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The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest. CLINICAL. RISK. AVMA Conference July 12th 2002. BRACHIAL PLEXUS INJURY AT BIRTH. A TRACTION INJURY. Roger V Clements Editor:Clinical Risk. The Brachial Plexus. CLINICAL. RISK. AVMA Conference July 12th 2002.

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the avma medical and legal journal incorporating healthcare law digest
The AVMA Medical and Legal Journal

Incorporating

Healthcare & Law Digest

brachial plexus injury at birth

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A TRACTION INJURY

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth4

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A TRACTION INJURY

always?

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth5

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A TRACTION INJURY

almost always

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth6

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

Vaginal delivery:

cephalic presentation

complicated by shoulder dystocia

breech delivery employing the

Mauriceau-Smellie-Veit manoeuvre

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth8

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

Caesarean delivery:

cephalic presentation - a large baby and an inadequate incision

breech delivery - a tiny preterm baby through an injudicious ‘lower segment’ incision

Roger V Clements

Editor:Clinical Risk

shoulder dystocia

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Incidence 1.02%

(range 0.1% - 2%)

(underourished Chinese - overweight Americans)

Roger V Clements

Editor:Clinical Risk

shoulder dystocia10

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Definition

“when the standard delivery procedures of gentle downward traction of the fetal head and moderate fundal pressure fail to accomplish delivery”

(O’Leary)

Roger V Clements

Editor:Clinical Risk

shoulder dystocia11

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Classification

O’Leary:According to treatment employed

Gibb: 3 degrees of difficulty

1. A little bit of difficulty with the shoulders

2. Unilateral

3. Bilateral

Roger V Clements

Editor:Clinical Risk

slide12

Bilateral

Unilateral

shoulder dystocia13

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Unilateral: usually deliverable with adequate technique

Bilateral: undeliverable vaginally

Roger V Clements

Editor:Clinical Risk

shoulder dystocia14

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

What if not relieved?

Asphyxia

brain damage

death

Roger V Clements

Editor:Clinical Risk

shoulder dystocia15

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Management at Delivery

McRoberts position/all fours

Suprapubic Pressure

Woods/Rubin Screw

Deliver Posterior Arm

Zavanelli Manoevre

Roger V Clements

Editor:Clinical Risk

shoulder dystocia23

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Management at Delivery

What not to do:-

firm traction

repeated traction

fundal pressure

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth24

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A TRACTION INJURY

almost always

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth25

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A TRACTION INJURY

but not quite always

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Anecdotal reports from 5 US centers of OBPI without recorded shoulder dystocia

Phoenix, Arizona

Green Bay, Wisconsin

Salt Lake City, Utah

Iowa City, Iowa

Los Angeles, California

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia27

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Phoenix, Arizona

Intra-uterine maladaptation

“incontrovertible evidence”

intrauterine pressures

uterine anomalies

Jennett R J, Tarby T J & Kreinick M A Brachial Plexus Palsy: An old problem revisited. Am J Obst Gynecol 1992; 166:16733-7

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia28

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Green Bay, Wisconsin

Propulsive theory

“strong retraction forces of the fetal head between…contractions after pushing…stretching of the nerves occurs because of the disproportionate descent of the head… before complete delivery”

Sandmire H F & DeMott RK Erbs’ palsy: Concepts of Causation. Obstetrics and Gynaecology 2000;95:941-942

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia29

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Salt Lake City, Utah

Propulsive theory

Observation of OBPI to the posterior shoulder

Hankins G D V & Clark S L Brachial Plexus Palsy involving the posterior shoulder at spontaneous vaginal delivery American J Perinatolgy 1995;12:44-45

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia30

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Los Angeles, California

Propulsive theory

Four cases that occurred in the absence of shoulder dystocia…...and four cases ….. in the posterior arm of infants with anterior shoulder dystocia

Ouzounian J G, Korst LM and Phelan J P Permanent Erb’s palsy: a traction-related injury? Obstetrics and Gynaecology 1997; 89:139-141

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia31

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

Iowa City, Iowa

Completely idiopathic

“The forces of labor, maternal pelvic anatomy, and fetal position interact in such a way as to make certain fetuses more vulnerable..”

