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Shoulder dystocia: an Evidence-Based approach

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Possible causes of birth injuries of the brachial plexus » Obstetrics and Gynecology

Purpose of the study. To highlight the literature data describing the causes and mechanism of development of birth damage to the brachial plexus in the absence of such a complication as fetal shoulder dystocia.
Material and methods. Using medical search engines (PubMed, Cochrane, Sage, Wiley Online), 27 literature sources were found and analyzed.
Results. The literature describes a large number of cases of birth paralysis in the absence of risk factors, complications of childbirth, provision of benefits. Possible mechanisms of injury are theoretically substantiated.
Conclusion. The occurrence of damage to the brachial plexus during childbirth is often not associated with the development of shoulder dystocia and the actions of obstetricians. There are a number of other reasons. The development of damage to the brachial plexus in such cases is excellent in mechanism, the clinical picture can often be different. No correlation with risk factors.

Birth injury of the brachial plexus is a relatively rare injury with serious consequences. The clinical manifestation of this injury is flaccid paralysis of the upper limb. There are Erb-Duchene palsy, in the structure of which there is an upper type of damage (C5-C6) and an average type of damage (C5-C7), Dejerine-Klumpke paralysis (lower type), caused by damage to the C8-Th2 roots of the spinal cord, and total paralysis - damage to C5-Th2 roots.

The incidence of birth injuries of the brachial plexus, according to different authors, ranges from 0. 38 to 5.1 per 1000 newborns [1–7].

The most common (up to 97%) complication of labor leading to damage to the brachial plexus is fetal shoulder dystocia [8]. With the development of this complication, damage to the brachial plexus occurs in 4–40% of cases [9]. Risk factors are: fetal macrosomia, maternal diabetes mellitus, discrepancy between the size of the fetus and the clinical size of the mother's pelvis [10, 11]. Unfortunately, it is often impossible to prevent the development of shoulder dystocia [9, 12].

The right upper limb is affected more often, which is associated with the biomechanics of labor in the most common (2nd position, anterior view, occipital insertion) position of the fetus [13].

It is generally accepted that traction of the fetus by the head with its deviation away from the axis of the body in conditions of shoulder dystocia leads to damage to the nerves of the brachial plexus. However, the results of studies conducted over the past 25 years indicate that there are a number of other equally significant reasons. Only about 50% of injuries are associated with the development of shoulder dystocia during childbirth [14, 15].

So, Acker et al. back in 1988, they suggested that in cases of rapid delivery, the rapid advance of the fetus into the small pelvis may be complicated by inadequate rotation of the shoulders (the shoulders of the fetus do not rise into the largest oblique diameter of the pelvis), which, in turn, can lead to damage to the brachial plexus in utero [16]. This point of view is shared by Sandmire and DeMott [17], stating that the incidence of brachial plexus injuries increases by 4.7 times in fast delivery. Alfonso [18] points to the conflict between the fetal posterior shoulder and the mother's sacral promontory as a possible cause of damage to the brachial plexus at the time of the fetus's advance into the small pelvis.

With the accumulation of experience, the fact that brachial plexus injuries during childbirth are not always accompanied by dystocia of the fetal shoulders has become indisputable.

Graham et al. in 1997 conducted a retrospective analysis of 14,358 births from 1987 to 1991 . [19].

Fifteen cases of damage to the brachial plexus during childbirth have been described: 14 of them by vaginal delivery and 1 by caesarean section. Only in 8 (53.3%) cases, the delivery was completed with complications (for example, shoulder dystocia). In this group, the weight of the children was higher than the gestational weight in seven (88%) of the eight newborns, averaging 4265±480 g (3550–5110 g). In the group of children born without complications, birth weight was significantly lower, on average 2906±745 g (1590–3950 g), weight corresponded to gestational age in six (86%) of seven cases. The authors conclude that damage to the brachial plexus is not always associated with a large fetal weight and trauma during childbirth, as previously thought.

Ouzounian et al. in 1997 published the data of their study, which identified four cases of severe damage to the brachial plexus in the absence of shoulder dystocia in labor, as well as four cases of severe damage to the brachial plexus of the posterior fetal handle with the development of anterior shoulder dystocia [20]. The authors conclude that damage to the brachial plexus during childbirth is not in all cases associated with traction.

Buljina et al. it was noted that out of 32 children treated for damage to the brachial plexus during childbirth, 8 (22.77%) had no evidence of shoulder dystocia in their anamnesis [21].

