application of shoulder presentation

• Vishal's account
• Prenatal Care

Shoulder Presentation – All You Should Be Aware Of

When Does the Fetus Move in Birthing Position?

What is shoulder presentation, what is transverse lie, what is the frequency of shoulder presentation, what causes shoulder presentation, how is shoulder presentation diagnosed, complications of shoulder presentation, how is shoulder presentation managed.

Most doctors and midwives will recommend that you have a natural vaginal birth if you have a choice. However, there are certain complications that can sometimes present themselves and stop this from happening. Shoulder presentation is one such complication.

A baby will most likely begin to move into the birthing position latest by week 30 . She will have her head down and facing your spine, her body and face more inclined to one side and arms will be folded across the chest. Any other position is not normal.

This is an abnormal fetus position where the baby is in a transverse lie , causing the baby’s shoulder to be positioned to come out first if vaginal delivery is attempted. However, since this is very easy to diagnose, doctors will always recommend a C-Section and never even suggest attempting to deliver the child through normal vaginal delivery.

A transverse lie is a position where your baby is lying sideways with her head to one of your sides and her bottom at your other side. This position is considered normal before 26 gestational weeks.

Shoulder presentation takes place in 1 out of every 300 births and is commonly seen in premature and macerated babies. It is five times more likely to happen in a woman who has had children before than it is to occur in a first-time mother. Mothers carrying twins are also 40% more likely to have at least one baby in shoulder position.

Here are some reasons why a shoulder presentation can take place:

1. Contracted Pelvis

A very narrow pelvis in the mother can cause a shoulder presentation to occur.

2. Placenta Previa

A condition where the placenta covers the uterus opening, either completely or partially. This makes it difficult for your baby’s head to enter the pelvic brim.

3. Intra-Uterine Fetal Death

There are times when the fetus dies inside the womb, and when this happens, the muscle tone starts to degenerate, which results in the fetus falling lower into the uterus.

4. Lax Abnormal Musculature

Women who have had multiple pregnancies may have more relaxed uterine and abdominal muscles. This will make their ability to keep the baby in a normal position very difficult.

5. Uterine Over Distension

There are many reasons why a uterus can become enlarged. Some of these include a large baby, polyhydramnios , multiple pregnancies and others. A uterus that is too large very often leads to shoulder presentation.

6. Polyhydramnios

A very large amount of amniotic fluid that is present in the uterus is known as polyhydramnios. This causes the fetus to be able to move very freely in the uterus and will lead to shoulder presentation.

7. Uterine Abnormalities

There are different abnormalities in the uterus that can cause your baby to move into shoulder presentation. Some of these are the bicornuate uterus, a sub-septate uterus and even a large fibroid  uterus .

Here is how Shoulder presentation diagnosed:

• The top of the mother’s uterus to the top of the pelvic bone is called a fundus. The height of the fundus is an indicator of whether or not the baby is in the shoulder presentation.
• The uterus becomes broader.
• The mother can feel the baby’s head on one abdominal side.
• If shoulder presentation takes place, arms prolapse will cause the baby’s arm to be seen outside the vagina.
• During a vaginal examination, the doctor will be able to feel the babies ribs.

If your doctor identifies that you have shoulder presentation before you go into labour, he will opt for a C-Section instead. If there is a case of neglected shoulder presentation and it is only identified after you go into labour, it becomes very dangerous, and you face many complications. Here are some of the complications that can occur:

1. Cord Prolapse

When the umbilical cord comes out before the fetus does, it is called a cord prolapse and is very dangerous as it can cause the baby’s heart rate to drop, cause changes in blood pressure and even result in brain damage or death of the baby.

2. Ruptured Uterus

The myometrial wall is the middle layer of the wall of the uterine. The breach of this layer during childbirth is a rupture in the uterus, and it is very dangerous for both mother and child.

3. Fetal Hypoxia

When your baby doesn’t get enough oxygen, it will lead to suffocation, and if the necessary measures are not taken, it will result in death.

4. Obstructed Labour

Though contractions are taking place, the baby is not able to come through the birth canal as there is something blocking the way. Failure to diagnose and remedy this condition is a major reason why both mother and child die during childbirth.

5. Trauma to Prolapsed Arm

If there is a prolapsed arm, there is a higher chance that it will be injured or damaged. This injury may be severe and could last for a lifetime.

Here is how Shoulder presentation is managed:

1. C-Section

The first choice for doctors who have a case of shoulder presentation is a C-Section. This is the safest method that ensures the safety of both mother and child.

2. External Cephalic Version

In this procedure, your baby’s heartbeat will be monitored, and you will be given medication through an IV to ensure a relaxed uterus. Your doctor will then place her hands on the outside of your stomach and attempt to turn your baby into the correct position. This is done only before labour starts.

3. Internal Podalic Version

This is only used in the case of twins, where the second twin will need to be moved into a breech position and then extracted.

Though it sounds scary, if you keep a careful track of your baby’s position in the weeks before delivery, you will be able to identify and rectify the problem before it becomes serious. Exercising throughout your pregnancy will be very helpful in ensuring that your baby gets into the correct position for labour.

Also Read:  When Does a Baby Turn Head Down During Pregnancy?

• RELATED ARTICLES
• MORE FROM AUTHOR

Microblading While Pregnant - Benefits, Side Effects, and Risks

Paracetamol Intake During Pregnancy

10 Activities to Avoid During Pregnancy

10 Adorable Baby Shower Ideas for Girls

Prednisone in Pregnancy – Benefits and Side Effects

First Trimester Yoga - Benefits and Poses to Try

Popular on parenting.

245 Rare Boy & Girl Names with Meanings

Top 22 Short Moral Stories For Kids

170 Boy & Girl Names That Mean 'Gift from God'

800+ Unique & Cute Nicknames for Boys & Girls

Latest posts.

Yoshi Coloring Pages - Free Printable Pages For Kids

Tractor Coloring Pages - Free Printable Pages For Kids

Avengers Coloring Pages - Free Printable Pages For Kids

Spongebob Coloring Pages - Free Printable Pages For Kids

7.6 Transverse lie and shoulder presentation

A transverse lie constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible.

This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.

7.6.1 Diagnosis

• The uterus is very wide: the transverse axis is virtually equivalent to the longitudinal axis; fundal height is less than 30 cm near term.
• On examination: head in one side, breech in the other (Figures 7.1a and 7.1b). Vaginal examination reveals a nearly empty true pelvis or a shoulder with—sometimes—an arm prolapsing from the vagina (Figure 7.1c).

