Objective
The purpose of this study was to report on all cases in which posterior axilla sling traction (PAST) has been used to deliver cases of intractable shoulder dystocia and to describe a new method of shoulder rotation with the sling.
Study Design
A record of all published and known cases was collected that included information on preliminary obstetric techniques that were used and how the PAST technique was performed. Maternal outcomes that included maternal injury and length of hospital stay and fetal outcomes, which included birthweight, Apgar scores, nerve injuries, fractures, hospital stay, and outcome, were documented.
Results
We have recorded 19 cases where PAST has been used. In 5 cases, the babies had died in utero. Ten were assisted deliveries. PAST was successful in 18 cases. In one case, it was partially successful because it enabled delivery of the posterior shoulder with digital axillary traction. The most commonly used material was suction tubing. Once the posterior shoulder was delivered, the shoulder dystocia was resolved in all cases. Time from insertion to delivery was <3 minutes when recorded. The birthweights of the infants varied from 3200-4800 g. Posterior arm humerus fractures occurred in 3 cases. There was one case of a permanent Erb’s palsy and 4 cases of transient Erb’s palsies. None were of the posterior arm. During this review, we found that, when direct delivery of the posterior shoulder was difficult because of very severe impaction, the sling could be used to rotate the shoulders easily through 180 degrees assisted by counter pressure on the back of the anterior shoulder. This new method was used in 5 cases and may reduce fetal trauma further during difficult shoulder delivery.
Conclusion
This review confirms that PAST can be a lifesaving technique when all another techniques for shoulder dystocia fail. Advantages are that it is easy to use (even by someone who has not seen it used previously), that the sling material is readily available, and that it is inserted quickly with 2 fingers. This is the first report of its use to rotate the posterior shoulder to the anterior position for delivery.
Shoulder dystocia is an unpredictable obstetric emergency; the outcomes rely on quick diagnosis and rapid management. After the birth of the baby’s head, no further progress takes place; the shoulders usually are entrapped in the anteroposterior diameter of the pelvis. Many techniques have been described for the management of shoulder dystocia; the most common is suprapubic pressure with McRoberts position (hyperflexion of the thighs). If this fails, a number of other maneuvers have been described, which include rotational procedures, maternal position changes, and techniques to deliver the anterior shoulder and arm. Recently, there has been a move towards favoring procedures that enable delivery of the posterior arm. Techniques that have been described include delivery of the posterior arm, digital axillary traction, and more recently the posterior axilla sling traction (PAST) procedure.
The PAST technique makes use of a sling that is placed around the posterior axilla. A suction catheter or firm urinary catheter is folded over the operator’s index finger to create a loop ( Figure 1 ). The loop is then fed posteriorly behind the posterior shoulder ( Figure 2 ). The index finger of the operator’s second hand is then used to catch the loop ( Figure 3 ). The loop is pulled through creating a sling around the posterior shoulder ( Figure 4 ). Traction is then applied to the sling to deliver the posterior shoulder ( Figure 5 ). If the posterior arm does not follow, it is then swept out easily because room has been created by delivering the posterior shoulder ( Figure 6 ). If the aforementioned procedure fails, the sling can be used to rotate the shoulders. The sling traction is directed laterally towards the side of the baby’s back then anteriorly while digital pressure is applied behind the anterior shoulder to assist rotation ( Figure 7 and Video ). Usually once the posterior shoulder is delivered the shoulder dystocia is resolved, and delivery of the baby occurs quickly.
This technique for delivery of the posterior arm with the use of a sling was first described in 2 cases of intractable shoulder dystocia with fetal intrauterine death. An editorial in Obstetrics and Gynaecology recommended that, if it was used, the cases should be documented and published because it is a new technique and because safety and reliability must be confirmed. In 2009, we published a series of 3 cases. We now present a case review of all the cases in which this technique has been used that have been published and reported to us.
Materials and Methods
A record of all cases was collected by the authors. Whenever the technique was taught, it was asked that cases be reported to one of the authors, and these cases were included in the review. Information on the maternal age, gravidity, parity, obstetric history, antenatal course, and labor and whether an assisted delivery was performed were collected. All techniques used to attempt to resolve the shoulder dystocia were noted and documented: how the PAST technique was performed, the type of catheter used, the time from insertion to delivery, the designation of the person who performed the technique, and how they learned to perform PAST. Maternal outcomes that included maternal injury and length of hospital stay and neonatal outcomes that included birthweight, 5-minute Apgar scores, nerve injury, fractures, hospital stay, and outcome were documented. If information was incomplete, the original birth attendant was contacted, where possible, to obtain as much missing information as possible. Ethical approval was obtained from the Health Research Ethics Committee at Tygerberg Hospital, Stellenbosch University, Institutional Review Board Number IRB0005239 for the protocol number N14/08/111.
