Skin-to-skin cesarean delivery means a lot to parents … and more

James Moruzzi, MD
Olympia, Washington

Study sheds light on risk factors for OBPI

I appreciate Dr. Barbieri’s editorial on OBPI. I would like to direct readers’ attention to a definitive article on the epidemiology of the injury by Foad and colleagues.¹ This article found that shoulder dystocia was associated with a risk of obstetric brachial plexus palsy 100 times greater than the risk in deliveries unmarked by dystocia. A macrosomic infant had a risk that was 14 times greater than the risk in deliveries involving infants of normal size. And forceps delivery increased the risk of obstetric brachial plexus palsy nine times, compared with unassisted delivery. Both cesarean delivery and multiple gestations were protective against obstetric brachial plexus palsy. Forty-six percent of all infants with obstetric brachial plexus palsy had one or more risk factors, and 54% had no risk factors.

Wayne A. Lippert, MD
Cincinnati, Ohio

Dr. Barbieri responds: Call for extra care is warranted

I appreciate Dr. Shields’ elegant description of the importance, during shoulder dystocia maneuvers, of taking great care to avoid inadvertently stretching the brachial plexus through the combined forces of suprapubic pressure and gentle downward guidance. She describes the challenge much better than I.

With the growing epidemic of obesity, the effectiveness of suprapubic pressure is likely decreasing. In the obese patient, the mass of tissue around the lower abdomen and pubic area probably reduces the effective transmission of force applied suprapubically to the fetal shoulders.

I appreciate Dr. Moruzzi’s advice to identify the position of the posterior and anterior axillae early to help guide the choice of intervention. He also describes the technique of hooking the posterior axilla to bring the posterior shoulder deeper into the pelvis. A similar technique was described by Menticoglou.¹ I recently used this technique, and it worked very well.

I thank Dr. Lippert for the excellent reference on the epidemiology of OBPI. This study analyzed factors associated with injury in over 17,000 newborns with OBPI. The rate of OBPI has been relatively stable over many years despite great efforts to improve our clinical response to shoulder dystocia. As reported by Dr. Shields in her letter, one contributing factor may be how we perform the initial shoulder dystocia maneuvers (McRoberts maneuver and suprapubic pressure), which may exert unintended forces, further compounding the stress on the brachial plexus.

“25 YEARS IN SERVICE TO YOU, OUR READERS”
ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2013)

Pleased to receive my own copy of OBG Management

Thanks to Dr. Barbieri and the OBG Management team for including me and other nurse practitioners and physician assistants in the mailing list. I have enjoyed reading your magazine for more than 20 years, having encouraged my collaborating physicians to share theirs. Now I can read my own. I am very grateful. The journal is wonderfully professional and evidence-based.

Colleen R. Nuxoll, WHNP, BC
Effingham, Illinois

Dr. Barbieri responds: A welcome to our colleagues

At OBG Management we are thrilled that our nurse practitioner and physician assistant colleagues will be receiving their own copy of the magazine. We welcome you and your colleagues to a vibrant community of clinicians dedicated to advancing women’s health. We want to hear from you! Tell us what you think.