Obstetric maneuvers for shoulder dystocia and associated fetal morbidity

OBJECTIVE: We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery. STUDY DESIGN: A retrospective review of 285 cases of shoulder dystocia that occurred between January 1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1) those resolved with McRoberts' maneuver, suprapubic pressure, or proctoepisiotomy or a combination of these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm, or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral fracture, or fetal death caused by asphyxial complications. RESULTS: The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%) clavicular fractures, and 12 (4.2%) humoral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of 158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs 21/158, p = 0.1). CONCLUSIONS: Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated with an increased rate of bone fracture or brachial plexus injury.