The procedure of pushing the infant's head back into the vagina and
performing a C-section is called the "Zavanelli maneuver" or "cephalic
replacement." This procedure is controversial, and it is not generally
employed until other techniques have been unsuccessful.
The most common condition for which the Zavanelli maneuver is
performed is "shoulder dystocia," in which the infant's shoulders will
not pass through the birth canal. In such cases, the infant is often
(but not always) larger than average.
Erb's palsy sometimes follows the use of the Zavanelli maneuver.
Fortunately, most instances of Erb's palsy in such cases are brief in
duration, and are resolved without long-term neurological effects.
I have gathered some online material for you. For reasons of
copyright, I can post only brief excerpts here; for an in-depth view
of the subject, you may want to read some of these pages in their
entirety.
"Several reports describe the replacement of the partially delivered
fetus into the vagina followed by Cesarean section after failed
vaginal delivery. Undeliverable shoulder dystocia is by far the most
common cause of failed vaginal delivery. The objective of this report
was to review the safety and to reconsider when to perform the
Zavanelli maneuver in the management of shoulder dystocia. We report
two cases of severe shoulder dystocia in which commonly recommended
therapeutic options failed. Cephalic replacement was performed with
ease followed by Cesarean section. Endometritis was the maternal
complication in both cases. Both infants had transient Erb's palsy.
Although traditionally the Zavanelli maneuver is a method of last
resort in the management of shoulder dystocia, consideration should be
given to its use earlier in the treatment of obstructed vaginal
delivery."
from the Journal of Maternal-Fetal and Neonatal Medicine
http://www.ingenta.com/isis/searching/Expand/ingenta?pub=infobike://ppg/mfn/2003/00000013/00000002/art00012
"Erb's Palsy, also known as Erb-Duchenne paralysis, describes a
partial paralysis of the brachial plexus nerve caused by stretching,
tearing and/or evulsion at birth... Birth related brachial plexus
injuries are caused by the Obstetrician applying excessive downward or
upward lateral traction to the baby's head and neck once it has
presented during the course of delivery. In lay terms, the angle of
presentation of the baby's shoulder prevents the baby from fitting
through the birth canal. It is the position of the baby in relation to
the mother which is known medically as Shoulder Dystocia...
The Zavanelli maneuver involves pushing the babies head back into the
uterus upon recognition that other management techniques will not
relieve the dystocia and performing a crash Caesarian section. It is
noteworthy that proper performance of this maneuver requires that the
hospital where the birth occurs be equipped for this procedure i.e.
has adequate surgical suits and personnel available. It is also
noteworthy that in the entire United States, this procedure is
performed only once or twice a year or one to two times per every four
million deliveries."
Evidence.com: Brachial Plexus Commentary
http://www.evidence.com/Articles/brachialplexus.text.html
"Shoulder dystocia is seldom a problem because most of the time it is
easily resolved by the corrective manual maneuvers... without any
problems occurring. Brachial Plexus (Erb-Duchenne's palsy) from injury
to the brachial nerve plexus does not occur, even as a temporary
consequence, in the vast majority of cases; and permanent BP palsy is
even rarer...
The cephalic replacement or Zavanelli maneuver is used for severe
shoulder dystocias. This maneuver involves repositioning of the fetal
head into the vaginal canal then displacing the fetal head above the
pelvic inlet, re-establishing the fetal placental umbilical profusion
(oxygen supply) and then effecting delivery via cesarean section."
Cerebral Palsy Experts: Shoulder Dystocia
http://www.cerebralpalsyexperts.com/index.php?intId=33
"In the unusual event that none of these maneuvers is successful, the
controversial Zavanelli maneuver may be attempted. In this procedure,
the fetal head is rotated to a direct occipitoanterior position,
flexed, replaced in the vagina and held there until a cesarean section
is performed."
American Family Physician: Common Peripartum Emergencies
http://www.aafp.org/afp/981101ap/morrison.html
"Ancillary maneuvers including McRoberts maneuver, suprapubic
pressure, direct fetal manipulation and proctoepisiotomy, and
Zavanelli maneuver (for catastrophic cases only) ... Cephalic
Replacement (Zavanelli maneuver). Zavanelli maneuver is associated
with significantly increased risk of fetal morbidity and mortality and
maternal morbidity."
