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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 independent of operator experience (3). Most cases resolve without permanent disability, with fewer than 10% resulting in permanent brachial plexus dysfunction (9). In the UK, neonatal brachial plexus injury is the single most common cause for litigation related to SD (3), while SD is among the four most common causes of medical litigation (10) and has been estimated to account for up to 11% of obstetric claims. Although it is recognised that not all brachial plexus injuries are due to excess traction and some brachial plexus injuries are not associated with clinically evident SD (11), good risk management requires that steps should be taken to address the possible prediction, prevention and management of SD, with good record-keeping standards throughout (12).Since the inception of the NHS Litigation Authority in 1995 it has received around 555 claims, in relation to SD, with an approximate value of £ 189.4 million.

Santo Bambino Hospital. Department of Microbiological and Gynecological Sciences. University of Catania, Italy 2 Artemisia Fetal Maternal Medical Centre, Department of Prenatal Diagnosis, Rome, ITALY 1

Corresponding author: Politi Salvatore, MD via Valverde n° 12 Santo Bambino Hospital. Department of Microbiological and Gynecological Sciences. University of Catania, Italy Mail: salvatore.politi@gmail.com

Summary
Shoulder Dystocia (SD) is the nightmare of obstetricians. Despite its low incidence, SD still represents a huge risk of morbidity for both the mother and fetus. Even though several studies showed the existence of both major and minor risk factors that may complicate a delivery, SD remains an unpreventable and unpredictable obstetric emergency. When it occurs, SD is difficult to manage due to the fact that there are not univocal algorithms for its management. Nevertheless, even if it is appropriately managed, SD is one of the most litigated cause in obstetrics, because it is frequently associated with permanent birth-related injuries and...
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