Diagnosis and Management of Macrosomia and Shoulder Dystocia: A Comprehensive Review of Major Guidelines.

Importance: Macrosomia represents the most significant risk factor of shoulder dystocia (SD), which is a severe and emergent complication of vaginal delivery. They are both associated with adverse pregnancy outcomes. Objective: The aim of this study was to review and compare the most recently published influential guidelines on the diagnosis and management of fetal macrosomia and SD. Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Department for Health and Wellbeing of the Government of South Australia on macrosomia and SD was conducted. Results: The ACOG and RANZCOG agree that macrosomia should be defined as birthweight above 4000-4500 g regardless of the gestational age, whereas the National Institute for Health and Care Excellence defines macrosomia as an estimated fetal weight above the 95th percentile. According to ACOG and RANZCOG, ultrasound scans and clinical estimates can be used to rule out fetal macrosomia, although lacking accuracy. Routine induction of labor before 39 weeks of gestation with the sole indication of suspected fetal macrosomia is unanimously not recommended, but an individualized counseling should be provided. Exercise, appropriate diet, and prepregnancy bariatric surgery are mentioned as preventive measures. There is also consensus among the reviewed guidelines regarding the definition and the diagnosis of SD, with the "turtle sign" being the most common sign for its recognition as well as the poor predictability of the reported risk factors. Moreover, there is an overall agreement on the algorithm of SD management with McRoberts technique suggested as first-line maneuver. In addition, appropriate staff training, thorough documentation, and time keeping are crucial aspects of SD management according to all medical societies. Elective delivery for the prevention of SD is discouraged by all the reviewed guidelines. Conclusions: Macrosomia is associated not only with SD but also with maternal and neonatal complications. Similarly, SD can lead to permanent neurologic sequalae, as well as perinatal death if managed in a suboptimal way. Therefore, it is crucial to develop consistent international practice protocols for their prompt diagnosis and effective management in order to safely guide clinical practice and improve pregnancy outcomes.

Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial.

This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.

A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia.

In the management of shoulder dystocia, it is often recommended to start with external maneuvers, such as the McRoberts maneuver and suprapubic pressure, followed by internal maneuvers including rotation and posterior arm delivery. However, this sequence is not based on scientific evidence of its success rates, the technical simplicity, or the related complication rates. Hence, this review critically evaluates the success rate, technique, and safety of different maneuvers. Retrospective reviews showed that posterior arm delivery has consistently higher success rates (86.1%) than rotational methods (62.4%) and external maneuvers (56.0%). McRoberts maneuver was thought to be a simple method, however, its mechanism is not clear. Furthermore, McRoberts position still requires subsequent traction on the fetal neck, which presents a risk for brachial plexus injury. The 2 internal maneuvers have anatomic rationales with the aim of rotating the shoulders to the wider oblique pelvic dimension or reducing the shoulder width. The techniques are not more sophisticated and requires the accoucher to insert the correct hand (according to fetal face direction) through the more spacious sacro-posterior region and deep enough to reach the fetal chest or posterior forearm. The performance of rotation and posterior arm delivery can also be integrated and performed using the same hand. Retrospective studies may give a biased view that the internal maneuvers are riskier. First, a less severely impacted shoulder dystocia is more likely to have been managed by external maneuvers, subjecting more difficult cases to internal maneuvers. Second, neonatal injuries were not necessarily caused by the internal maneuvers that led to delivery but could have been caused by the preceding unsuccessful external maneuvers. The procedural safety is not primarily related to the nature of the maneuvers, but to how properly these maneuvers are performed. When all these maneuvers have failed, it is important to consider the reasons for failure otherwise repetition of the maneuver cycle is just a random trial and error. If the posterior axilla is just above the pelvic outlet and reachable, posterior axilla traction using either the accoucher fingers or a sling is a feasible alternative. Its mechanism is not just outward traction but also rotation of the shoulders to the wider oblique pelvic dimension. If the posterior axilla is at a higher sacral level, a sling may be formed with the assistance of a long right-angle forceps, otherwise, more invasive methods such as Zavanelli maneuver, abdominal rescue, or symphysiotomy are the last resorts.