Results
We have recorded 19 cases. Most of the women were multiparous; 5 of the women had had a previous cesarean delivery. All of the women were at term gestation; 5 of the babies had died in utero. Four women had had inductions of labor; 11 of them had had assisted deliveries with 10 ventouse deliveries and 1 forceps delivery ( Table 1 ).
| Cases | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age | 21 | 25 | 34 | 20 | 15 | NA | NA | 31 | NA | 20 | 35 | 32 | 31 | 38 | NA | 31 | NA | 24 | 24 |
| Gravidity | 1 | 1 | 2 | 2 | 1 | M | M | 2 | 2 | 2 | 4 | 1 | 2 | 3 | 2 | 3 | 1 | 3 | 1 |
| Parity | 0 | 0 | 1 | 1 | 0 | — | — | 0 | 1 | 1 | 3 | 0 | 1 | 2 | 1 | 2 | 0 | 2 | 0 |
| Gestation | 38 wk | T | 39 wk | T | T | 38 wk | T | T | 37 wk | T | 40 wk | 41 wk 5 d | 38 | 38 wk 6 d | T | T | 42 wk 6 d | 40 wk 6 d | 42 wk |
| Previous cesarean delivery | Yes | No | Yes | Yes | No | No | No | No | No | Yes | No | No | Yes | No | Yes | No | No | No | No |
| Antenatal complications | IUFD | IUFD | Nil | Nil | Nil | DM; IUFD | IUFD | Nil | DM | Nil | Nil | Nil | IUFD | Increased body mass index; cardiac disease | Nil | Wolf-Parkinson White syndrome | Nil | Nil | Nil |
| Spontaneous labor | No | Yes | Yes | Yes | Yes | Yes | NA | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Yes | Yes | Yes | No |
| Assisted delivery | V | V | V | V | V | No | NA | V | No | V | No | F | No | No | V | V | No | V | No |
All of the cases, except one, were severe shoulder dystocia for which other maneuvers had failed to facilitate delivery. In case 11, the operator judged that it was going to be a difficult case and proceeded to the PAST technique after McRoberts and suprapubic pressure failed because she believed that this was the most appropriate technique for the situation. The PAST technique was successful in delivering the posterior shoulder in 18 of the 19 cases. In case 7, the PAST technique was partially successful because it brought the posterior shoulder down low enough to enable digital axillary traction to achieve delivery of the posterior shoulder ( Table 2 ). In this case, a Foley catheter was used that was believed to be too elastic. The most commonly used material for the sling was a suction catheter. Oxygen tubing was used once. A Foley catheter was used 3 times.
| Cases | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mc Roberts | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U |
| Suprapubic pressure | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U | U |
| Delivery of posterior arm | U | U | U | U | U | U | U | U | U | U | N | U | U | U | U | U | U | U | U |
| Posterior axilla traction | U | U | U | U | U | U | U | U | U | U | N | U | U | U | U | U | U | N | U |
| Rotational maneuvers | U | U | U | U | U | U | U | U | U | U | N | U | U | U | N | U | U | N | N |
| Posterior axilla sling traction | S | S | S | S | S | S | PS | S | S | S | S | S | S | S | S | S | S | S | S |
Once the posterior shoulder was delivered, the shoulder dystocia was resolved; in all cases, the original anterior shoulder delivered spontaneously. In cases in which the time from insertion to delivery was reported, it was always <2-3 minutes. The operators included medical officers, midwives, obstetric trainees, consultants, and the authors ( Table 3 ).
| Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Sling material | SC | SC | SC | SC | SC | OT | Foleys | Foleys | SC | SC | SC | SC | SC | SC | SC | SC | SC | SC | SC |
| Size (French) | 14 | 14 | 12 | 14 | 14 | IU | IU | IU | 14 | 14 | IU | IU | IU | 10 | IU | 12 | 14 | 10 | 12 |
| Easy insertion | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Posterior shoulder delivered with posterior axilla sling traction | Yes | Yes | Yes | Yes | Yes | Yes | Posterior axilla sling traction then digital axilla traction | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Spontaneous posterior arm delivery after posterior axilla sling traction | Yes | No post arm swept down | No post arm swept down | No post arm swept down | No post shoulder rotated with posterior axilla sling traction delivered as ant shoulder | Yes | Yes | Yes | Yes | No post arm swept down digitally | Yes | Yes | Yes | No post shoulder rotated with posterior axilla sling traction delivered as ant shoulder | Yes | No post shoulder rotated with posterior axilla sling traction delivered as ant shoulder | No post shoulder rotated with posterior axilla sling traction delivered as ant shoulder | Yes | No post shoulder rotated with posterior axilla sling traction delivered as ant shoulder |
| Spontaneous delivery of anterior shoulder | Yes | Yes | Yes | Yes | Yes delivered as post shoulder | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes delivered as post shoulder | Yes | Yes delivered as post shoulder | Yes delivered as post shoulder | Yes | Yes |
| Spontaneous anterior arm delivery | Yes | Yes | Yes | Yes | Yes delivered as post arm | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes delivered as post arm | Yes | Yes delivered as post arm | Yes delivered as post arm | Yes | Yes delivered as post arm |
| Time from insertion to delivery (min) | 2 | 3 | 2 | IU | IU | IU | IU | 3 | 3 | IU | IU | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 |
| Designation of person using posterior axilla sling traction | A | A | A | A | A | MO | ObT | ObT | MO | A | M | ObT | A | A | A | A | A | ObT | Ob T and A |
| How did they learn posterior axilla sling traction | NA | NA | NA | NA | NA | P | P | P | P | NA | T | P | NA | NA | NA | NA | NA | P | NA |
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