acog simulation committee. outline learning objectives background management / treatment summary...
TRANSCRIPT
Outline
• Learning Objectives• Background• Management / Treatment• Summary• References
ACOG Simulation Committee
Learning ObjectivesAt the end of this presentation, participants should be able to:
• Identify factors for shoulder dystocia
• Communicate critical tasks that should be performed when this complication occurs
• Demonstrate proper technique for basic maneuvers to relieve shoulder dystocia
• Communicate effectively with delivery team during a shoulder dystocia
ACOG Simulation Committee
• Head successfully delivered• Shoulder lodged behind pubic bone• Posterior shoulder may be lodged
behind sacral promontory• Delivery arrested
Shoulder Dystocia
Identification of Shoulder Dystocia• Delivery of head with retraction against
maternal perineum (Turtle Sign)
• Delivery of head with arrest of shoulder delivery with usual delivery maneuver (axial traction on fetal head)
• Difficulty with or arrest of delivery of fetal head and chin
Risk Factors Shoulder Dystocia
• High fetal weight (actual vs. estimated)
• Obesity• Diabetes• Prior shoulder dystocia• Excessive weight gain• Prior macrosomic infant
• Abnormal labor pattern• Operative vaginal
delivery
Antepartum:
Intrapartum:
Prevention of Shoulder Dystocia • Prevention of shoulder dystocia with Cesarean
section prior to labor should only be considered in unusual circumstances:
– Estimated fetal weight (EFW) in diabetic of ≥4250 gms
– EFW in non diabetic of ≥5000 gms
– Prior shoulder dystocia with injury to infant (brachial plexus, limb fracture or asphyxia)
Effectiveness/Costs of Elective C/S for Fetal Macrosomia Diagnosed by U/S
per Million Non-Diabetic Women
Cesarean, Permanent Cost
Non-Diabetic BPP Avoided (Millions)
Standard Care — —
U/S: C/S if ≥4000 g 2345 $4.9
U/S: C/S if ≥4500 g 3695 $8.7
Effectiveness/Costs of Elective C/Sfor Fetal Macrosomia Diagnosed by U/S
per Million Diabetic Women
Cesarean, Permanent CostDiabetic BPP Avoided (Millions)
Standard Care — —
U/S: C/S if ≥4000 g 489 $0.93
U/S: C/S if ≥4500 g 443 $0.88
Rouse DJ, et al. JAMA 1996;276:1480–1486.
Complications with Shoulder Dystocia
Neonatal: • Brachial plexus injury, fracture
(humerus, clavicle)• Hypoxemia• Stillbirth
Maternal: • Perineal laceration• Uterine rupture• Hemorrhage• PTSD
Sever JW. Am J Diseases of Children Dec 1916;12(6):541–78.
One Presumed MechanismBrachial Plexus Injury
Natural Position Forcibly Separated
“The author, by numerous dissections on infantile cadavers, has shown that traction and forcible separation of the head and shoulder puts the upper cords, the 5th and 6th roots of the brachial plexus, under dangerous tension. This tension is so great that the two upper cords stand out like violin strings.”
Mollberg M et al. Jour Child Neurology Dec 2008;23(12):1424–32.
Correlation Between Degrees of Force Used in Downward Traction on Fetal Head and Number of Nerve Roots Affected
in Brachial Plexus Palsy at Birth
Obstetric Brachial Plexus PalsyNatural History
• The 2 studies (out of 7) which come closest to an ideal study show a tendency towards a 20–30% residual deficit, in contrast to the optimistic view of over 90% complete or almost complete recovery
• Physicians should exercise caution in predicting excellent recovery shortly after birth
Pondaag 2004. Develop Med and Child Neurology. Vol 46.
Allen RH et al. AJOG Oct 2002;187(4):839–42.
5-Min Apgars vs Head-to-Body Delivery Intervals
36 Neonates Who Sustained PBPI
Annual Shoulder Dystocia Training
1996–20002001–2004
Births 15,908 13,117
Shoulder Dystocia 324 (2.04%) 262 (2.0%)
Injuries 30 (9.3%) 6 (2.3%)*
§RR = 0.25 (0.11–5.7) *p< 0.001
Neonatal Injury§
Crofts & Draycott. Ob Gyn 2008;112:14–20.
