The largest study of its kind has shed new light on how obstetricians should manage shoulder dystocia, a rare but serious complication of childbirth.
Data gathered from 132,098 births of babies delivered vaginally at term, including more than 15,000 at Christiana Hospital, indicate that doctors should deliver the posterior shoulder after they have tried two other widely accepted maneuvers for shoulder dystocia.
Christiana Care setting standards
The study, funded by the National Institute of Child Health and Human Development, was published as the lead article in the June edition of the journal Obstetrics & Gynecology.
“We look to data to help us make better decisions,” says Matt Hoffman, M.D., MPH., director of OB/GYN Education & Research and principal author of the study. “Christiana Care is helping to define and improve standards of care through large studies with the NICHD.”
Shoulder dystocia occurs when a baby’s anterior shoulder cannot pass beneath the joint that connects the mother’s pubic bones after the baby’s head has been delivered.
Because the condition is so rare, there was a lack of evidence-based knowledge on how to best manage the complication.
In addition to Christiana Care, the study involved nine other diverse, high-volume systems around the country. Overall, 1.5 percent of deliveries in this study — a total of 2,018 births — were complicated by shoulder dystocia.
Research by Dr. Hoffman and other investigators determined that delivery of the posterior shoulder had a successful outcome in 84.4 percent of cases, far higher than other methods. That method would be used after two less technically demanding interventions, the McRoberts maneuver, in which the mother’s legs are flexed tightly to her abdomen to widen the pelvis, and suprapubic pressure, in which pressure is applied to the lower abdomen as the baby’s head is gently pulled.
The rate of neonatal injury associated with delivery of the posterior shoulder was 8.4 percent, compared to 6.1-14 percent for other methods. None of the babies died.
Fewer maneuvers is safer for baby
The study also found that the risk of injury increased along with the number of maneuvers. Dr. Hoffman and the other researchers conclude that this strengthens the case for attempting posterior shoulder delivery before other, less-effective maneuvers.
Because shoulder dystocia occurs so infrequently and unpredictably, it had been difficult for doctors to prepare for the event. Now, clinicians are safety practicing maneuvers in a simulated setting at Christiana Care’s Virtual Education and Simulation Training (VEST) Center.
Dr. Hoffman also will teach a VEST course on delivery of the posterior shoulder in Cleveland this fall.
“This study provides a road map for dealing with this rare but potentially very serious condition,” he says.