In severe shoulder dystocia,when in itial maneuvers fail,either episiotomy or fetal manipula tion(Rubin,Woods’screw,or posterior arm release)is recommended.We sought to compare maternal and neonatal outcomes between severe shoulder dystocia deliverie s managed with episioto-my versus fetal manipulation.We identified severe shoul-der dystocia deliveries from three d atabases:all shoulder dystocia deliveries(1993-2003and 1994-1997)from two teaching institutions and litig ated cases of shoulder dystocia -associated permanent bra chial plexus palsy from multiple U.S.institutions.Pair -wise comparisonswere made among three groups of deliverie s:those managed by fetal manipulation without episiotomy (fetal manipula-tion -only),those managed by episiotomy withou t fetal manipulation(episiotomy -only),and those managed with both(episiotomy +fetal manipulation).Rates of brachial plexus palsy,neonatal dep ression,and anal sphincter trauma were compared amon g groups usingχ2,with significance at P<.05.Among episiotomy -only,13of 22(59.1%)sustained brachial plexus palsy,co mpared with 20of 57(35.1%)among fetal manipulation -only(P =.05).Twenty -eight of 48(58.3%)-in epi-siotomy +fetal manipulation had bra chial plexus palsy,which did not differ from episiotomy -only(P =.95)but was higher than fetal manipulation -only(P =.02),suggesting that the addition of epis iotomy conferred no benefit in averting neonatal injury.Anal sphincter trauma was significantly more common among episiotomy -only and episiotomy +fetal manipulation,compared with fetal manipulation -only.In severe shoul der dystocia,if fetal manipulation can be performedwithout episiotomy,severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.
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