Figures 7.1 - Transverse lie and shoulder presentation

7.6.2 Possible causes

• Grand multiparity (5 deliveries or more)
• Uterine malformation

Twin pregnancy

• Prematurity
• Placenta praevia
• Foeto-pelvic disproportion

7.6.3 Management

This diagnosis should be made before labour begins, at the last prenatal visit before the birth.

At the end of pregnancy

Singleton pregnancy.

• External version 4 to 6 weeks before delivery, in a CEmONC facility ( Section 7.7 ).
• If this fails, delivery should be carried out by caesarean section, either planned or at the beginning of labour (Chapter 6, Section 6.4.1 ).
• External version is contra-indicated.
• If the first twin is in a transverse lie (unusual): schedule a caesarean section.
• If the second twin is in a transverse lie: there is no indication for caesarean section, but plan delivery in a CEmONC facility so that it can be performed if necessary. Deliver the first twin and then, assess the foetal position and give a few minutes for the second twin to adopt a longitudinal lie. If the second twin stays in a transverse lie, and depending on the experience of the operator, perform external version ( Section 7.7 ) and/or internal version ( Section 7.8 ) on the second twin.

During labour, in a CEmONC facility

Foetus alive and membranes intact.

• Gentle external version, between two contractions, as early as possible, then proceed as with normal delivery.
• If this fails: caesarean section.

Foetus alive and membranes ruptured

• Multipara with relaxed uterus and mobile foetus, and an experienced operator: internal version and total breech extraction.
• Primipara, or tight uterus, or immobile foetus, or engaged arm, or scarred uterus or insufficiently-experienced operator: caesarean section.
• Incomplete dilation: caesarean section.

Caesarean section can be difficult due to uterine retraction. Vertical hysterotomy is preferable. To perform extraction, grasp a foot in the fundus (equivalent to a total breech extraction, but by caesarean section).

Foetus dead

Embryotomy for transverse lie (Chapter 9, Section 9.7.7 ).

During labour, in remote settings where surgery is not available

Try to refer the patient to a CEmONC facility. If not feasible:

• Attempt external version as early as possible.
• If this fails, wait for complete dilation.
• Perform an external version ( Section 7.7 ) combined with an internal version ( Section 7.8 ), possibly placing the woman in various positions (Trendelenburg or knee-chest).
• Put the woman into the knee-chest position.
• Between contractions, push the foetus back and try to engage his head.
• Vacuum extraction (Chapter 5, Section 5.6.1 ) and symphysiotomy (Chapter 5, Section 5.7 ) at the slightest difficulty.
• Incomplete dilation: Trendelenburg position and watchful waiting until complete dilation.

Try to refer the patient, even if referral takes some time. If not feasible, embryotomy for transverse lie (Chapter 9, Section 9.7.7 ).

D. ASHLEY HILL, MD, JORGE LENSE, MD, AND FAY ROEPCKE, MD, MPH

Am Fam Physician. 2020;102(2):84-90

Author disclosure: No relevant financial affiliations.

Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. This can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder, anal sphincter, and rectum, and postpartum hemorrhage. Although fetal macrosomia, prior shoulder dystocia, and preexisting or gestational diabetes mellitus increases the risk of shoulder dystocia, most cases occur without warning. Labor and delivery teams should always be prepared to recognize and treat this emergency. Training and simulation exercises improve physician and team performance when shoulder dystocia occurs. Unequivocally announcing that dystocia is happening, summoning extra assistance, keeping track of the time from delivery of the head to full delivery of the neonate, and communicating with the patient and health care team are helpful. Calm and thoughtful use of release maneuvers such as knee to chest (McRoberts maneuver), suprapubic pressure, posterior arm or shoulder delivery, and internal rotational maneuvers will almost always result in successful delivery. When these are unsuccessful, additional maneuvers, including intentional clavicular fracture or cephalic replacement, may lead to delivery. Each institution should consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal rescue and practice this during simulation exercises.

Shoulder dystocia is an obstetric emergency in which gentle downward traction of the fetal head does not lead to delivery and additional maneuvers are required to deliver the fetal shoulders. 1 Shoulder dystocia is usually attributed to impaction of the anterior shoulder against the maternal symphysis after delivery of the fetal head; less commonly, it is caused by impaction of the posterior shoulder against the sacral promontory. 2

Shoulder dystocia complicates 0.3% to 3% of all vaginal deliveries. 3 , 4 The exact incidence can be difficult to determine because the diagnosis is subjective and there are no agreed upon diagnostic criteria for shoulder dystocia. Objective criteria of a head-to-body delivery interval of 60 seconds or the need for additional delivery maneuvers are proposed based on the incidence of significantly more birth injuries and lower Apgar scores during these deliveries. 5

Risk Factors and Prevention

Risk factors for shoulder dystocia include fetal macrosomia (odds ratio = 16.1), prior shoulder dystocia (odds ratio = 8.25), and preexisting or gestational diabetes mellitus (odds ratio = 1.8). 6 – 8 Other risk factors include maternal obesity, excessive maternal weight gain during pregnancy, oxytocin (Pitocin) use, prolonged first or second stage labor, and operative vaginal delivery (forceps or vacuum); however, these are poorly predictive of shoulder dystocia. 9 There are no accurate models to predict or prevent shoulder dystocia. 10 , 11

Fetal macrosomia is difficult to accurately predict. At term, fetal sonography has at least a 10% margin of error for diagnosis of macrosomia. 11 Although the incidence of shoulder dystocia increases with increasing fetal weight and maternal diabetes, one study of pregnancies complicated by shoulder dystocia found that half of the neonates weighed less than 4,000 g (8 lb, 13 oz) and that only 20% of the patients had diabetes. 12 Results from studies evaluating labor induction for suspected macrosomia are inconsistent, and induction is not recommended to prevent shoulder dystocia. 13 Given the increased risk of shoulder dystocia with increasing fetal weights, the American College of Obstetricians and Gynecologists (ACOG) recommends consideration of cesarean delivery for a patient who does not have diabetes and is carrying a fetus with an estimated fetal weight of 5,000 g (11 lb). ACOG also recommends consideration of cesarean delivery for a patient who has diabetes and is carrying a fetus with an estimated fetal weight of 4,500 g (9 lb, 15 oz). 10

