Following the devastating incident that has happened recently, it might be useful to review what the literature says about this very critical situation.
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Accidental Fetal Decapitation: A Case of Medical and Ethical Mishap
American Journal of Forensic Medicine & Pathology
Abstract
Blunt trauma to the head and neck of a newborn during delivery process is a rare event. We report a peculiar case of decapitation of a live fetus during vacuum-assisted delivery, where excessive traction on the head of the full-term macrosomic fetus with shoulder dystocia resulted in overstretching of the neck up to the point of decapitation. The ethical considerations related to the case are discussed in light of the policy of complete transparency advocated by the medical profession. Despite the existence of regulations regarding full disclosure of errors to the medical institution, the Ministry of Health and to the patient, medical practitioners are reluctant to divulge all the details of adverse events to the patient.
(C) 2011 Lippincott Williams & Wilkins, Inc.
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Shoulder dystocia: An update and review of new techniques
C A Cluver, MB ChB
Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Tygerberg, W CapeG J Hofmeyr, MB ChB, MRCOG
Effective Care Research Unit, University of the Witwatersrand/Fort Hare and Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, E CapeAbstract
The definition of shoulder dystocia and the incidence vary. Worldwide, shoulder dystocia may be increasing. In this update we look at the complications for both mother and fetus, and review the risk factors and strategies for possible prevention. Management options include the McRoberts position, techniques to deliver the anterior and posterior shoulder, and finally salvage manoeuvres, which include posterior axillary sling traction (PAST), the Zavanelli manoeuvre and fracture of the clavicles. In cases of fetal death associated with undelivered shoulder dystocia, one can consider the trans-abdominal performance or facilitation of traditional vaginal manoeuvres. We suggest a simplified mnemonic, ‘MAPS’ – M: McRoberts, A: anterior shoulder, P: posterior shoulder, and S: salvage. A video teaching programme will be available shortly on the World Health Organization Reproductive Health Library (www.who.int/rhl; rhl@who.int).
To read the fulltext article follow the link: http://www.ajol.info/index.php/sajog/article/viewFile/50343/39030
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Determining factors associated with shoulder dystocia: a population-based study
Eyal Sheinera, Amalia Levy, Reli Hershkovitz, Mordechai Hallak, Rachel D. Hammel, Miriam Katz, Moshe Mazor
Abstract
Objective: The study was aimed to define obstetric factors associated with shoulder dystocia. Methods: A population-based study comparing all singleton, vertex, term deliveries with shoulder dystocia with deliveries without shoulder dystocia was performed. Statistical analysis was done using multiple logistic regression analysis. Results: Shoulder dystocia complicated 0.2% (n = 245) of all deliveries included in the study (n = 107965). Independent risk factors for shoulder dystocia in a multivariable analysis were birth-weight 4000 g (OR = 24.3; 95% CI 18.5–31.8), vacuum delivery (OR = 5.7, 95% CI 3.4–9.5), diabetes mellitus (OR = 1.7, 95% CI 1.2–2.5) and lack of prenatal care (OR = 1.5, 95% CI 1.1–2.3). A significant linear association was found between birth-weight and shoulder dystocia, using the Mantel–Haenszel procedure. Pregnancies complicated with shoulder dystocia had higher rates of third-degree perineal tears as compared to the comparison group (0.8% versus 0.1%; P < 0.001). Similarly, perinatal mortality was higher among newborns delivered after shoulder dystocia as compared to the comparison group (3.7% versus 0.5%; OR = 7.4, 95% CI 3.5–14.9, P<0.001). In addition, these newborns had higher rates of Apgar scores lower than 7 at 1 and 5 min as compared to newborns delivered without shoulder dystocia (29.7% versus 3.0%; OR = 13.8, 95% CI 10.3–18.4, P<0.001 and 2.1% versus 0.3%; OR = 7.2, 95% CI 2.8–18.1, P <0.001, respectively). Combining risk factors such as large for gestational age, diabetes mellitus and vacuum delivery increased the risk for shoulder dystocia to 6.8% (OR = 32.6, 95% CI 10.1–105.8, P <0.001). Conclusions: Independent factors associated with shoulder dystocia were birth-weight 4000 g, vacuum delivery, diabetes mellitus
and lack of prenatal care.Keywords: Shoulder dystocia; Birth-weight greater than 4000 g; Gestational diabetes; Vacuum delivery
To read the fulltext article follow the link: http://www.reseau-naissance.com/joomla/images/dystocie_epaule.pdf
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Safety of Induction of Labor with Vaginal Prostaglandins (E2) in Grandmultipara
Abstract
Objectives: The aim of this study is to determine safety of induction of labor with vaginal Prostaglandins (E2) in Grand Multipara.