National Guideline Clearinghouse: Shoulder dystocia
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3988&nbr=3127
"Anticipate the possibility of shoulder dystocia with vaginal delivery
if any of the following risk factors are present, expressed in the
mnemonic DOPES.
Diabetes
Obesity
Postdates
Excessive fetal or maternal weight gain
Short maternal stature...
If the posterior arm is lodged behind the sacral promontory and the
anterior shoulder is behind the symphysis, it may be impossible to
affect vaginal delivery without permanent fetal injury. In this case,
cephalic replacement may be the best option. To perform cephalic
replacement, rotate the fetal head to the occiput anterior position
and
put pressure on the occiput, causing flexion while simultaneously
using the other hand to
reintroduce the chin into the vagina (Zavanelli Maneuver)."
Norcal Mutual Insurance Company: Anticipating Shoulder Dystocia
http://www.norcalmutual.com/information_center/claimsrx/se_shoulder_dystocia_may_04_flashcards.pdf
"Shoulder dystocia is an acute obstetric emergency that can result in
brachial plexus injuries, including Erb?s Palsy, fractures of the
clavicle or humerus and even death...
Extreme Maneuvers
Cephalic Replacement
(Zavanelli Maneuver)
This procedure is the replacement of the head into the vagina under
anesthesia and subsequent delivery by Cesarean section. The procedure
requires the reversal of the mechanisms of labor with the head being
returned to the occipito-anterior or posterior position that it
delivered in. The head is then flexed and replaced into the vagina.
Effective analgesia (often general anesthesia) is essential and a
bolus of tocolytic - for example, ritodrine 5-10 mg intravenously -
will facilitate replacement and hopefully minimize the risk of uterine
rupture. There are no adequate, unselected series by which this
technique can be evaluated, but successful replacement of 53 from 59
cases has been reported (O?Leary, 1993). Two infants died, four
experienced convulsions (two with possible long-term impairment) and
five experienced permanent BPP. Two mothers required a hysterectomy
due to ruptured uterus. These results are encouraging in light of the
desperate nature of the situation, but others have reported far less
favorable outcomes (Spellacy, 1995)."
Norcal Mutual Insurance Company: Shoulder Dystocia
http://www.norcalmutual.com/information_center/claimsrx/jul_01.pdf
"Shoulder dystocia occurs in < 1% of vaginal births and 12% to 15% of
cases are associated with some evidence of injury to the brachial
plexus. Injury to the C5-6 nerve roots leads to Erb's-Duchenne palsy,
whereas injury to the nerve root C8-T1 leads to Klumpke's palsy
Fortunately, 80% to 90% of Erb's palsies and up to 50% of Klumpke's
resolve without leaving any persistent neurologic deficits.
Although approx. half of all shoulder dystocia cases involve babies of
normal weight, large babies with shoulder dystocia are more likely to
suffer Erb's palsy (a specific brachial plexus injury) than small
babies with shoulder dystocia. They appear not to be any more likely
to suffer other serious consequences though, eg oxygen deprivation.
The causes of brachial plexus injury are controversial, but all the
evidence is that they are caused mainly, not by shoulder dystocia
itself, but by some delivery methods attempted to resolve shoulder
dystocia."
HomeBirth: Large Babies and Home Birth
http://www.homebirth.org.uk/big.htm#sd
Google search strategy:
Google Web Search: "zavanelli maneuver" OR "cephalic replacement"
://www.google.com/search?hl=en&ie=UTF-8&q=%22zavanelli+maneuver%22+OR+%22cephalic+replacement%22
Google Web Search: "erb's palsy" + "zavanelli"
://www.google.com/search?hl=en&ie=UTF-8&q=%22erb%27s+palsy%22+zavanelli
Please keep in mind that Google Answers is not a source of
authoritative medical advice; the material I've posted is strictly
informational, and should not be viewed as a diagnosis nor as a
substitute for the services of a qualified medical professional.
I hope this is helpful. If anything is unclear, or if a link doesn't
work for you, please request clarification; I'll be glad to offer
further assistance before you rate my answer.
Best wishes,
pinkfreud |
