The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

1. The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

2. CLINICAL RISK AVMA Conference July 12th 2002 BRACHIAL PLEXUS INJURY AT BIRTH A TRACTION INJURY Roger V Clements Editor:Clinical Risk

3. The Brachial Plexus

4. CLINICAL RISK AVMA Conference July 12th 2002 BRACHIAL PLEXUS INJURY AT BIRTH A TRACTION INJURY always? Roger V Clements Editor:Clinical Risk

5. CLINICAL RISK AVMA Conference July 12th 2002 BRACHIAL PLEXUS INJURY AT BIRTH A TRACTION INJURY almost always Roger V Clements Editor:Clinical Risk

6. 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

7. The Mauriceau-Smellie-Veit Manoeuvre

8. 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

9. 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

10. 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

11. 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

12. Bilateral Unilateral

13. CLINICAL RISK AVMA Conference July 12th 2002 SHOULDER DYSTOCIA Unilateral: usually deliverable with adequate technique Bilateral: undeliverable vaginally Roger V Clements Editor:Clinical Risk

14. CLINICAL RISK AVMA Conference July 12th 2002 SHOULDER DYSTOCIA What if not relieved? Asphyxia brain damage death Roger V Clements Editor:Clinical Risk

15. 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

16. McRoberts Position

17. Suprapubic Pressure - Single-handed

18. The Woods Screw Manoeuvre in All-Fours

19. Delivery of the posterior arm 1

20. Delivery of the posterior arm 2

21. Delivery of the posterior arm 3

22. Delivery of the posterior arm 4

23. 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

24. CLINICAL RISK AVMA Conference July 12th 2002 BRACHIAL PLEXUS INJURY AT BIRTH A TRACTION INJURY almost always Roger V Clements Editor:Clinical Risk

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. CLINICAL RISK AVMA Conference July 12th 2002 SHOULDER DYSTOCIA Date Dependent Difficult to Win Notes Eye Witnesses Roger V Clements Editor:Clinical Risk

42. Incidence of Shoulder Dystocia in Diabetics and Non-Diabetics

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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