ACOG and the Advanced Life Support in Obstetrics program recommend that labor and delivery teams conduct regular team training drills that include identification and management of shoulder dystocia. 10 , 14

Complications

Shoulder dystocia can cause several maternal and neonatal complications ( Table 1 ) . 10 The most common maternal complications are postpartum hemorrhage (11%) and obstetric anal sphincter injuries (3.8%). 15 The most common neonatal injuries are brachial plexus injuries and clavicular or humeral fractures. 16 Transient brachial plexus injuries may occur in up to 20% of deliveries complicated by shoulder dystocia. 3 Most resolve without permanent disability, although approximately 10% may result in permanent neurologic injury. 17 The head-to-body delivery interval does not predict fetal asphyxia or death. 10 However, due to the potential for serious maternal or neonatal harm, a systematic approach to expeditious delivery is necessary. 10 , 15

Initial Response

Physicians should announce delivery of the fetal head so that an assistant can start a timer. If the fetus fails to deliver using normal traction or if retraction of the fetal head against the perineum (turtle sign) occurs, the physician should announce that there is a shoulder dystocia, and the delivery team should call for additional team members to assist. A longitudinal study of a shoulder dystocia simulation program found a significant reduction in neonatal brachial plexus injuries at discharge (7.6% to 1.3%) when the delivery team performed specified actions during shoulder dystocia deliveries . 18 These included an unequivocal announcement of the shoulder dystocia, calling for additional assistance from qualified personnel, and having an assistant announce the time from delivery of the fetal head every 30 seconds.

Physicians should also obtain assistance from a physician qualified to perform cesarean delivery and someone to resuscitate the neonate. Additional helpful actions that have not been studied include communicating with the patient so that she knows when to push, lowering the bed, using a stool for the assistant applying suprapubic pressure, and having someone record events for precise documentation.

Delivery Maneuvers

If the fetus does not deliver using gentle traction, release maneuvers can be used in a thoughtful and sequential manner to deliver the impacted shoulder ( Figure 1 ) . Aggressive lateral or downward traction on the fetal head and neck should be avoided because it can injure the brachial plexus. 4 There are no randomized trials comparing the various maneuvers used to release an impacted shoulder 10 ( Table 2 10 , 18 , 19 ) . ACOG, the Royal College of Obstetricians and Gynaecologists, and the Advanced Life Support in Obstetrics program recommend using the McRoberts maneuver first, followed by suprapubic pressure if necessary. 10 , 14 , 19 The McRoberts maneuver, performed by flexing the hips and bringing both knees toward the chest, rotates the symphysis pubis cephalad and further opens the pelvic outlet  ( Figure 2 ) . This is a simple and proven method to manage shoulder dystocia, with a success rate of up to 42% as the sole maneuver. 10 , 15

If delivery does not occur, firm, steady suprapubic pressure should be performed concurrently with the McRoberts maneuver. An assistant should apply firm downward or oblique pressure just above the symphysis pubis toward the side the infant is facing. This decreases the distance between the infant's shoulders (bisacromial distance), potentially assisting anterior shoulder dislodgement ( Figure 3 ) . Fundal pressure increases the risk of uterine rupture. 20

If the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm should be considered 10 , 14 , 21 ( Figure 4 ) . A retrospective review revealed that the combination of the McRoberts maneuver, suprapubic pressure, and posterior arm delivery resulted in successful delivery within four minutes in 95% of cases. 21 Computer modeling suggests that delivery of the posterior arm results in the least amount of brachial plexus stretch compared with other maneuvers. 22 Delivery of the posterior arm requires patience and communication to keep the patient calm. Training with a birth simulator will likely improve operator confidence and performance of this procedure.

An episiotomy may help depending on the size of the physician's hands and ability to enter the posterior vagina, but it is not mandatory for this or any release maneuver. 23 The physician should apply lubricant, compress all five fingers from the appropriate hand into a “duck-bill” shape, and gently maneuver the hand into the posterior vagina, under the baby (see a video of a posterior arm release ). The physician should then slide the hand along the fetal chest, not the back, up to the fetal hip, or until the posterior hand is identified. Grasping the wrist by forming an OK sign with the physician's thumb and index finger ( Figure 4 ) , he or she should flex the fetal elbow and slide the arm along the fetal chest to deliver from the posterior vagina. Using the operator's fifth finger as a fulcrum by placing it along the fetal elbow may help.

Posterior Arm Release

If the posterior arm is tight against the vaginal sidewall and cannot be delivered, other methods of delivering the posterior shoulder can be used. The Menticoglou maneuver involves placing one finger from each hand under the posterior axilla and applying gentle traction along the curve of the pelvis to deliver the posterior shoulder. 24 After the shoulder delivers, it should be easier to deliver the entire posterior arm. The posterior axilla sling traction maneuver uses a suction catheter or urinary catheter placed under the posterior shoulder axilla to apply downward traction to deliver the posterior shoulder. 25 Alternatively, the physician can use the sling to rotate the posterior shoulder 180 degrees to anterior, similar to the Woods maneuver. A description and video of this technique  is available.

Additional maneuvers include rotational methods (e.g., Rubin II, the Woods or reverse Woods [corkscrew] maneuvers) and rolling the patient to her hands and knees (Gaskin all-fours maneuver). To perform the Rubin II maneuver, the physician places two fingers into the vagina to push the scapula of the anterior fetal shoulder toward the fetal face to attempt to rotate the fetus 30 degrees ( Figure 5 ; see a video of the Rubin II maneuver ).

Rubin II Maneuver

The Woods maneuver combines the hand placement for the Rubin II maneuver with two fingers on the anterior aspect of the posterior fetal shoulder with the intent of rotating the fetus 180 degrees ( Figure 5 ; see a video of the Woods maneuver ). For the reverse Woods maneuver, fingers or hands are placed on the front side of the anterior shoulder and back side of the posterior shoulder to rotate the fetus 180 degrees. An episiotomy may be helpful for the Woods maneuvers to be able to gain access with two hands. The Gaskin all-fours maneuver requires the patient to roll onto her hands and knees. This had an 83% success rate as the sole maneuver used in one series. 26 This maneuver may be more difficult if the patient is fatigued or has neuraxial anesthesia.

