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Am J Perinatol
DOI: 10.1055/a-2589-3709
Original Article

Neonatal and Maternal Outcomes following Shoulder Dystocia Resolution Utilizing ≥ versus < 3 Maneuvers

Authors

  • Fabrizio Zullo 

    1   Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
    2   Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy

  • Teresa C. Logue

    1   Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware

  • Daniele Di Mascio

    2   Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy

  • Giuseppe Rizzo

    2   Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy

  • Antonella Giancotti

    2   Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy

  • Matthew K. Hoffman 

    1   Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware

  • Hector Mendez Figueroa

    3   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas

  • Anthony C. Sciscione

    1   Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
    4   Department of Maternal-Fetal Medicine, Delaware Center for Maternal-Fetal Medicine of Christiana Care, Newark, Delaware

  • Suneet P. Chauhan

    1   Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
    4   Department of Maternal-Fetal Medicine, Delaware Center for Maternal-Fetal Medicine of Christiana Care, Newark, Delaware

Funding None.
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Abstract

Objective

Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with ≥3 maneuvers, compared with fewer, is associated with a higher likelihood of adverse outcomes. The secondary objective was to examine if postpartum hemorrhage is associated with SD managed with ≥3 maneuvers versus fewer.

Study Design

This was a secondary analysis of the assessment of perinatal excellence (APEX) study, an observational cohort of over 115,000 deliveries in 25 U.S. hospitals from 2008 to 2011. We included individuals with singleton, vertex, and nonanomalous fetuses at ≥34 weeks who had SD requiring at least one maneuver. We stratified participants according to if ≥3 maneuvers, versus fewer, were utilized to resolve the SD. The primary outcome was the incidence of a neonatal composite adverse outcome including APGAR <5 at 5 minutes, fetal fractures, intracranial hemorrhage, brachial plexus palsy, facial nerve palsy, hypotension treated, hypoxic-ischemic encephalopathy, or neonatal death. Using modified-Poisson-regression, we calculated adjusted incidence relative risk (aIRR) with 95% confidence intervals (CI).

Results

The rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 cases of SD, 96% met the inclusion criteria. ≥3 maneuvers were utilized in 18.9% (391/2,062) of SD cases. The composite neonatal adverse outcome occurred in 8.1% (168/2,062) of cases, and in adjusted models, the risk for the composite outcome was significantly higher with SD requiring ≥3 maneuvers (15.1%) versus <3 maneuvers (6.5%; aIRR: 2.08; 95% CI: 1.50–2.89). Additionally, APGAR <5 at 5 minutes (aIRR: 4.10; 95% CI: 1.18–14.25), neonatal brachial plexus palsy (aIRR: 2.58; 95% CI: 1.45–4.60), and hypoxic-ischemic encephalopathy (aIRR: 2.83; 95% CI: 1.36 and 5.89) were significantly more likely when ≥3 were used. No significant difference was noted for postpartum hemorrhage (PPH) by number of maneuvers (aIRR: 0.74; 95% CI: 0.44 and 1.21).

Conclusion

SD relieved by ≥3 maneuvers, compared with <3, was associated with a 2-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for PPH.

Key Points

  • ≥3 Maneuvers increase neonatal adverse outcomes.

  • With ≥3 maneuvers, higher risk of low APGAR and HIE.

  • PPH rates similar for ≥3 versus <3 maneuvers.

Keywords

APGAR score - fetal fracture - hypoxic-ischemic encephalopathy - McRoberts maneuver - neonatal brachial plexus palsy - postpartum hemorrhage - posterior arm extraction - rotational maneuver - suprapubic pressure

Authors' Contributions

Conceptualization: F.Z., T.C.L., M.K.H., A.C.S., H.M.F., and S.P.C.


Data curation: F.Z. and T.C.L.


Formal analysis: F.Z. and D.D.M.


Investigation, methodology, visualization, and writing—original draft: F.Z., M.K.H., and S.P.C.


Resources: F.Z., M.K.H., and A.C.S.


Supervision: S.P.C.


Validation: F.Z. and S.P.C.


Writing—review and editing: F.Z., T.C.L., D.D.M., G.R., A.G., M.K.H., H.M.F., A.C.S., and S.P.C.


Supplementary Material



Publication History

Received: 27 February 2025

Accepted: 15 April 2025

Accepted Manuscript online:
16 April 2025

Article published online:
08 May 2025

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