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong.

INTRODUCTION: Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019. METHODS: This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods. RESULTS: The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045). CONCLUSION: More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study.

OBJECTIVE: To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI). DESIGN: Retrospective observational study. SETTING: Helsinki University Women's Hospital, Finland. SAMPLE: Deliveries with SD. METHODS: Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed. RESULTS: During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm. CONCLUSIONS: Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

Incidence of obstetric brachial plexus palsy after a training program in shoulder dystocia.

INTRODUCTION: Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis. MATERIAL AND METHODS: Retrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008-2016). RESULTS: In the 2017-2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation). CONCLUSION: These results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.

[Knowledge assessment of shoulder dystocia management by Spanish professionals.] / Evaluación del conocimiento en la resolución de la distocia de hombros en profesionales españoles.

OBJECTIVE: Shoulder dystocia (SD) training is recommended by diverse international healthcare organizations; however, it is not so in Spain, and there is no specific programmes. The objective of the study was to evaluate the level of knowledge and attitudes towards resolving a SD among a large sample of spanish obstetricians and midwives. METHODS: A multi-professional team carried out simulation-based training courses. Descriptive observational study where mean, standard deviation, minimum and maximum or median and interquartile intervals according to the distribution will be used for continuous variables. For the discrete variables, the number and the corresponding percentages will be reported. RESULTS: Between December 2015 and 2019, the team carried out 17 editions of SD workshop and 904 active professionals were trained in labour wards in different parts of Spain. The results showed that 64.8% of the professionals had learned to solve shoulder dystocia through books and/or 58.4% theoretical classes. 60.4% (380) of the respondents had not received any type of training in simulation in obstetrics. 87.1% (415/476) of the students had not felt prepared to face a SD when they finished the residency At the time of answering this survey, 61.8% (358) did not feel prepared to solve a SD. CONCLUSIONS: Training in Shoulder Dystocia in Spain is mainly theoretical and a high number of professionals recognize that they are not sufficiently prepared to face it with guarantees.

OBJETIVO: El entrenamiento en distocia de hombros (DH) está recomendado por numerosas sociedades médicas internacionales y, sin embargo, en España, no existen programas específicos de entrenamiento. El objetivo de este estudio fue evaluar el nivel de conocimiento y habilidades prácticas para resolver una distocia de hombros de un amplio número de matronas y ginecólogos españoles que habían realizado un curso basado en simulación. METODOS: El equipo multiprofesional de simulación obstétrica realizo talleres basados en simulación para la resolución de la DH. Estudio descriptivo observacional donde para las variables continuas se utilizará media, desviación estándar, mínimo y máximo o mediana e intervalos intercuartiles de acuerdo con la distribución. Para las variables discretas se reportarán el número y los porcentajes correspondientes. RESULTADOS: Entre diciembre de 2015 y 2019, el equipo llevo a cabo 17 ediciones del taller de DH y formo a 904 profesionales de diferentes partes de España. Los resultados mostraron que Un 64,8% de los profesionales había aprendido a solucionar la distocia de hombros a través de libros y/o un 58,4% clases teóricas. El 60,4% (380) de los encuestados, no había recibido ningún tipo de formación en simulación en obstetricia. Un 87,1% (415/476) de los alumnos no se había sentido preparado para enfrentarse a una DH cuando terminó la residencia En el momento de contestar esta encuesta, un 61,8% (358) no se sentía preparado para resolver una DH. CONCLUSIONES: La formación en distocia de hombros en España es principalmente teórica y un alto numero de profesionales reconoce que no están suficientemente preparados para afrontarla con garantías.

Shoulder Dystocia: Managing an Obstetric Emergency.

Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. This can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder, anal sphincter, and rectum, and postpartum hemorrhage. Although fetal macrosomia, prior shoulder dystocia, and preexisting or gestational diabetes mellitus increases the risk of shoulder dystocia, most cases occur without warning. Labor and delivery teams should always be prepared to recognize and treat this emergency. Training and simulation exercises improve physician and team performance when shoulder dystocia occurs. Unequivocally announcing that dystocia is happening, summoning extra assistance, keeping track of the time from delivery of the head to full delivery of the neonate, and communicating with the patient and health care team are helpful. Calm and thoughtful use of release maneuvers such as knee to chest (McRoberts maneuver), suprapubic pressure, posterior arm or shoulder delivery, and internal rotational maneuvers will almost always result in successful delivery. When these are unsuccessful, additional maneuvers, including intentional clavicular fracture or cephalic replacement, may lead to delivery. Each institution should consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal rescue and practice this during simulation exercises.

Maneuvering Through a Birth Complicated by Shoulder Dystocia.

Shoulder dystocia is an unpredictable intrapartum emergency with potentially devastating consequences. In this article, the etiology, pathophysiology, and clinical management of shoulder dystocia are reviewed; institutional readiness and potential legal implications are discussed. Also considered are posttraumatic stress disorder and secondary traumatic stress, adverse psychological consequences that may be experienced by women, midwives, and other intrapartum care providers, including staff.

Hybrid simulation for obstetrics training: A systematic review.

Hybrid simulation is defined as the use of a patient actor combined with a task trainer within the same session. We sought to investigate the level of evidence about the clinical benefits of hybrid simulation training in obstetrics. We searched MEDLINE using the keywords: Obstetrics AND Medical Education AND (Standardized patient OR Hybrid simulation). A total of 155 studies were screened, from which we selected 11 articles were selected from the title and the abstract in PubMed. For each study, data about the type of simulation, the level of evidence according KirkPatrick's hierarchy was collected. There is evidence that clinical benefit for patients exists for Shoulder Dystocia, and Cord prolapse. For Non-technical skills, such as communication or team training, hybrid simulation was also effective. Whether hybrid simulation offers better training for communication and better immersion than high-fidelity simulation for learners remains to be investigated.

The use of a hybrid mannequin for the modern high-fidelity simulation in the labor ward: the Italian experience of the Ecografia Gestione Emergenze Ostetriche (EGEO) group.

Regular training in the management of intrapartum emergencies has been demonstrated to yield measurable benefits in terms of maternal and perinatal outcomes. Thanks to technologic advances, computerized, full-body mannequins have been created and made available for high-fidelity simulation in obstetrics. The technical skills subjected to training are conventionally represented by classical manual maneuvers, which are recommended in the case of instrumental vaginal delivery, shoulder dystocia, or postpartum hemorrhage. During the past few years, manual skills in the labor ward have been increasingly supported by the use of ultrasound, and this has substantially altered the practical management of intrapartum emergencies in real life. Based on this, a new generation of mannequins suitable for both clinical maneuvers and ultrasound examination seems to be the most appropriate tool for the modern high-fidelity simulation in the management of intrapartum complications. The use of these new hybrid clinical ultrasound mannequins may usher in a new era in high-fidelity obstetric simulation and can hopefully optimize the competencies and technical skills of labor ward professionals in the management of obstetric emergencies. It is from this background that at the beginning of 2018, the Ecografia Gestione Emergenze Ostetriche group was founded in Italy. This group has aggregated a multiprofessional labor ward team including obstetricians, midwives, and anesthesiologists under the common philosophy that ultrasound provides an essential added value in the management of obstetric emergencies. Thanks to the use of these mannequins, the multiprofessional Italian Ecografia Gestione Emergenze Ostetriche group has started to run practical workshops to promote the culture of extraordinary synergy of ultrasound and clinical skills as the best approach to handle intrapartum complications.

Effect of Implementing a Standardized Shoulder Dystocia Documentation Form on Quality of Delivery Notes.

