Shoulder dystocia related fetal neurological injuries: the predisposing roles of forceps and ventouse extractions

Abstract

On the basis of 333 documented cases of permanent perinatal neurological damage, associated with arrest of the shoulders at birth, the authors conducted a retrospective study in order to evaluate the predisposing role, if any, of the utilization of extraction instruments. The investigation revealed that 35% of all injuries occurred in neonates delivered by forceps, ventouse or sequential ventouse-forceps procedures. This frequency was several-fold higher than the prevailing instrument use in the practices of American obstetricians during the same years. A high rate of forceps and ventouse extractions was demonstrable in all birth weight categories. Average weight and moderately large for gestational age fetuses underwent instrumental extractions more often than grossly macrosomic ones. This circumstance indicates that forceps and ventouse are independent risk factors, unrelated to fetal size. Their use entailed central nervous system injuries significantly more often than did spontaneous deliveries. The findings suggest that extraction procedures may be as important as macrosomia among the factors that lead to neurological damage in the child in connection with shoulder dystocia. Because they augment the intrinsic dangers of excessive fetal size exponentially, the authors consider their use in case of > or =4,000 g estimated fetal weight inadvisable. Sequential forceps-ventouse utilization further doubles the risks and is, therefore, to be avoided in all circumstances.

Shoulder dystocia related fetal neurological injuries: the role of diabetic control

“…Forceps and vacuum extractions proved to be d) independent risk factors. They were found to increase the danger of fetal damage exponentially in all birth weight groups [16], rather than selectively for very large babies as previously thought [19]. The above findings necessitated an unattractive conclusion, namely that protection of babies from injuries required expansion of indications for elective abdominal delivery.…”

“…Taking into account the entire data base, including that used for the previous relevant publications [4,15,16,24], Table 6 Birth of ≥4000 g baby in the past 25…”

“…weight range, instrumental extractions increase the risk of fetal injury close to 10-fold [11,16]. In the authors' material one-third of macrosomic fetuses who suffered permanent injuries were delivered by forceps or ventouse [16].…”

“…Yet it is a prominent cause of shoulder dystocia and its dire sequelae [1,2,9,12,15,24]. It has been estimated that a 250 g fetal weight increase approximately doubles the risk of shoulder dystocia related fetal damage [15,16]. Close dietary and diabetic control during gestation can usually avoid weight accumulation of this degree [20,22].…”

“…It was further proposed subsequently that major predisposing factors for arrest of the shoulders should be studied in isolation, detached -as far as possible-from others, in order to eliminate confounding factors. Implementation of these principles opened the way to some new observations [15,16]:…”