Allen and Gurewitsch described a case of damage to the brachial plexus during childbirth in a child whose parents demanded non-intervention of medical personnel in the delivery process. The child was born in cephalic presentation through the birth canal. Traction by the head, vacuum extraction of the fetus was not used. The second period of contractions was 30 minutes. The weight of the fetus corresponded to the gestational age. However, Erb-Duchene paresis was diagnosed on the right (on the side of the posterior handle of the fetus), which resolved on the 4th day of the child's life. The authors conclude that damage to the brachial plexus of the posterior handle of the fetus is also possible during a normally ongoing labor process, natural delivery, in the absence of shoulder dystocia and traction behind the fetal head [22].

Torki et al. report 8 cases of severe damage to the brachial plexus during normal labor [23]. In none of these eight cases, any factors predisposing to the development of damage were identified. Seven out of eight newborns had a normal weight (3514±1043 g). One fetus weighing more than 4800 g on ultrasound (at birth 4940 g) was delivered by caesarean section. In the rest of the cases, children were born through the natural birth canal in cephalic presentation, six - without obstetric assistance (in one case, obstetric forceps were applied). The average duration of the second period of contractions was normal. The observation period for children was 1 month. At the time of the 1st month of life, all had a clinical picture of severe damage to the brachial plexus. The authors conclude that severe brachial plexus injury is possible in the absence of fetal shoulder dystocia and any other predisposing factors.

Gherman et al. in 1998, he conducted a study, the purpose of which was to find out whether the mechanism of development of brachial plexus injuries that arose with shoulder dystocia and in the absence of the latter differ in the mechanism of development. The authors evaluated the consequences of 17 cases of brachial plexus injury not associated with shoulder dystocia and 23 cases associated with dystocia in children aged 1 year. In the group of injuries not associated with dystocia, 7 (41.2%) of 17 children at the time of the 1st year of life had a pattern of persistent paresis, while in the group of injuries associated with dystocia, only 2 (8, 7%) of 23 children. In the first group, improvements came more slowly (6.4±0.9months versus 2.6 ± 0.7 in the second group), fractures of the clavicle were more common (12 out of 17 versus 5 out of 23), the posterior arm of the fetus was more often affected (10 out of 15 versus 4 out of 21). The authors conclude that injuries of the brachial plexus during childbirth that occurred in the absence of shoulder dystocia are a qualitatively different injury than injuries associated with dystocia [24].

A similar study was conducted in 2006 by Gurewitsch et al., comparing two similar groups of children with brachial plexus injury. In the group of children with injuries of the brachial plexus in the absence of shoulder dystocia, the posterior arm of the fetus was also more often affected, however, in almost all cases, the picture of paresis was temporary. The authors conclude that injuries of the brachial plexus that are not associated with shoulder dystocia are rare and differ from injuries that occur during the development of dystocia [25].

Damage to the nerve trunks can also occur with pressure from the pubic symphysis on the shoulder and shoulder girdle of the fetus. Gonik et al. created a mathematical model for calculating the forces exerting pressure on the fetal neck and underlying nerve trunks in the second stage of labor [26, 27]. The authors calculated that the pressure resulting from the traction behind the head was, on average, 22.9 kPa. The pressure resulting from the action of the expelling forces of the uterus varied from 91.1 to 202.5 kPa, that is, it was higher by 4–9once. The authors conclude that the actions of obstetricians are not always the cause of damage to the brachial plexus during childbirth, it may spontaneously occur as a result of the action of endogenous forces (propulsive uterine contractions), which the obstetrician cannot safely control. This view is shared by Sandmire and DeMott [11, 15].

It should be noted that, despite the extreme vigilance of obstetrician-gynecologists regarding the prevention of complications in childbirth, the departure from the previously accepted position on fully controlled childbirth, the more frequent use of caesarean section, the incidence of birth damage to the brachial plexus does not tend to decrease. Which, in turn, may indirectly indicate that in many cases the brachial plexus is damaged in utero [23]. Graham et al. give the following data: despite the increase in the frequency of caesarean section in their clinic from 5 to 20%, the incidence of brachial plexus injuries remained the same - 0.12% in the period from 1954 to 1959, 0.10% between 1987 and 1991 [19].

