: Kings College Hospital, London, UK. POPULATION: Forty-seven women of any gestation. METHODS: Validation: The British Hypertension Society (BHS) Protocol (1993) was used for the validation of the Withings BP-800. Two trained observers took nine sequential same arm measurements alternating between the Withings BP-800 and the mercury sphygmomanometer. Assessment of factors affecting the disagreement between the two devices: The associations between discrepancies in the measured systolic and diastolic blood pressure by the two devices and potential predictors of discrepancy and/or possible confounders of associations including age, gestational age, ethnicity, body mass index and arm circumference were investigated using two-level mixed effects models to take into account the repeated measurements. MAIN OUTCOME MEASURES: Accuracy of the Withings BP-800 based on the grading criteria of the BHS Protocol (1993). RESULTS: The Withings BP-800 failed to meet the validation criteria of the BHS protocol for pregnancy and preeclampsia. Inter-device discrepancy was significantly associated with larger arm circumferences and was more pronounced with diastolic blood pressure. This relationship was independent of other maternal characteristics. CONCLUSIONS: The Withings BP-800 cannot be recommended for the measurement of blood pressure in pregnancy or preeclampsia. The inaccuracy of the Withings BP-800 increases when used in patients with larger arm circumferences with a propensity to over-read.