In the rare but serious case of shoulder dystocia, in which an infant's shoulders get stuck in the birth canal after its head emerges, mother and baby might fare better if doctors use their hands to manipulate the baby's position to ease delivery than if they cut perineal tissue to widen the opening, a Johns Hopkins study suggests.
"Shoulder dystocia is a problem of fit," says lead author Edith Gurewitsch, M.D., assistant professor of gynecology/obstetrics. "It is an issue of bony disproportion or misalignment between the mother's pelvic bones and the infant's bony shoulders, so cutting the soft tissue is controversial. If manual techniques alone can be used to deliver the baby, the mother can be spared a significant perineal injury and there might even be fewer complications for the infant after delivery."
Shoulder dystocia occurs in about 5 percent of births, Gurewitsch estimates, and up to a quarter of these deliveries can result in an injury to the baby's brachial plexus, the nerves that control movement and sensation in the arm. Up to 10 percent of infants who sustain such an injury can wind up with permanent damage.
Gurewitsch and colleagues compared the outcomes of more severe "stuck shoulder" births at Hopkins during deliveries between 1993 and 2003, and evaluated records from legal cases nationwide in which babies sustained permanent brachial plexus damage. They compared outcomes for both mother and baby when physicians used either episiotomies (cutting a wider opening) without manual techniques or manual techniques without episiotomy to finish delivering the baby.
Of the 40 episiotomy cases, 24 babies had permanent brachial plexus damage, 12 had poor Apgar scores at birth and 20 of the mothers had severe perineal injuries involving the anal sphincter muscle. Of the 38 cases where manual techniques were employed, 15 babies had permanent brachial plexus damage, and six had poor Apgar scores at birth but only one mother had a severe perineal injury.
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