title: A comparison of obstetric maneuvers for the acute management of shoulder dystocia.
abstract: OBJECTIVE
  To assess the efficacy of obstetric maneuvers for resolving shoulder dystocia and the effect that these maneuvers have on neonatal injury when shoulder dystocia occurs.
  
  
  METHODS
  Using an electronic database encompassing 206,969 deliveries, we identified all women with a vertex fetus beyond 34 0/7 weeks of gestation who incurred a shoulder dystocia during the process of delivery. Women whose fetuses had a congenital anomaly and women with an antepartum stillbirth were excluded. Medical records of all cases were reviewed by trained abstractors. Cases involving neonatal injury (defined as brachial plexus injury, clavicular or humerus fracture, or hypoxic-ischemic encephalopathy or intrapartum neonatal death attributed to the shoulder dystocia) were compared with those without injury.
  
  
  RESULTS
  Among 132,098 women who delivered a term cephalic liveborn fetus vaginally, 2,018 incurred a shoulder dystocia (1.5%), and 101 (5.2%) of these incurred a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of delivery when compared with other maneuvers (84.4% compared with 24.3-72.0% for other maneuvers; P<.005 to P<.001) and similar rates of neonatal injury (8.4% compared with 6.1-14.0%; P=.23 to P=.7). The total number of maneuvers performed significantly correlated with the rate of neonatal injury (P<.001).
  
  
  CONCLUSIONS
  Delivery of the posterior shoulder should be considered following the McRoberts maneuver and suprapubic pressure in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury.
authors.affiliation: From Christiana Care Health System, Newark, Delaware; MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; Intermountain Healthcare and the University of Utah, Salt Lake City, Utah; Tufts University, Baystate Medical Center, Springfield, Massachusetts; the EMMES Corporation, Rockville, Maryland; Indiana University Clarian Health, Indianapolis, Indiana; the University of Illinois at Chicago, Chicago, Illinois; Georgetown University Hospital, MedStar Health, Washington, DC; Maimonides Medical Center, Brooklyn, New York; the University of Miami, Miami, Florida; Cedars-Sinai Medical Center, Los Angeles, California; Summa Health Systems Akron City Hospital, Akron, Ohio; the University of Texas Health Science Center at Houston, Houston, Texas; and the Pregnancy and Perinatology Branch and the Division of Epidemiology, Statistics and Prevention Research, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
authors.forename: Matthew K
authors.initials: MK
authors.lastname: Hoffman
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Bailit
authors.forename: D Ware
authors.initials: DW
authors.lastname: Branch
authors.forename: Ronald T
authors.initials: RT
authors.lastname: Burkman
authors.forename: Paul
authors.initials: P
authors.lastname: Van Veldhusien
authors.forename: Li
authors.initials: L
authors.lastname: Lu
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Kominiarek
authors.forename: Judith U
authors.initials: JU
authors.lastname: Hibbard
authors.forename: Helain J
authors.initials: HJ
authors.lastname: Landy
authors.forename: Shoshana
authors.initials: S
authors.lastname: Haberman
authors.forename: Isabelle
authors.initials: I
authors.lastname: Wilkins
authors.forename: Victor H
authors.initials: VH
authors.lastname: Gonzalez-Quintero
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: Gregory
authors.forename: Christos G
authors.initials: CG
authors.lastname: Hatjis
authors.forename: Mildred M
authors.initials: MM
authors.lastname: Ramirez
authors.forename: Uma M
authors.initials: UM
authors.lastname: Reddy
authors.forename: James
authors.initials: J
authors.lastname: Troendle
authors.forename: Jun
authors.initials: J
authors.lastname: Zhang
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods*; D004420:Dystocia / Q000628:therapy*; D005260:Female; D006801:Humans; D016015:Logistic Models; D011247:Pregnancy; D012189:Retrospective Studies; D012782:Shoulder