SHOULDER DYSTOCIA - AN ANALYSIS OF RISKS AND OBSTETRIC MANEUVERS

OBJECTIVE: The purpose of this study was to determine whether there is a risk profile for predicting or preventing shoulder dystocia and whe ther any of the obstetric maneuvers to disimpact a shoulder reduce the likelihood of permanent injury. STUDY DESIGN: A retrospective analysi s of 14.297 parturients with 12,532 vaginal deliveries and 1765 cesare an sections (12.4%) from January 1986 through June 1990 was performed. A total of 204 maternal and infant charts, related to shoulder dystoc ia or neonatal injury, were reviewed in depth for age, parity, episiot omy, type of delivery, hemorrhage, maternal obesity, diabetes, weight gain, fetal weight, sex, and Apgar scores. In addition, the type of ma neuver or combination thereof used to relieve the dystocia, type of in jury to the infant, and follow-up of the injury were reviewed. RESULTS : The 185 coded episodes of shoulder dystocia represent 1.4% of all va ginal deliveries (12,532). There were 42 injuries recorded: 14 fractur ed clavicles and 28 brachial plexus injuries. An additional 19 patient s, not coded for shoulder dystocia, sustained 14 fractured clavicles a nd five brachial plexus injuries. All but one of the brachial plexus i njuries resolved by 6 months. The occurrence of shoulder dystocia incr eased in direct relationship to the birth weight and becomes significa nt in newborns over 4000 gm (p < 0.01). The occurrence of a previous l arge infant was also a significant risk factor (p < 0.01). Diabetes an d midforceps delivery become significant factors only in the presence of a large fetus. Obesity, multiparity, postdate pregnancy, use of oxy tocin, low forceps delivery, episiotomy, and type of anesthesia were u nrelated to shoulder dystocia. No delivery method was without injury. CONCLUSIONS: This study clearly indicates that most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for pe rmanent injury are virtually impossible to predict. In addition, no de livery method in shoulder dystocia was superior to another with respec t to injury. Thus no protocol should serve to substitute for clinical judgment.