Management of shoulder dystocia by post axillary sling traction

10 April 2019


Shoulder dystocia is defined as a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed.1
Owing to the emergency nature of the condition, most published series examining procedures for the management of shoulder dystocia are retrospective case series or case reports.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is aware of recent recognition that McRoberts’ manoeuvre alone is not as effective as previously thought.2 A recent paper describes an increase in the use of suprapubic pressure and internal manoeuvres over a 16 year period which was associated with a 100% reduction in permanent brachial plexus injuries and a reduction in the head-body delivery interval, suggesting that these techniques are safe and effective.3
Most shoulder dystocia guidelines recognise tertiary manoeuvres (cleidotomy, Zavanelli manoeuvre, and symphysiotomy) once the standard internal manoeuvres have been unsuccessful. However, all recognise that these are associated with a high incidence of serious maternal morbidity and poor neonatal outcome. Consideration should be given to these facts, particularly where practitioners are not trained in the technique, with recent data suggesting that these may be unnecessary with standard care.3
More recently, posterior axillary sling traction (PAST) has been proposed for cases of intractable shoulder dystocia.4-5 However, this technique can also cause significant morbidity, with the largest published series of 14 liveborn cases indicating that one third of liveborn babies sustained a brachial plexus injury employing this technique and 15% sustained a fractured humerus.6
The high rate of neonatal injury in the PAST series likely reflects, at least in part, the severity of the shoulder dystocia cases in which it was employed or injuries sustained during attempts at other manoeuvres.
The demonstrated success and safety of standard manoeuvres suggest that, based on the current evidence, PAST should not be attempted unless all standards efforts have been unsuccessful. It would be reasonable to attempt PAST prior to Zavanelli, cleidotomy or symphisiotomy given the high potential for maternal morbidity with these techniques.  
RANZCOG wishes to highlight guidance from RCOG1 in relation to the adoption of PAST : “there is not any real reliable evidence to support its wide use”.  Additionally, obstetric emergency training (including both PROMPT and MOET) does not teach this manoeuvre due to the limited data available to recommend its use. Effective training for shoulder dystocia using the standard evidence-based manoeuvres likely obviates the need for this potentially higher-risk intervention.
Additionally, practitioners should be aware that medical equipment and devices are provided for use on the basis that it meets the Therapeutic Goods Association (TGA) and manufacturer’s standards in its current form.  Modifying equipment to be used for different purposes may cancel the TGA status.

1.         RCOG Shoulder Dystocia (Green-top Guideline 42) 2nd edition March 2012.
2.         Leung, T., et al., Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres:  a retrospective review. BJOG : an international journal of obstetrics and gynaecology, 2011.
3.         Crofts, J.F., et al., Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study. BJOG, 2016. 123(1): p. 111-8.
4.         Cluver, C.A. and G.J. Hofmeyr, Posterior axilla sling traction: a technique for intractable shoulder dystocia. Obstetrics and gynecology, 2009. 113(2 Pt 2): p. 486-8.
5.         Gherman, R., Posterior axillary sling traction: another empiric technique for shoulder dystocia alleviation? Obstetrics and gynecology, 2009. 113(2 Pt 2): p. 478-9.
6.         Cluver CA and Hofmeyr GJ, Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling. Am J Obstet Gynecol., 2015. 212(6): p. 784. 17.


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