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Comment and Controversy

Force is a 2-way street

December 2006 · Vol. 18, No. 12
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“Shoulder dystocia: What is the legal standard of care?” by Henry M. Lerner, MD

I have practiced obstetrics for 25 years and sometimes serve as an expert witness in the defense of physicians and nurses accused of below-standard care. In my experience, “excessive force” has no concrete definition and therefore very little defense. Moreover, force is not always applied by a health-care provider moving the fetal head away from the perineum to effect delivery. In some cases, the health-care provider is simply holding the infant’s head still, and it is the mother who is pulling back. These cases often involve a lack of good pain control or regional anesthesia. The mother often panics, pulling upward or closing her legs, obstructing further delivery of the fetus.

As for shoulder dystocia, when it occurs, I use my own variation of the Woods screw maneuver. Once the dystocia is diagnosed, I have the mother hyperflex her thighs, as with the McRoberts maneuver, and ask her to take a deep breath and push. At the same time, I rotate the fetal head clockwise or counterclockwise, depending on the position of the fetus in relation to the “y” axis. This creates the dynamics of a screw technique. The force applied is lateral, and the forward movement of the vertex is effected by the patient’s pushing.

I have yet to see this maneuver fail.

Jeffrey H. Kotzen, MD
West Palm Beach, Fla

Dr. Lerner responds: Woods articulated a similar principle

It is of interest that in Dr. Woods’ original 1943 article, he describes the use of fundal pressure along with intravaginal posterior shoulder rotation. He said that this screw-like action (force from above, rotation below) duplicates the principle of multiplication of force found in the simple “machine” of the screw. Dr. Kotzen’s technique applies a similar principle.

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