Simulation & Outcomes
• Shoulder dystocia management protocol introduced
• All providers trained • Didactics • Simulations & Debriefing
• Evaluated fetal outcomes for three time periods
• 6 months before• 6 months during implementation• 6 months after
(Grobman 2011)
Neonatal Outcomes
Before During After0
2
4
6
8
10
12
BP Injury birthBP injury D/C
Shoulder Dystocia Algorithm• Call for Help: RN, Pediatrics, OB• Brief team huddle (clearly state problem, assign roles) • McRobert’s Maneuver (thighs to abdomen) • Suprapubic pressure routine delivery traction • Episiotomy if necessary to do internal maneuvers• Deliver posterior arm OR• Internal rotational maneuvers• All fours position and delivery of posterior shoulder• Cephalic replacement and Cesarean section
ACOG Simulation Committee
Move Thumb to Palm of Hand Prior to Vaginal Insertion
Shoulder Dystocia
Effect of Posterior Arm Delivery(reducing obstructing part of fetal shoulder)
ACOG Simulation Committee
Documentation After Shoulder Dystocia
Identification of complication as shoulder dystocia Pediatrician called/present at delivery Identification of anterior shoulder Quantification of traction Duration of shoulder dystocia Maneuvers used to resolve dystocia Cord blood gases sent or values noted Moro reflex Communication with patient about
events of delivery
Implementation of a standard checklist may be necessary to achieve complete documentation:
Documentation• Three important items uncommonly completed,
even after simulation training:– Quantification of traction– Neonatal evaluation for Moro reflex – Discussion of delivery events with mother
• Specific documentation components more likely to be present if checkboxes or headings to be completed:
– Position of fetal head– Head-to-shoulder delivery time – Classification as shoulder dystocia
What We Do Not Know • How to determine exact cause and timing
of brachial plexus injury • Correct delivery techniques to avoid injury
– Spontaneous delivery maneuvers – Shoulder dystocia maneuvers
• How to estimate fetal weight in a manner that will enhance clinical decision making
• Force characteristics to injure the brachial plexus • How to use antenatal and intrapartum risk
factors in a manner that will enhance clinical decision making
Optimal Management Suspected Fetal Macrosomia, Shoulder
Dystocia and Brachial Plexus Injury
• Discussion • Diagnosis• Documentation • Disclosure
Summary• Shoulder dystocia unpredictable and
most occur in patients with no risk factors
• Permanent fetal injury may be prevented by – limiting non-axial traction on fetal head – simulation training
• Documentation and debriefing after shoulder dystocia essential part of good patient care
ACOG Simulation Committee
References• Ouounian JG, Gherman RB. Shoulder dystocia: are historic risk factors reliable predictors? Am J Obstet Gynecol 2005;
192:1933-5.• Smith RB, Lane C, Pearson JF, Should dystocia: what happens at the next delivery? Br J Obstet Gynaecol 1994; 101:713-5.• Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am
J Obstet Gynecol 1998; 179:476-80.• Bahar AM. Risk factors and fetal outcome in cases of shoulder dystocia compared with normal deliveries of a similar birthweight.
Br J Obstet Gynaecol 1996; 103:868-72.• Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk.
Am J Obstet Gynecol 1987; 156:1408-18.• Rouse DJ, Owen J. Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography –
A Faustian bargain? Am J Obstet Gynecol 1999; 181:332-8.• Benedetti TJ, Gabbe SG. Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage labor
with midpelvic delivery. Obstet Gynecol 1978; 52:526-9.• Sandmire HF, O’Halloin TJ. Shoulder dystocia: its incidence and associated risk factors. Int J Gynaecol Obstet 1988; 26:65-73.• Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of pregnancy in a woman with an increased body mass index.
BJOG 2005; 112:768-72.• Bruner JP, Drummond SB, Meenan AL, Gaskin IM. All-fours maneuver for reducing shoulder dystocia during labor.
J Reprod Med 1998; 43:439-43.• Sandberg EC. The Zavanelli maneuver: a potentially revolutionary method for the resolution of shoulder dystocia.
Am J Obstet Gynecol 1985; 152:479-84.• Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training.
Obstet Gynecol 2008; 112:906-912.• Draycott TJ, Crofts JF, et al. Improving neonatal outcome through practical shoulder dystocia training.
Obstet Gynecol 2008; 112:14-20.• Grobman WA, Miller D, Burke C, et al. Outcomes associated with introduction of a shoulder dystocia protocol.
Am J Obstet Gynecol 2011; 205:513-517.• Crofts JF, Lenguerrand E, et al. Prevention of brachial plexus injury – 12 years of shoulder dystocia training:
an interrupted time-series study. BJOG 2015; doi: 10.1111/1471-0528.13302.• Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence
of brachial plexus injury. Am J Obstet Gynecol 2011; 204:322.e1-6.• Deering SH, Weeks L, Benedetti TJ. Evaluation of force applied during deliveries complicated
by shoulder dystocia using simulation. Am J Obstet Gynecol 2011; 204:234.e1-5.
Disclaimer• Every effort has been made to ensure that the instruction
and materials contained within this course are based on current evidence-based practice, but new recommendations may become available and inadvertent errors are always possible. In every case all variables must be taken into consideration and clinical judgment must be used. ACOG do not accept any liability for medical care rendered by those who take this course.
• All materials are copyrighted and provided for educational use and may not be modified, altered, or otherwise distributed without prior authorization.
ACOG Simulation Committee