OBJECTIVES: Complete and accurate documentation by the delivering provider in cases of shoulder dystocia is critical for providing clinical information and care to the patient and protecting providers from litigation risks. Standardized forms improve inclusion of certain data elements in the medical record, but the impact on subsequent narrative notes is unknown. We aimed to determine if implementation of a standardized shoulder dystocia documentation form improves obstetric provider written narrative delivery notes. METHODS: In February 2005, our institution introduced a mandatory, standardized shoulder dystocia form containing 29 discrete data points relevant to shoulder dystocia documentation. We identified all deliveries complicated by shoulder dystocia from 1 year before and 4 years after implementation of this form and analyzed medical records for inclusion of delivery information in both the required form and the narrative delivery notes. RESULTS: We identified 52 cases before and 100 cases after implementation of the standardized form. Inclusion of elements from the form in narrative delivery notes increased significantly after implementation (P = 0.01). Elements present at higher rates included prepregnancy maternal weight (13% before vs 28% after, P = 0.043), total maternal weight gain (19% vs 36%, P = 0.03), estimated fetal weight (60% vs 77%, P = 0.03), duration of active labor (40% vs 65%, P < 0.01), duration of second stage (27% vs 52%, P < 0.01), and time of delivery from head to body (4% vs 30%, P < 0.01). CONCLUSIONS: Use of a mandatory shoulder dystocia documentation form is associated with significant improvement in the comprehensiveness of delivering provider narrative notes and may encourage more complete and accurate charting. Such improvements can allow for more complete and accurate explanation of events to patients and better demonstrate adherence to standards of care in the management of shoulder dystocia and may improve litigation defensibility.

Shoulder Shrug Maneuver to Facilitate Delivery During Shoulder Dystocia.

BACKGROUND: Shoulder dystocia is a potential complication of vaginal delivery that increases the chances of injury to the neonate and the mother. The incidence of dystocia can be up to 3%, and sudden presentation and the lack of reliable predictors make shoulder dystocia a challenge for obstetricians. TECHNIQUE: The shoulder shrug technique involves shrugging the posterior shoulder and rotating the head-shoulder unit 180 degrees to resolve the shoulder dystocia. EXPERIENCE: We describe successful delivery in three cases of persistent shoulder dystocia using the shoulder shrug technique after the dystocia could not be resolved with McRoberts maneuver. CONCLUSION: When successful, the shoulder shrug maneuver may decrease the likelihood of morbidity for the neonate. The technique has resolved dystocia in three cases in which the posterior shoulder could be shrugged. Because it does not take much time to perform the shoulder shrug maneuver, it is worth considering this technique during management of unresolved shoulder dystocia.

Difficult Delivery and Neonatal Resuscitation: A Novel Simulation for Emergency Medicine Residents.

INTRODUCTION: Newborn delivery and resuscitation are rare, but essential, emergency medicine (EM) skills. We evaluated the effect of simulation on EM residents' knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation. METHODS: We developed a novel simulation that integrates a shoulder dystocia with neonatal resuscitation and studied a convenience sample of EM residents. Each 15-minute simulation was run with one learner, a simulated nurse, and a standardized patient in situ in the emergency department. The learner was required to reduce a shoulder dystocia and then perform neonatal resuscitation. We debriefed with plus/delta format, standardized teaching points, and individualized feedback. We assessed knowledge with a nine-question multiple choice test, confidence with five-point Likert scales, and clinical performance using a checklist of critical actions. Residents repeated all measures one year after the simulation. RESULTS: A total of 23 residents completed all measures. At one-year post-intervention, residents scored 15% higher on the knowledge test. All residents increased confidence in managing shoulder dystocia on a five-point Likert scale (1.4 vs 2.8) and 80% increased confidence in performing neonatal resuscitation (1.8 vs 3.0). Mean scores on the checklist of critical actions improved by 19% for shoulder dystocia and by 27% for neonatal resuscitation. CONCLUSION: Implementing simulation may improve EM residents' knowledge, confidence, and clinical skills in managing shoulder dystocia and neonatal resuscitation.