Woods Maneuver

Maneuvers for catastrophic shoulder dystocia.

If these maneuvers do not result in delivery, options include performing the maneuvers again ( Figure 1 ) or enlisting assistance from another experienced physician who might try the previously attempted maneuvers again or who can collaborate to attempt less proven maneuvers, such as abdominal rescue, cephalic replacement (Zavanelli maneuver), and intentional clavicular fracture ( Table 3 ) . 10 , 27 , 28 Each institution should consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal rescue and practice this during simulation exercises.

Documentation

Precise documentation is extremely important after a shoulder dystocia to inform the clinical team of the delivery events, including the head-to-body delivery interval and maneuvers used. ACOG has provided a checklist for documenting the occurrence of shoulder dystocia . 29

This article updates a previous article by Baxley and Gobbo . 30

Data Sources: A PubMed search was completed in Clinical Queries using the key terms shoulder dystocia, shoulder, brachial plexus, and abnormal labor. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. We also searched Ovid, Clinical Key, Cochrane Library, Web of Science, the Agency for Healthcare Research and Quality evidence reports, and Essential Evidence Plus. Search dates: September 5, 2019, and April 13, 2020.

Resnik R. Management of shoulder girdle dystocia. Clin Obstet Gynecol. 1980;23(2):559-564.

Hankins GD, Clark SL. Brachial plexus palsy involving the posterior shoulder at spontaneous vaginal delivery. Am J Perinatol. 1995;12(1):44-45.

Gherman RB, Chauhan S, Ouzounian JG, et al. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006;195(3):657-672.

American College of Obstetricians and Gynecologists; Task Force on Neonatal Brachial Plexus Palsy. Neonatal Brachial Plexus Palsy . American College of Obstetricians and Gynecologists; 2014.

Beall MH, Spong C, McKay J, et al. Objective definition of shoulder dystocia: a prospective evaluation. Am J Obstet Gynecol. 1998;179(4):934-937.

Tsur A, Sergienko R, Wiznitzer A, et al. Critical analysis of risk factors for shoulder dystocia. Arch Gynecol Obstet. 2012;285(5):1225-1229.

Bingham J, Chauhan SP, Hayes E, et al. Recurrent shoulder dystocia: a review. Obstet Gynecol Surv. 2010;65(3):183-188.

Zhang C, Wu Y, Li S, et al. Maternal prepregnancy obesity and the risk of shoulder dystocia: a meta-analysis. BJOG. 2018;125(4):407-413.

Ouzounian JG, Gherman RB. Shoulder dystocia: are historic risk factors reliable predictors?. Am J Obstet Gynecol. 2005;192(6):1933-1935.

Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 178: shoulder dystocia. Obstet Gynecol. 2017;129(5):e123-e133.

Gupta M, Hockley C, Quigley MA, et al. Antenatal and intrapartum prediction of shoulder dystocia. Eur J Obstet Gynecol Reprod Biol. 2010;151(2):134-139.

Ouzounian JG, Korst LM, Miller DA, et al. Brachial plexus palsy and shoulder dystocia: obstetric risk factors remain elusive. Am J Perinatol. 2013;30(4):303-307.

American College of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics. Practice bulletin number 173: fetal macrosomia. Obstet Gynecol. 2016;128(5):e195-e209.

Shields SG, Ratcliffe S. Chapter F: labor dystocia. In: Leeman L, Quinlan JD, Dresang LT, et al. Advanced Life Support in Obstetrics Provider Manual . 8th edition. American Academy of Family Physicians; 2017:1–14.

Gherman RB, Goodwin TM, Souter I, et al. The McRoberts' maneuver for the alleviation of shoulder dystocia: how successful is it?. Am J Obstet Gynecol. 1997;176(3):656-661.

Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol. 1998;178(6):1126-1130.

Gherman RB, Ouzounian JG, Miller DA, et al. Spontaneous vaginal delivery: a risk factor for Erb's palsy?. Am J Obstet Gynecol. 1998;178(3):423-427.

Grobman WA, Miller D, Burke C, et al. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205(6):513-517.

Royal College of Obstetricians and Gynaecologists. Shoulder dystocia (green-top guideline No. 42). March 28, 2012. Updated February 2017. Accessed March 11, 2020. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg42/

Sturzenegger K, Schäffer L, Zimmermann R, et al. Risk factors of uterine rupture with a special interest to uterine fundal pressure. J Perinat Med. 2017;45(3):309-313.

Leung TY, Stuart O, Suen SS, et al. Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres: a retrospective review. BJOG. 2011;118(8):985-990.

Grimm MJ, Costello RE, Gonik B. Effect of clinician-applied maneuvers on brachial plexus stretch during a shoulder dystocia event: investigation using a computer simulation model. Am J Obstet Gynecol. 2010;203(4):339.e1-339.e5.

Sagi-Dain L, Sagi S. The role of episiotomy in prevention and management of shoulder dystocia: a systematic review. Obstet Gynecol Surv. 2015;70(5):354-362.

Menticoglou SM. A modified technique to deliver the posterior arm in severe shoulder dystocia. Obstet Gynecol. 2006;108(3 pt 2):755-757.

Cluver CA, Hofmeyr GJ. Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling. Am J Obstet Gynecol. 2015;212(6):784.e1-784.e7.

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med. 1998;43(5):439-443.

O'Shaughnessy MJ. Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia. Obstet Gynecol. 1998;92(4 pt 2):693-695.

Sandberg EC. The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol. 1999;93(2):312-317.

American College of Obstetricians and Gynecologists. Patient safety checklist no. 6: documenting shoulder dystocia. Obstet Gynecol. 2012;120(2 pt 1):430-431.

Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician. 2004;69(7):1707-1714. Accessed March 11, 2020. https://www.aafp.org/afp/2004/0401/p1707.html

Continue Reading

More in AFP

More in pubmed.