Peleg D, Hasnin J & Shalev E Fractured clavicle and Erb’s palsy unrelated to birth trauma Am J Obstet Gynecol 1997;177:1038-40

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth32

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

1. Downward and lateral traction in an attempt to free the anterior shoulder in the presence of shoulder dystocia is the most likely cause of damage to the anterior brachial plexus

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth33

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

2. There is currently no good evidence for asserting that, when there has clearly been shoulder dystocia and the anterior brachial plexus has been damaged,………………..

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth34

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

2. ……the injury was due to anything other than lateral and downward traction against resistance.

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth35

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

3. There, is in many cases, no documented account of shoulder dystocia when there is brachial plexus injury. Even when under-reporting is taken into consideration there may remain some cases in which shoulder dystocia has not occurred.

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury without shoulder dystocia36

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA

a. a vulnerable hypotonic fetus

b. pressure from the sacral promontory

c. pressure from fetal or uterine tumour/abnormality

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth37

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

4. The mechanism by which propulsive forces can produce traction on nerves that are below the point at which the force operates is not clear. The fact that the anterior aspect of the neck is flexed when the head is born…………………………………..

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth38

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

4. ………………..and the anterior shoulder is fixed above the pelvic brim must be an added safeguard against stretching of the anterior plexus.

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth39

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

5. Unanswered questions remain about both shoulder dystocia and brachial plexus injury and these require carefully planned, large, prospective studies…………….

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

brachial plexus injury at birth40

CLINICAL

RISK

AVMA Conference July 12th 2002

BRACHIAL PLEXUS INJURY AT BIRTH

A review of the literature leads to the following conclusions:-

5. Despite the practical difficulties, there is some expectation that valid studies might eventually be forthcoming.

Stirrat GM & Taylor R Mechanisms of Obstetric Brachial Plexus Palsy - A Critical Analysis

Clinical Risk November 2002 (in Press)

Roger V Clements

Editor:Clinical Risk

shoulder dystocia41

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Date Dependent

Difficult to Win

Notes

Eye Witnesses

Roger V Clements

Editor:Clinical Risk

shoulder dystocia date dependent

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADate Dependent

McRoberts 1983-1991

O’Leary (US) 1992

Safe Practice late 1994

Clinical Risk March 1995

Mayes’ Midwifery 1997

Roger V Clements

Editor:Clinical Risk

shoulder dystocia difficult to win

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADifficult to Win

Elective Caesarean Section

Emergency CS (in labour)

Management at Delivery

Roger V Clements

Editor:Clinical Risk

shoulder dystocia difficult to win45

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADifficult to Win

Elective Caesarean Section

Suspicion of Macrosomia

Confirmation of Macrosomia

Diabetic > 4.5 Kg

Non-Diabetic > 5 Kg

Roger V Clements

Editor:Clinical Risk

shoulder dystocia difficult to win46

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADifficult to Win

Elective Caesarean Section

Previous Shoulder Dystocia?

Previous Brachial Plexus Injury

Previous Associated Asphyxial Injury

Roger V Clements

Editor:Clinical Risk

shoulder dystocia difficult to win47

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADifficult to Win

Emergency C S in Labour

Foreseeable risk of injury

Foreseeable risk of asphyxia

Roger V Clements

Editor:Clinical Risk

shoulder dystocia difficult to win48

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIADifficult to Win

Management At Delivery

What is in the notes?

What do the eye witnesses remember?

What actually happened?

Roger V Clements

Editor:Clinical Risk

shoulder dystocia49

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIA

Management at Delivery

McRoberts position/all fours

Suprapubic Pressure

Woods/Rubin Screw

Deliver Posterior Arm

Zavanelli Manoevre

Roger V Clements

Editor:Clinical Risk

shoulder dystocia easy to defend

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIAEasy To Defend

Particularly if:-

Nothing in the notes

No third party or can’t remember

Roger V Clements

Editor:Clinical Risk

shoulder dystocia relationship with asphyxia

CLINICAL

RISK

AVMA Conference July 12th 2002

SHOULDER DYSTOCIARelationship with Asphyxia

Early in labour favours the claimant

Late in labour favours the defendant

Roger V Clements

Editor:Clinical Risk

the avma medical and legal journal incorporating healthcare law digest52
The AVMA Medical and Legal Journal

Incorporating

Healthcare & Law Digest