Expert Commentary
Does episiotomy at vacuum delivery increase maternal morbidity?
Yes: Median episiotomy was associated with an increased rate of 3rd- and 4th-degree perineal laceration in both nulliparous and multiparous women...
Shoulder dystocia is an unpredictable obstetric emergency that challenges all obstetricians and midwives. In response to a shoulder dystocia emergency, most clinicians implement a sequence of well-practiced steps that begin with early recognition of the problem, clear communication of the emergency with delivery room staff, and a call for help to available clinicians. Management steps may include:
- instructing the mother to stop pushing and moving the mother's buttocks to the edge of the bed
- ensuring there is not a tight nuchal cord
- committing to avoiding the use of excessive force on the fetal head and neck
- considering performing an episiotomy
- performing the McRoberts maneuver combined with suprapubic pressure
- using a rotational maneuver, such as the Woods maneuver or the Rubin maneuver
- delivering the posterior arm
- considering the Gaskin all-four maneuver.
When initial management steps are not enoughIf this sequence of steps does not result in successful vaginal delivery, additional options include: clavicle fracture, cephalic replacement followed by cesarean delivery (Zavanelli maneuver), symphysiotomy, or fundal pressure combined with a rotational maneuver. Another simple intervention that is not discussed widely in medical textbooks or taught during training is the posterior axilla maneuver.
Posterior axilla maneuversVarying posterior axilla maneuvers have been described by many expert obstetricians, including Willughby (17th Century),1 Holman (1963),2 Schramm (1983),3 Menticoglou (2006),4 and Hofmeyr and Cluver (2009, 2015).5−7
Willughby maneuverPercival Willughby’s (1596−1685) description of a posterior axilla maneuver was brief1:
After the head is born, if the child through the greatness of the shoulders, should stick at the neck, let the midwife put her fingers under the child's armpit and give it a nudge, thrusting it to the other side with her finger, drawing the child or she may quickly bring forth the shoulders, without offering to put it forth by her hands clasped about the neck, which might endanger the breaking of the neck.
Holman maneuverHolman described a maneuver with the following steps2:
- perform an episiotomy
- place a finger in the posterior axilla and draw the posterior shoulder down along the pelvic axis
- simultaneously have an assistant perform suprapubic pressure and
- if necessary, insert two supinated fingers under the pubic arch and press and rock the anterior shoulder, tilting the anterior shoulder toward the hollow of the sacrum while simultaneously gently pulling the posterior axilla along the pelvic axis.
Schramm maneuverSchramm, working with a population enriched with women with diabetes, frequently encountered shoulder dystocia and recommended3:
If the posterior axilla can be reached—in other words, if the posterior shoulder is engaged—in my experience it can always be delivered by rotating it to the anterior position while at the same time applying traction....I normally place 1 or 2 fingers of my right hand in the posterior axilla and “scruff” the neck with my left hand, applying both rotation and traction. Because this grip is somewhat insecure, the resultant tractive force is limited and I consider this manoeuvre to be the most effective and least traumatic method of relieving moderate to severe obstruction.
Practice your shoulder dystocia maneuvers using simulation
Obstetric emergencies trigger a rush of adrenaline and great stress for the obstetrician and delivery room team. This may adversely impact motor performance, decision making, and communication skills.1 Low- and high-fidelity simulation exercises create an environment in which the obstetrics team can practice the sequence of maneuvers and seamless teamwork needed to successfully resolve a shoulder dystocia.2,3 Implementing a shoulder dystocia protocol and practicing the protocol using team-based simulation may help to reduce the adverse outcomes of shoulder dystocia.3,4
Reference
1. Wetzel CM, Kneebone RL, Woloshynowych M, et al. The effects of stress on surgical performance. Am J Surg. 2006;191(1):5−10.
2. Crofts JF, Fox R, Ellis D, Winter C, Hinshaw K, Draycott TJ. Observations from 450 shoulder dystocia simulations. Obstet Gynecol. 2008;112(4):906−912.
3. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112(1):14−20.
4. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205(6):513−517.
Manipulation of the posterior axilla |
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The right and left third fingers are locked into the posterior axilla, one finger from the front and one from the back of the fetus. Gentle downward guidance is provided by the fingers to draw the posterior shoulder down and out along the curve of the sacrum, thus releasing the anterior shoulder.4 In this drawing, an assistant gently holds the head up. |
Menticoglou maneuverMenticoglou noted that delivery of the posterior arm generally resolves almost all cases of shoulder dystocia. However, if the posterior arm is extended and trapped between the fetus and maternal pelvic side-wall, it may be difficult to deliver the posterior arm. In these cases he recommended having an assistant gently hold, not pull, the fetal head upward and, at the same time, having the obstetrician get on one knee, placing the middle fingers of both hands into the posterior axilla of the fetus.4