Copyright © 2020 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Fastest Obstetric, Gynecology and Pediatric Insight Engine

• Abdominal Key
• Anesthesia Key
• Basicmedical Key
• Otolaryngology & Ophthalmology
• Musculoskeletal Key
• Obstetric, Gynecology and Pediatric
• Oncology & Hematology
• Plastic Surgery & Dermatology
• Clinical Dentistry
• Radiology Key
• Thoracic Key
• Veterinary Medicine
• Gold Membership

Malpresentation, Malposition, Cephalopelvic Disproportion and Obstetric Procedures

26 Malpresentation, Malposition, Cephalopelvic Disproportion and Obstetric Procedures Kim Hinshaw 1,2 and Sabaratnam Arulkumaran 3 1 Sunderland Royal Hospital, Sunderland, UK 2 University of Sunderland, Sunderland, UK 3 St George’s University of London, London, UK Malpresentation, malposition and cephalopelvic disproportion Definitions The vertex is a diamond‐shaped area on the fetal skull bounded by the anterior and posterior fontanelles and laterally by the parietal eminences. Vertex presentation is found in 95% of labours at term and is associated with flexion of the fetal head. Breech, brow, face and shoulder presentations constitute the remaining 5% and are collectively known as malpresentations . Their aetiology is usually unknown, but associations include macrosomia, multiparity, polyhydramnios, multiple pregnancy, placenta praevia, preterm labour, and anomalies of the uterus or pelvis (congenital or acquired, e.g. lower segment fibroids) and more rarely the fetus. The denominator is a laterally sited bony eminence on the presenting part (‘occiput’ for vertex presentation, ‘mentum’ for face, ‘acromium’ for shoulder and ‘sacrum’ for breech). The position of the presenting part is defined by the relationship of the denominator to the maternal bony pelvis. The vertex enters the pelvis in the occipito‐transverse (OT) position and during descent rotates to an occipito‐anterior (OA) position in 90% of cases. This position is associated with a well‐flexed head, allowing the smallest anteroposterior (suboccipito‐bregmatic) and lateral (biparietal) diameters to pass through the pelvis (both 9.5 cm). Malposition occurs when the occiput remains in a tranverse or posterior position as labour progresses. Persistent malposition results in deflexion with a larger anteroposterior diameter presenting (occipito‐frontal 11.5 cm). It is associated with increasing degrees of anterior or posterior asynclitism , with one of the parietal bones preceding the sagittal suture (in posterior asynclitism, the posterior parietal bone leads; Fig. 26.1 ). Significant degrees of asynclitism can result in labour dystocia and a higher risk of operative delivery [1] . Fig. 26.1 Posterior asynclitism of the vertex: posterior parietal bone presenting below the sagittal suture. In most cases, flexion occurs as the vertex descends onto the pelvic floor, leading to correction of the malposition and a high chance of spontaneous delivery. The level of the presenting part should be critically assessed as labour progresses. On abdominal examination, the head should descend until it is no more than 1/5 palpable in the late first stage. On vaginal examination the presenting part is assessed relative to the level of the ischial spines. Care must be taken to assess the level using the lowest bony part . Malposition is associated with increased moulding of the fetal skull and a large caput succedaneum, which may give false reassurance about the true degree of descent. In modern obstetric practice, operative vaginal delivery is not attempted if the leading edge of the skull is above the ischial spines (i.e. above ‘0’ station; Fig. 26.2 ). Fig. 26.2 Level of the presenting part relative to the ischial spines. Malpresentations Breech presentation The incidence of breech presentation varies according to gestation: 20% at 30 weeks falling to 4% by term. The aetiology of most breech presentations at term is unclear but known factors to consider include placenta praevia, polyhydramnios, bicornuate uterus, fibroids and, rarely, spina bifida or hydrocephaly. Types of breech presentation Between 50 and 70% of breech presentations manifest with hips flexed and knees extended (extended breech) Complete (or flexed) breech is more common in multiparous women and constitutes 5–10% at term (hips and knees flexed; Fig. 26.3 ). Incomplete or footling breech (10–30%) presents with one or both hips extended, or one or both feet presenting and is most strongly assoiated with cord prolapse (5–10%). Knee presentation is rare. Fig. 26.3 The common types of breech presentation. Clinical diagnosis may miss up to 20% of breech presentations, relying on identifying the head as a distinct hard spherical hard mass to one or other side under the hypochondrium which distinctly ‘ballots’. In such cases the breech is said to feel broader and an old adage reminds us: ‘Beware the deeply engaged head – it is probably a breech!’ Auscultation may locate the fetal heart above the maternal umbilicus and ultrasound confirmation should be considered. Antenatal management If breech presentation is suspected at 36 weeks, ultrasound assessment is recommended as it allows a comprehensive assessment of the type of breech, placental site, estimated fetal weight, confirmation of normality and exclusion of nuchal cord or hyperextension of the fetal neck. External cephalic version (ECV) is encouraged after 36 or more weeks as the chance of spontaneous version to cephalic presentation after 37 weeks is only 8%. Absolute contraindications are relatively few but include placenta praevia, bleeding within the last 7 days, abnormal cardiotocography (CTG), major uterine anomaly, ruptured membranes and multiple pregnancy [2] . Couples should receive counselling about the procedure and its success rates and complications, and the subsequent management of persistent breech presentation. Tocolysis increases the likelihood of success, with average rates of 50% (range 30–80%). Women should be made aware that even with a cephalic presentation following ECV, labour is still associated with a higher rate of obstetric intervention than when ECV has not been required. ECV should be performed in a setting where urgent caesarean section (CS) is available in case of fetal compromise during or soon after ECV. CTG for 30–40 min prior to and after ECV should provide confirmation of fetal health. The chance of success is greater with multiparity, flexed breech presentation and an adequate liquor volume. The use of moxibustion at 33–35 weeks, in combination with acupuncture, may reduce the numbers of births by CS. Training specialist midwives is potentially cost‐efficient with success rates comparable to consultant‐led services (51–66%) [3] . The first step in ECV involves disengaging the breech by moving the fetus up and away from the pelvis, shifting it to a sideways position, followed by a forward somersault to move the head to the lower pole; if this fails a backward somersault can be tried. The need for emergency delivery by CS because of suspected fetal compromise is estimated to be 0.5%. Mothers who are rhesus‐negative should have a Kleihauer–Betke test after the procedure and receive anti‐D. If ECV is unsuccessful, women who are keen to avoid CS may be offered a repeat attempt under neuraxial blockade. This increases the chances of success (58.4% vs. 43.1%; relative risk, RR 1.44, 95% CI 1.27–1.64) and reduces the incidence of CS (46.0% vs. 55.3%; RR 0.83, 95% CI 0.71–0.97) [4] . Otherwise appropriate counselling about