Maternal Morbidity Associated With Obstetrical Maneuvers in Shoulder Dystocia

Abstract

Complications from shoulder dystocia during birth can result in morbidity for both the mother and infant, although past studies have largely focused only on risk factors for dystocia and perineal tears. This case-control study was done to learn whether the obstetrical maneuvers used to relieve shoulder dystocia and dystocia itself have adverse effects on the perineum or on the immediate postpartum outcome. A total of 140 cases of shoulder dystocia were compared with 280 control cases. All were singleton, vertex, full-term vaginal deliveries. Shoulder dystocia was more than twice as frequent in women having spontaneous vaginal delivery than in those having instrumental delivery. One type of direct fetal manipulation was needed to relieve shoulder dystocia in 29% of cases, and two types in 34%. Indirect fetal manipulation, usually the McRobert maneuver and/or suprapubic pressure, was used in 74 (53%) cases. Direct fetal manipulation, most often in the form of posterior arm delivery, was performed in 66 (47%) patients. Macrosomia was diagnosed in 42% of cases of shoulder dystocia and in 5% of control cases. Episiotomy was performed significantly less often in parturients with shoulder dystocia (55%) than in the control group (72%). Obstetrical maneuvers did not influence rates of postpartum urinary or vaginal infection. The risk of a third-degree perineal tear appeared unrelated to the number of obstetrical maneuvers carried out. The one anal sphincter rupture occurred in a case of shoulder dystocia where fetal manipulation was not necessary. Mean hemoglobin values were nearly identical in the two groups. Postpartum hospital time averaged 4½ days in both the case and control groups. The incidence of involuntary urine loss was 4.7% when fetal manipulation was carried out and 3.7% in control cases. These findings suggest that neither shoulder dystocia itself nor the fetal manipulations needed to relieve it increase maternal morbidity. Specifically, fetal manipulation did not increase the risk of urinary incontinence, fecal incontinence, or anal sphincter damage.