There are a number of other causes of damage to the brachial plexus during childbirth. Disturbed position of the fetus in the uterine cavity, anomalies in the development of the uterus (bicornuate uterus, the presence of an intrauterine septum), cervical ribs, Kaiser Wilhelm syndrome (a consequence of chronic feto-placental insufficiency), osteomyelitis of the proximal shoulder and cervical vertebrae, tumors of the brachial plexus and hemangiomas, congenital varicella -syndrome [18].

The cited literature data indicate that the occurrence of birth injuries of the brachial plexus is often not associated with the development of shoulder dystocia or the actions of obstetricians. There are a number of other reasons. The development of damage to the brachial plexus in such cases is excellent in mechanism, the clinical picture is also different. There is no correlation with risk factors - that is, the occurrence of damage is difficult to predict and take measures to prevent it in advance. Further research is needed to explain the causes of the development of brachial plexus damage during childbirth in the absence of shoulder dystocia in order to improve the system of prevention and care for this group of patients.

Khusainov Nikita Olegovich, post-graduate student of the department of arthrogryposis, FGBU Research Children's Orthopedic Institute named after. G.I. Turner of the Ministry of Health of Russia. Address: 196603, Russia, St. Petersburg, Parkovaya st. 64-68. Phone: 8 (812) 465-28-57, +7 (911) 902-55-34. E-mail: [email protected]
Oreshkov Anatoly Borisovich, Doctor of Medical Sciences, Leading Researcher department of arthrogryposis FGBU Research Children's Orthopedic Institute named after. G.I. Turner of the Ministry of Health of Russia. Address: 196603, Russia, St. Petersburg, Parkovaya st. 64-68. Phone: 8 (812) 465-28-57. E-mail: [email protected]

Obstructed childbirth, description of the disease on the Medihost.ru portal

Obstructed childbirth (or dystocia) is a violation of the birth process caused by anomalies in the development of the fetus or its incorrect presentation, anomalies of the pelvis in the woman in labor or a discrepancy between the size of the fetus and the birth canal.

Obstructed childbirth is a significant problem in obstetrics and gynecology, accounting for about 8% of maternal deaths worldwide¹. Given that 99% of all maternal deaths occur in developing countries², it becomes clear how great the chances of avoiding the death of a mother with high-quality medical support are.

Obstructed labor is included in the ICD-10 classification of diseases in three sections at once, which determines their classification. There are the following types of obstructed labor:

1. Caused by incorrect presentation or position of the fetus.
2. Caused by maternal pelvic abnormalities.
3. Other types of obstructed labor (specified and unspecified).

To put it simply, the two main causes of obstructed labor are the incorrect position of the fetus in the uterus and the birth canal that is too narrow (in a certain place or along its entire length). The remaining cases include the full range of possible disorders: fusion or adhesion of twins, tumors, hydrocephalus, etc., but they are extremely rare.

Let's dwell on the more common types of obstructed labor.

Very often, the birth process is hampered by incorrect fetal presentation. Head presentation is considered normal: the position in which the baby's head comes out of the uterus (and out of the vagina) first. However, in some cases, the fetus may not be positioned correctly.

There are breech, frontal and frontal presentations, as well as shoulder presentation. In the first case, the fetus is turned to the cervix with the buttocks or legs, the facial and frontal presentation suggests an incorrect position of the head, and in the case of the shoulder presentation, the fetus is located in the uterus "across" the birth canal.

All described cases are subject to correction, however, in order to implement it, it is necessary to identify risks in time and prepare for possible difficult childbirth. In this matter, a large degree of responsibility lies with the pregnant woman herself, which does not eliminate the need to improve one's qualifications for a doctor. We will return to risk factors in more detail below.

As already mentioned, obstructed labor is most often caused by incorrect presentation and problematic structure of the woman's pelvis. In critical cases, obstructed labor can result in the death of the fetus or newborn, and even the death of the woman in labor.

So, for example, in the case of a very large (compared to the pelvis of the woman in labor) fetus, shoulder dystocia is possible - a pathology in which the fetus gets stuck at the exit from the vagina: the child's head is already outside, while the shoulder rests against the pubic bone.

If the pelvis is not wide enough, the fetus may get stuck in the birth canal. If the fetal head rests against the mother's sacrum, serious injuries to his skull are possible.

In the case of a breech presentation, there may be complications caused by the obstetrician's attempt to help the woman in labor and "pull out" the fetus. This type of presentation is also dangerous because it is very difficult for the doctor to make a decision on the need for a caesarean section in time: this question arises at the moment when the fetus has left the uterus to the shoulder girdle, and in most cases (with breech presentation) it is already too late to do a caesarean section .

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