the options of elective CS or assisted vaginal breech delivery should be offered. Deciding mode of delivery Despite increasing evidence supporting elective CS for breech delivery at term, controversy and debate continue among professional groups. Breech presentation at term diagnosed antenatally . The Term Breech Trial is the largest published randomized controlled trial where the primary outcome (serious perinatal morbidity and mortality) favoured planned CS over planned vaginal birth: 17/1039 (1.6%) versus 50/1039 (5.0%; RR 0.33, 95% CI 0.19–0.56; P <0.0001) [5] . The trial concluded that ‘planned CS is better than planned VB for the term fetus in the breech presentation; serious maternal complications are similar between the groups’. This has significantly changed practice in many countries despite continuing debate and criticism about the trial design and intepretation of outcomes. However, the latest systematic review has confirmed a significant increased perinatal risk associated with planned vaginal birth [6] . Breech at term diagnosed in labour and preterm breech delivery . Observational trials of term breech ‘undiagnosed’ until presentation in labour confirm that this group has a high vaginal delivery rate with relatively low perinatal morbidity. In a similar vein, the evidence to guide best practice for delivery of the preterm breech remains equivocal, decisions often being based on individual interpretation of the data and local custom and practice. Conducting a vaginal breech delivery For women who wish to deliver vaginally, antenatal selection aims to ensure optimal outcome for mother and baby but remains relatively subjective. Women with frank and complete breech presentations (fetal weight <4000 g) encounter minimal problems, while those with footling breech are advised elective CS because of the increased risk of cord prolapse. CT or X‐ray pelvimetry do not appear to improve outcome. Spontaneous onset of labour is preferred and labour management is similar to vertex presentation. Successful outcome depends on a normal rate of cervical dilatation, descent of the breech and a normal fetal heart rate (FHR) pattern. Where progress of labour is poor and uterine contractions are inadequate, oxytocin augmentation can be used juidiciously with early resort to emergency CS if progress remains slow (<0.5 cm/hour), particularly in the late first stage. Epidural anaesthesia prevents bearing down before the cervix is fully dilated and is particularly important for labour with a preterm breech, when there is a real risk of head entrapment in the incompletely dilated cervix if pushing commences too early. For all breech labours, the mother should be encouraged to avoid bearing down for as long as possible. It is best to wait until the anterior buttock and anus of the baby are in view over the mother’s perineum, with no retraction between contractions. Classically, the mother’s legs are supported in the lithotomy position (the alternative upright breech technique is described later). Primigravidae will usually require an episiotomy with appropriate analgesia, although multigravidae can be assessed as the perineum stretches up. The buttocks deliver in the sacro‐tranverse position. The mother should be encouraged to push with contractions, aiming for an unassisted delivery up to and beyond the level of the umbilicus. There is no need to pull down a loop of cord. The accoucheur should sit with hands ready, but resting on their own legs. Assistance is only required if the legs do not deliver. Gentle abduction of the fetal thigh whilst hyperflexing the hip, followed by flexing the lower leg at the knee will release the foot and leg ( Fig. 26.4 ). Fig. 26.4 Delivery of extended legs by gentle abduction of the thigh with hyperflexion at the hip, followed by flexion at the knee: (a) right leg; (b) left leg. When the scapulae are visible with the arms flexed in front of the chest, sweep each arm around the side of the fetal chest to deliver using a finger placed along the length of the humerus. If the scapulae are not easily seen or if the arms are not easily reached, they may be extended above the shoulders. This can be resolved using the Løvset manoeuvre. Hold the baby by wrapping both hands around the bony pelvis, taking care not to apply pressure to the soft fetal abdomen. Rotate the baby 180° to bring the posterior shoulder to the front, i.e. to lie anteriorly ( Fig. 26.5 a). Complete delivery of the anterior arm by gently flexing the baby laterally downwards towards the floor; the arm will deliver easily from under the pubic ramus ( Fig. 26.5 b). Repeat the 180° rotation in the opposite direction, bringing the posterior shoulder to the front, then flex the baby laterally downwards to deliver the second arm. Fig. 26.5 Løvset’s manoeuvre for extended arms: (a) rotation to bring the posterior (left) arm to the front followed by (b) delivery of the left arm (now anterior) from under the pubic ramus. Nuchal displacement (an arm trapped behind the fetal neck) is rare. If the left arm is trapped, the baby will need to be rotated in a clockwise direction to ‘unwrap’ the arm so that it can be reached. If the right arm is involved, anticlockwise rotation is needed. Allow the head to descend into the pelvis, assisted by the weight of the fetus until the nape of the neck is visible under the symphysis pubis. Ensure slow controlled delivery of the head using one of four methods. Mauriceau–Smellie–Veit manoeuvre: two fingers are placed on the maxilla, lying the baby along the forearm. Hook index and fourth fingers of the other hand over the shoulders with the middle finger on the occiput to aid flexion. Apply traction to the shoulders with an assistant applying suprapubic pressure if needed ( Fig. 26.6 ). Burns–Marshall method: grasp the feet, apply gentle traction and swing the baby gently up and over the maternal abdomen until the mouth and nose appear. Forceps are applied to the head from below, with an assistant supporting the baby’s body in the horizontal plane avoiding hyperextension. Kielland’s forceps can be useful as they lack a pelvic curve. Apply traction, bringing the forceps upwards as the mouth and nose appear. The upright breech technique is increasingly popular in midwifery deliveries. Mobility is encouraged with delivery on all fours, sitting (on a birth stool), kneeling, standing or lying in a lateral position. Delivery is spontaneous with no manual assistance in 70% of cases and a reduced incidence of perineal trauma (14.9%). Fig. 26.6 Delivery of the head using the Mauriceau–Smellie–Veit manoeuvre assisted by suprapubic pressure. Entrapment of the aftercoming head This rare complication occurs in two situations. If the fetal back is allowed to rotate posteriorly, the chin may be trapped behind the symphysis pubis. Correction requires difficult internal manipulation to free the chin by pushing it laterally. McRoberts’ manoeuvre and suprapubic pressure may help. Symphysiotomy is a last resort that can increase the available pelvic diameters. In preterm delivery, the body can slip through an incompletely dilated cervix, with resulting head entrapment. If the cervix cannot be ‘stretched up’ digitally, surgical incisions are made in the cervical ring at 2, 6 and 10 o’clock (Dührssen incisions). Head entrapment in the contractile upper segment can occur at CS. Acute tocolysis and/or extension of the uterine incision may be required to release the head. Women should be intimately involved in decisions about mode