547

548

549 EPISIOTOMY VS FETAL MANIPULATION MANEUVERS IN THE MAN-AGEMENT OF SEVERE SHOULDER DYSTOCIA: A COMPARISON OFOUTCOMES EDITH GUREWITSCH1, MICHELE DONITHAN2, SCOTTPETERSEN1, PATRICIA MOORE1, LEORA ALLEN3, ROBERT ALLEN4,1Johns Hopkins University, Gyn/Ob, Baltimore, MD 2Johns HopkinsUniversity, Epidemiology, Baltimore, MD 3Johns Hopkins University, Nurs-ing, Baltimore, MD 4Johns Hopkins University, Biomed Eng, Baltimore, MD

OBJECTIVE: In severe shoulder dystocia (SD), when initial maneuvers fail,either episiotomy (Epis) or fetal manipulation maneuvers (Rubin, Woods orposterior arm release) are recommended. We sought to compare maternal andneonatal outcomes between severe SD deliveries managed with Epis and severeSD deliveries managed with fetal manipulation maneuvers (FMM).

STUDY DESIGN: Using at least 1 of 3 criteria: head-to-body interval$90 s,use of proctoepisiotomy and/or FMM, or 5-min Apgar < 7 and/or UA pH#7.1,we identified severe SD deliveries from 2 databases: all SD deliveries (1993-2003)at a single institution and litigated cases of SD-associated permanent brachialplexus palsy (BPP) from multiple U.S. institutions. We restricted our analysis todeliveries managed by FMM without Epis and those managed by Epis withoutFMM. Rates of permanent BPP, neonatal depression (NeoDep), and analsphincter trauma (3/4 lac) were compared between groups, using chi-square,with significance at P < 0.05. A stepwise linear regression analysis was performedto control for potential confounders.

RESULTS: Of 175 severe SD deliveries, 83 managed with both Epis andFMM and 14 managed with neither Epis nor FMM were excluded. Of 40 Episwithout FMM (Table), 9 were deliberate proctoepisiotomies. Epis wassignificantly correlated with 3/4 lac, with a trend toward more permanentBPP. After controlling for birth weight and maternal weight, neither FMM norEpis was correlated with either permanent BPP or NeoDep, but Epis was highlyassociated with 3/4 lac (OR 59.4, CI: 6.5-543.9).

CONCLUSION: Although Epis and FMM are most often used together inmanagement of severe SD, if FMM can be accomplished without Epis, 3/4 laccan be averted and fewer permanent BPP may occur.

Maternal and neonatal complications

Epis without FMM FMM without Epis P value

Permanent BPP 24 (60%) 15 (39.5%) 0.07Neonatal depression 12 (30%) 6 (16%) 0.1538 or 48 Laceration 20 (50%) 1 (2.6%) < 0.0001

December 2003Am J Obstet Gynecol

S208 SMFM Abstracts

DO ANTEPARTUM AND INTRAPARTUM RISK FACTORS DIFFER BE-TWEEN MILD AND SEVERE SHOULDER DYSTOCIA? ROBERT ALLEN1,SCOTT PETERSEN2, PATRICIA MOORE2, LEORA ALLEN3, YONAHHELLER4, EDITH GUREWITSCH2, 1Johns Hopkins University, BiomedEng, Baltimore, MD 2Johns Hopkins University, Gyn/Ob, Baltimore, MD3Johns Hopkins University, Nursing, Baltimore, MD; 4RDA, Research,Baltimore, MD

OBJECTIVES: To propose objective criteria to distinguish mild from severeshoulder dystocia (SD) and to evaluate whether antepartum (AP) orintrapartum (IP) variables differ between these 2 groups.

STUDY DESIGN: SD deliveries were identified from 2 databases: all SDdeliveries (1993-2003) from a single institution and litigated cases of SD-associated permanent brachial plexus palsy from multiple U.S. institutions. AnSD delivery was labeled severe if at least 1 of 3 conditions weremet: head-to-bodydelivery interval $90 s, use of proctoepisiotomy and/or any fetal maneuvers(Rubin, Woods or posterior arm release), 5-min Apgar < 7 and/or UA pH#7.1.AP and IP variables (Table) were compared between groups, using v2, withsignificance at P < 0.05.

RESULTS: Maternal weight was significantly greater in patients with severeSD compared to mild SD. Other AP and IP variables were not significant.

CONCLUSION: Among SD deliveries, only maternal weight correlatessignificantly with severity of SD. Abnormal 2nd-stage labor is no more prevalentin severe SD than in mild SD.

Antepartum and intrapartum risk factors

Mild ShoulderDystocia

(N = 256)

Severe ShoulderDystocia

(N = 175) P Value

Mat age (yrs) 25.2 ± 6.5 26.3 ± 6.4 0.08Mat ht (cms) 162 ± 6.7 163.2 ± 6.6 0.32Mat wt (kg) 87.0 ± 17.9 94.3 ± 21.8 0.0005Gest age (wks) 39.5 ± 1.4 39.4 ± 1.7 0.44Multiparity 62.8% (160/255) 64.5% (109/171) 0.83Diabetes 13.5% (34/252) 16.6% (28/169) 0.38Prolonged 2nd stage 14.3% (32/224) 14.8% (22/149) 0.90Precipitous 2nd stage 29.5% (66/224) 22.5% (34/151) 0.14Operative vag deliv 32.8% (84/256) 34.3% (60/175) 0.75

OUTCOMES OF MILD VS SEVERE SHOULDER DYSTOCIA EDITHGUREWITSCH1, MICHELE DONITHAN2, PATRICIA MOORE1, LEORAALLEN3, SCOTT PETERSEN1, ROBERT ALLEN4, 1Johns Hopkins Univer-sity, Gyn/Ob, Baltimore, MD 2Johns Hopkins University, Epidemiology,Baltimore, MD 3Johns Hopkins University, Nursing, Baltimore, MD 4JohnsHopkins University, Biomed Eng, Baltimore, MD

OBJECTIVES: To propose objective criteria to distinguish mild from severeshoulder dystocia (SD) and compare maternal and neonatal complications andtheir severity between these two groups.

