God Knows
Original article
Shoulder dystocia: an Evidence-Based approach
Salvatore Politi1 Laura D’Emidio2 Pietro Cignini2 Maurizio Giorlandino2 Claudio Giorlandino2
Introduction
Most often an unpredictable and unpreventable obstetric emergency, Shoulder Dystocia (SD) continues to evoke terror and fear among physicians, nurse midwives and other healthcare providers (1,2). SD is defined as a delivery that requires additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. SD occurs when either the anterior or, less commonly, the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory (3). Typically SD is heralded by the classic “turtle sign”: after the fetal head is delivered, it retracts back tightly against the maternal perineum (4). In order to objectively define SD, Spong and colleagues (5) proposed defining shoulder dystocia as a ‘‘prolonged head-to-body delivery time (eg, more than 60 seconds) and/or the necessitated use of ancillary obstetric maneuvers’’. The 60-second interval was selected because, in their study, it was approximately two standard deviations above the mean value for head-to-body time for uncomplicated deliveries. Despite this recommendation, SD remains an entity without a clear definition (6). Differences in reported rates are partly because of clinical variation in describing SD, the patient population studied and because milder forms may be over-diagnosed or under-diagnosed (1). The reported incidence ranges from 0,6% to 3% among vaginal deliveries of fetuses in the vertex presentation, but there can be a high perinatal mortality and morbidity even when SD is managed appropriately (7,8). Failure of the shoulder to delivery spontaneously places both the pregnant woman and fetus at high risk for permanent birth-related injury (1). Brachial plexus injuries are one of the most important fetal complications of SD, complicating 4–16% of such deliveries (7). This appears to be
Shoulder dystocia: an Evidence-Based approach
Salvatore Politi1 Laura D’Emidio2 Pietro Cignini2 Maurizio Giorlandino2 Claudio Giorlandino2
Introduction
Most often an unpredictable and unpreventable obstetric emergency, Shoulder Dystocia (SD) continues to evoke terror and fear among physicians, nurse midwives and other healthcare providers (1,2). SD is defined as a delivery that requires additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed. SD occurs when either the anterior or, less commonly, the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory (3). Typically SD is heralded by the classic “turtle sign”: after the fetal head is delivered, it retracts back tightly against the maternal perineum (4). In order to objectively define SD, Spong and colleagues (5) proposed defining shoulder dystocia as a ‘‘prolonged head-to-body delivery time (eg, more than 60 seconds) and/or the necessitated use of ancillary obstetric maneuvers’’. The 60-second interval was selected because, in their study, it was approximately two standard deviations above the mean value for head-to-body time for uncomplicated deliveries. Despite this recommendation, SD remains an entity without a clear definition (6). Differences in reported rates are partly because of clinical variation in describing SD, the patient population studied and because milder forms may be over-diagnosed or under-diagnosed (1). The reported incidence ranges from 0,6% to 3% among vaginal deliveries of fetuses in the vertex presentation, but there can be a high perinatal mortality and morbidity even when SD is managed appropriately (7,8). Failure of the shoulder to delivery spontaneously places both the pregnant woman and fetus at high risk for permanent birth-related injury (1). Brachial plexus injuries are one of the most important fetal complications of SD, complicating 4–16% of such deliveries (7). This appears to be