of breech delivery and the available evidence presented appropriately. A senior midwife or a doctor experienced in assisted breech delivery must be present. As vaginal breech deliveries decline, developing expertise in breech delivery now relies on simulation training and experience of breech delivery at CS. Summary box 26.1 ECV has a high success rate (51–66%) and should be encouraged. Ensure the fetal back does not rotate posteriorly during breech delivery. The most experienced accoucheur available should directly supervise vaginal breech delivery. Brow presentation Brow presentation occurs in 1 in 1500–3000 deliveries. The head is partially deflexed (extended), with the largest diameter of the head presenting (mento‐vertical, 13.5 cm). The forehead is the lowest presenting part but diagnosis relies on identifying the prominent orbital ridges lying laterally. The eyeballs and nasal bridge may just be palpated lateral to the orbital ridges. Position is defined using the frontal bone as the denominator (i.e. ‘fronto‐‘). Persistent brow presentation results in true disproportion, but when diagnosed in early labour careful assessment of progress is appropriate. Flexion to vertex or further extension to face presentation occurs in 50% and vaginal delivery is possible. Cautious augmentation with oxytocin should only be considered in nulliparous patients for delay in the early active phase of labour. If brow presentation persists, emergency CS is recommended. Vaginal delivery of a brow presentation is possible in extreme prematurity. Preterm labour is best managed in the same way as term labour, with delivery by CS if progress slows or arrests. Cord prolapse is more common and, though rare, uterine rupture can occur in neglected labour or with injudicious use of oxytocin. For this reason labour should not be augmented in multigravid patients with a confirmed brow presentation if progress is inadequate. Face presentation Face presentation occurs in 1 in 500–800 labours. The general causes of malpresentation apply for face presentation, but fetal anomalies (neck or thyroid masses, hydrocephalus and anencephaly) should be excluded. The fetal head is hyperextended and the occiput may be felt higher and more prominently on the same side as the fetal spine. However, face presentation is rarely diagnosed antenatally. On vaginal examination in labour, diagnosis relies on feeling the mouth, malar bones, nose and orbital ridges. Position is defined using the chin or mentum as the denominator. The mouth and malar bones form a triangle which can help differentiate face presentation from breech, where the anus lies in a straight line between the prominent ischial tuberosities. Face presentation is often first diagnosed in late labour. The submento‐bregmatic diameter (9.5 cm) is compatible with normal delivery but only with the fetus in a mento‐anterior position (60%) ( Fig. 26.7 ). The same diameter presents with a persistent mento‐posterior position (25%) but this cannot deliver vaginally as the fetal neck is maximally extended. Fetal scalp clips, blood sampling and vacuum extraction are absolutely contraindicated. Forceps delivery from low cavity can be undertaken for mento‐anterior or mento‐lateral positions by an experienced accoucheur but CS may still be required when descent is poor. Fig. 26.7 The anteroposterior submento‐bregmatic diameter of face presentation. Shoulder presentation The incidence of shoulder presentation at term is 1 in 200 and is found with a transverse or oblique lie. Multiparity (uterine laxity) and prematurity are common associations and placenta praevia must be excluded. The lie will usually correct spontaneously before labour as uterine tone increases, although prolapse of the cord or arm is a significant risk if membranes rupture early. For this reason, hospital admission from 38 weeks is recommended for persistent transverse lie. External version can be offered (and may also be considered for transverse lie presenting in very early labour). On vaginal examination, the denominator is the acromium but defining position can be difficult. If membrane rupture occurs at term with the uterus actively contracting, delivery by CS should be undertaken promptly to avoid an impacted transverse lie. If the uterus is found to be moulded around the fetus, a classical CS is recommended to avoid both fetal and maternal trauma. In cases of intrauterine death with a transverse lie, spontaneous vaginal delivery is possible for early preterm fetuses by extreme flexion of the body (spontaneous evolution). However, CS will usually be required beyond mid‐trimester, although a lower segment approach may be used. Malposition and cephalopelvic disproportion In higher‐income countries, cephalopelvic disproportion is usually ‘relative’ and due to persistent malposition or relative fetal size (macrosomia). Classically we consider these problems with regard to the passage, the passenger or the powers, either alone or in combination. The passage Absolute disproportion due to a contracted pelvis is now rare in higher‐income countries unless caused by severe pelvic trauma and this should be known before the onset of labour. Caldwell and Moloy described four types of pelvis: gynaecoid (ovoid inlet, widest transversely, 50%), anthropoid (ovoid inlet, widest anteroposterior, 25%), android (heart‐shaped inlet, funnel‐shaped, 20%) and platypelloid (flattened gynaecoid, 3%). These can influence labour outcome but as pelvimetry is rarely used and clinical assessment of pelvic shape is inaccurate, this rarely influences clinical mangement in labour. The anthropoid pelvis is associated with a higher risk of persistent occipito‐posterior (OP) position and relative disproportion. The passenger and OP malposition Fetal anomalies (e.g. hydrocephalus, ascites) where disproportion may be a problem in labour are usually assessed antenatally and delivery by elective CS considered. Fetal macrosomia is increasing, related to the rising body mass index (BMI) in many pregnant populations. The evidence for inducing non‐diabetic women with an estimated fetal weight above the 90th centile (or >4000 g) in order to reduce cephalopelvic disproportion remains equivocal. Malposition is an increasingly common cause of disproportion and may be related to a sedentary lifestyle. OP position is associated with deflexion and/or asynclitism with a larger diameter presenting. Optimal uterine activity will correct the malposition in 75% of cases. Flexion occurs as the occiput reaches the pelvic floor with long rotation through 135° to an OA position and a high chance of normal delivery. Moulding of the fetal skull and pelvic elasticity (related to changes at the symphysis pubis) are dynamic changes that facilitate progress in labour and delivery. Short rotation through 45° to direct OP can result in spontaneous ‘face to pubes’ delivery, although episiotomy may be required to allow the occiput to deliver. Persistent OP position occurs in up to 25% of cases and is associated with further deflexion. The risk of assisted delivery is high because of relative disproportion as the presenting skull diameters increase. Delivery in the OP position from mid‐cavity (0 to +2 station) requires critical assessment to decide whether delivery should be attempted vaginally or abdominally and is discussed in later sections. The powers Disproportion is intimately related to dystocia and failure to progress in labour. National Institute for Health and Care Excellence (NICE) guidelines