Consider early delivery of posterior arm: approaches outlined for managing shoulder dystocia.(Obstetrics)

MAUI, HAWAII -- The different maneuvers to deliver a baby with shoulder dystocia fall into three categories: the good, the not bad, and the downright ugly.

Leading off the ugly category is traction with fundal pressure, which increased the neonatal death rate to 16% in one study, increased the rate of complications to 77% in another study, and increased complications by 28-fold compared with no fundal pressure in a third study, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

"Fundal pressure absolutely should not be used," he said.

To avoid litigation if a baby with shoulder dystocia has a bad outcome, train delivery room nurses to document suprapubic pressure if it is performed, but first to be sure that suprapubic pressure was actually used. "I frequently see situations where the nurse writes fundal pressure, and the doctor emphatically denies that fundal pressure was used," said Dr. Belfort, professor of ob.gyn. at the University of Utah, Salt Lake City.

Instead, address shoulder dystocia by trying the McRoberts maneuver, suprapubic pressure, and early attempts to deliver the posterior arm, he advised. Exaggerated flexion of the mother's legs in the McRoberts maneuver will not change the diameter of the pelvis, but it decreases the angle of inclination and may allow the blocked shoulder to dislodge. Don't be too exuberant with this maneuver, though, he cautioned. Prolonged or overly forceful flexion of the patient's hips can damage maternal femoral nerves, ligaments, or other body parts.

A recent case report from Georgetown University in Washington suggested that physicians should make earlier attempts to deliver the posterior arm of a baby with shoulder dystocia.

Also called the Barnum maneuver, delivery of the posterior arm allowed the fetal trunk to follow easily after initial attempts at the McRoberts maneuver with traction had failed. A geometric analysis concluded that using posterior arm delivery reduces the shoulder obstruction by more than a factor of two relative to the McRoberts maneuver (Obstet. Gynecol. 101[5, pt. 2]: 1068-72, 2003).