Methods: Prostaglandin E2 was used in the form of vaginal tablets or gel in post fornix for induction as per protocol. Maternal and fetal data collected included age, parity, and indication of induction, bishops score, total dose of PGE2 used & complications of induction of labor. The data was collected and analyzed using Epi info – 6.
Results: 50% cases were induced for past dates, the ceasarean rate was high in the induction group (19.5% ) compared to the control (12.5% ) OR 1.69 RR 1.37(95% CI-1.07-1.75) difference was statistically significant. Adverse neonatal outcome was found to be similar in both groups. Special Care Baby Unit (SCBU) admissions were 19 in the induction group and 21 in the control group, which was not statistically significant. No severe maternal complications were observed such as infection or uterine rupture.
Conclusion: As there were no adverse events in the study, it may be safe to use vaginal PGE2 as method of choice for induction of labour in grand mutipara. However, RCT for further validation of these findings is recommended.
To read the fulltext article follow the link: http://www.omjournal.org/OriginalArticles/PDF/200907/OA_SafetyofInductionofLabor.pdf
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Negligent Antenatal Disclosure and Management of Labour
Rob Heywood, UEA Law School
Nadine Montgomery v Lanarkshire Health Board [2010] CSOH 104; 2010 WL 3073077
Introduction
The recent Scottish case of Nadine Montgomery v Lanarkshire Health Board [2010] CSOH 104; 2010 WL 3073077, heard in the Outer House of the Court of Session, raises numerous issues in respect of negligent management of labour and antenatal disclosure. The pursuer in the case, Nadine Montgomery, brought the action as guardian of her son, Sam Montgomery. She alleged negligence against Dr McLellan, the consultant obstetrician who was in charge of her antenatal care and labour during the course of her pregnancy. On the September 30 1999, the pursuer’s labour began. At or around 17:45 on the October 1 1999, Sam’s head was delivered and, at that point, he started to show signs of shoulder dystocia. The remainder of his body was not delivered until about 17:57. This delay caused Sam to experience a period of acute hypoxia lasting for at least twelve minutes, the effect of which was that Sam was pronounced clinically dead at birth. He was resuscitated but unfortunately suffered renal damage, epileptic seizures, and was diagnosed with dyskinetic cerebral palsy which affected all four limbs. In addition, the medical procedures which were used to remedy the shoulder dystocia caused a brachial plexus injury involving Erb’s palsy of the upper limb. The pursuer argued her case under two distinct headings. First, it was claimed that no ordinary competent obstetrician acting with reasonable skill and care would have: (a) allowed a diabetic woman of short stature with a macrosomic foetus in ‘early trial of labour’ whose foetal heartbeat was grossly abnormal to continue in labour and attempt a vaginal delivery; (b) failed to recommend delivery by caesarean section between 08:10 and 17:00 h on the 1st October at the latest; and (c) failed to take foetal blood samples (FBS) between 08:10 and 17:00 h on the same day. …
To read the fulltext article follow the link: http://medlaw.oxfordjournals.org/content/19/1/140.extract
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Shoulder dystocia: The unpreventable obstetric emergency with empiric management guidelines
Abstract
Objective
Much of our understanding and knowledge of shoulder dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is shoulder dystocia predictable? (2) Can shoulder dsytocia be prevented? (3) When shoulder dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of shoulder dystocia?
Study design
Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word “shoulder dystocia.” We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion.
Results
There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of shoulder dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of shoulder-dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a shoulder dystocia event before any iatrogenic intervention may be associated with brachial plexus injury.
Conclusion
For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of shoulder dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by shoulder dystocia.
Key words: Shoulder dystocia, Brachial plexus palsy, Risk factors, Management
To read the fulltext article follow the link: http://www.ajog.org/article/S0002-9378%2805%2901463-8/abstract
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Clinical Obstetrics & Gynecology:June 2000 – Volume 43 – Issue 2 – pp 226-235Shoulder Dystocia: Lessons From the Past and Emerging Concepts
Romoff, Adam MD
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Haven’t come across any article that talks about a procedure where such drastic action was taken as was the case at IGMH. These types of incidences would not be very public and might be very rare. If any of you come across a useful article in this topic please leave a comment with details of the article/book.