STUDY DESIGN: SD deliveries culled from 2 databases (all SD [1993-2003]from a single institution and litigated cases of SD-associated permanent brachialplexus palsy [BPP] from multiple U.S. institutions) were categorized as severe ifat least 1 of 3 conditions were met: head-to-body delivery interval $90 s, use ofproctoepisiotomy and/or any fetal maneuvers (Rubin, Woods or posterior armrelease), or 5-min Apgar < 7 and/or UA pH#7.1. The remainder were deemedmild. Maternal and neonatal complications (Table) were compared betweengroups, using v2, with significance at P < 0.05. Temporary BPP resolved within 2years. A permanent BPP was considered severe if there was lower nerve rootinvolvement (C8 and/or T1) and/or at least one avulsion. For BPP cases,a stepwise linear regression model was used to evaluate the effect of SD severityon outcome.

RESULTS: Anal sphincter trauma (3/4 lac) and BPP occur more often insevere SD than in mild SD. After controlling for maternal obesity and birthweight, severe SD is significantly associated with permanent BPP (OR3.0, CI: 1.3-6.8). However, when a permanent BPP is sustained, the frequency of severe BPPis the same in mild and severe SD.

CONCLUSION: Among SD deliveries, 3/4 lac and BPP correlate withseverity of shoulder dystocia. However, among permanent BPP, severe palsiesoccur with equal frequency in either mild or severe SD deliveries.

550 AN OBJECTIVE EVALUATION OF MCROBERTS’ AND RUBIN’S MANEU-VERS FOR SHOULDER DYSTOCIA EDITH GUREWITSCH1, ESTHERKIM2, JASON YANG2, KATHERINE OUTLAND3, ROBERT ALLEN2, 1JohnsHopkins University, Gyn/Ob, Baltimore, MD 2Johns Hopkins University,Biomed Eng, Baltimore, MD 3Johns Hopkins University, Biomed Engin,Baltimore, MD

OBJECTIVE: To objectively compare the effect of two different initialshoulder dystocia (SD)maneuvers on traction force, neck rotation, and brachialplexus (BP) stretch.

STUDY DESIGN: We developed a laboratory birthing simulator with aninstrumented fetal model, a force-sensing glove, and a computer-based dataacquisition system. Peak traction force, BP stretch, and fetal neck rotation weremeasured during 30 simulated SD deliveries carried out by a single operatorusing standard downward traction after the head was delivered and 1 maneuverwas performed. 10 deliveries simulated McRoberts’ maneuver (MM) with fetalshoulders in the A-P diameter of the pelvis and fetal head in ROT position. 20deliveries simulated Rubin’s maneuver (RbM). 10 deliveries involved rotatingthe shoulders;308 clockwise to align with the oblique pelvic diameter, with thespine oriented anteriorly and head in ROA position externally (ROA rotation).10 deliveries involved rotating the shoulders ;308 counterclockwise to theopposite oblique diameter, with the spine oriented posteriorly and head in ROPposition externally (ROP rotation). Variables (peak values) listed in the Tablewere compared between groups using ANOVA, with significance at P < 0.05.

RESULTS: RbMs were found to require less traction force than MMs. BPstretch was significantly lower with rotation of the shoulders in a direction thatorients the spine anteriorly.

CONCLUSION: As an initial maneuver for SD in a laboratory model,oblique rotation of the fetal shoulders that orients the spine anteriorly results inthe least traction needed for delivery and produces the least amount of BPstretch.

Maternal and neonatal complications

Mild SD(N = 256)

Severe SD(N = 175) P Value

38 or 48 Laceration 38 (14.8%) 68 (38.9%) <0.0001Fractured clavicle 30 (11.7%) 12 (6.9%) 0.10Any BPP (temp or perm) 100 (39.1%) 118 (67.4%) <0.0001Perm BPP (mild or severe) 60 (23.4%) 102 (58.3%) <0.0001Severe Perm BPP 22 (8.6%) 44 (25.1%) <0.0001Severe BPP among Perm BPP 22/60 (36.7%) 44/102 (43.1%) 0.42

Initial shoulder dystocia maneuver comparison

McRoberts’ ROP rotation ROA rotation P value

Traction force (lbs) 16.2 ± 2.1 8.8 ± 2.2 6.5 ± 1.8 < 0.0001Anterior BP stretch

(mm)7.3 ± 2.5 6.9 ± 2.9 2.9 ± 1.0 0.0003

Posterior BP stretch(mm)

2.3 ± 0.7 1.5 ± 0.4 0.9 ± 0.1 < 0.0001

Fetal neck rotation(degrees)

14.5 ± 6.7 9.6 ± 4.3 13.2 ± 3.3 0.09