recommend that first stage delay is suspected with cervical dilatation of less than 2 cm in 4 hours when forewater amniotomy should be offered. Delay is confirmed if progress is less than 1 cm 2 hours later and oxytocin augmentation should be offered [6] . This shortens labour but does not affect operative delivery rates. High‐dose oxytocin may reduce CS rates but larger trials are required before these regimens are used routinely. The decision to use oxytocin in labour arrest in multigravid patients must only be made by the most senior obstetrician and should always be approached with extreme caution as uterine rupture is a possible consequence. In the second stage, particularly with epidural analgesia, passive descent for at least 1 hour is recommended, and possibly longer if the woman wishes, before encouraging active pushing. With regional analgesia and a normal FHR pattern, birth should occur within 4 hours of full dilatation regardless of parity [7] . Oxytocin may be commenced in nulliparous patients in the passive phase if contractions are felt to be inadequate and particularly with the persistent OP position. Failure of second‐stage descent combined with excessive caput or moulding suggests disproportion and requires critical assessment to decide the appropriate mode of delivery. Summary box 26.2 OP position with deflexion of the head and asynclitism results in relative disproportion compounded by inadequate uterine activity. With epidural analgesia in place, passive descent should be encouraged for at least 1 hour. Augmentation with oxytocin should be used with extreme caution in multigravid patients with labour arrest. Instrumental vaginal deliveries Background The incidence of instrumental vaginal delivery (IVD) varies widely and in Europe ranges from 0.5% (Romania) to 16.4% (Ireland), although there is no direct relationship with CS rates [ 8 , 9 ]. Epidural analgesia is associated with higher IVD rates. Allowing a longer passive second stage for descent results in less rotational deliveries and possibly a reduction in second‐stage CS [ 10 , 11 ]. Common indications for IVD include delay in the second stage of labour due to inadequate uterine activity, malposition with relative disproportion, maternal exhaustion and fetal compromise. Women with severe cardiac, respiratory or hypertensive disease or intracranial pathology may require IVD to shorten the second stage (when forceps may be preferred). Assessment and preparation for IVD The condition of the mother and fetus and the progress of labour should be assessed prior to performing IVD. Personal introductions to the woman and her partner are essential, explaining the reason for IVD and ensuring a chaperone and enough support are available. The findings, plan of action and the procedure itself should be explained and the discussions carefully recorded. Verbal or written consent is obtained. The mother and her partner may be physically and emotionally exhausted and great care should be exercised in terms of behaviour, communication and medical action. On abdominal examination, the fetal head should be no more than 1/5 palpable (preferably 0/5). A scaphoid shape to the lower abdomen may indicate an OP position. The FHR pattern should be assessed, noting any clinical signs of fetal compromise (e.g. fresh meconium). With acute fetal compromise (e.g. profound bradycardia, cord prolapse) delivery must be expedited urgently and this may only allow a brief explanation to be given to the patient and her partner at the time. If contractions are felt to be infrequent or short‐lasting, an oxytocin infusion should be considered in the absence of signs of fetal compromise. Both vacuum and forceps deliveries are associated with an almost threefold increased risk of shoulder dystocia compared with spontaneous delivery and this should be anticipated. However, it remains unclear whether this increased incidence is a cause or effect phenomenon [12] . On vaginal examination the cervix should be fully dilated with membranes absent. The colour and amount of amniotic fluid is recorded. Excessive caput or moulding may suggest the possibility of disproportion. Inability to reduce overlapping skull bones with gentle pressure is designated ‘moulding +++’; overlapping that reduces by gentle digital pressure is ‘moulding ++’, and meeting of the bones without overlap is ‘moulding +’. Identification of position, station, degree of deflexion and asynclitism will help decide whether IVD is appropriate, where it should be undertaken and who should undertake the procedure. Successful IVD is associated with station below the spines and progressive descent with pushing. If the head is 1/5 palpable abdominally, the leading bony part of the head is at the level of the ischial spines (mid‐cavity). When the head is more than 1/5 palpable and/or when station is above the spines, delivery by CS is recommended. Position is determined by identification of suture lines and fontanelles. The small posterior fontanelle (PF) lies at the Y‐shaped junction of the sagittal and lambdoidal sutures but may be difficult to feel when there is marked caput. The anterior fontanelle (AF) is a larger diamond‐shaped depression at the junction of the two parietal and two frontal bones. It can be differentiated from the PF by identifying the four sutures leading into the fontanelle. In deflexion (particularly OP positions) the AF lies centrally and is easily felt. Position can be confirmed by reaching for the pinna of the fetal ear, which can be flicked forwards indicating that the occiput lies in the opposite direction. Reaching the ear suggests descent below the mid‐pelvic strait. The degree of asynclitism should be assessed (see Fig. 26.1 ), with increasing degrees suggesting disproportion and a potentially more difficult IVD. Assessment of level and position can be difficult with OP position and in obesity. If there is any doubt after careful clinical examination, ultrasound assessment is recommended. The fetal orbits are sought and the position of the spine is noted. This is simple to do and can reduce the incorrect diagnosis of fetal position without delaying delivery, although on its own may not reduce morbidity associated with IVD [13] . IVD is normally performed with the mother in the dorsal semi‐upright position with legs flexed and abducted, supported by lithotomy poles or similar. The procedure is performed with good light and ideally aseptic conditions. The vulva and perineum should be cleansed and the bladder catheterized if the woman is unable to void. Adequate analgesia is essential and requires careful individualized assessment. Epidural anaesthesia is advisable for mid‐cavity IVD (i.e. station 0 to +2 cm below the ischial spines; see Fig. 26.2 ). In the absence of a pre‐existing epidural, spinal anaesthesia may be considered. IVD at station +2 cm or below is termed ‘low‐cavity’ and regional or pudendal block with local perineal infiltration (20 mL 1% plain lidocaine) can be used. Outlet IVD is performed when the head is on or near the perineum with the scalp visible without separating the labia. Descent to this level is associated with an OA position requiring minimal or no rotation and perineal infiltration with pudendal anaesthesia is effective. When the vertex is below the spines, IVD is carried out with different types of forceps or vacuum equipment, depending on the position and station of the vertex and the familiarity and experience of the doctor. Overall, comparing outcomes is easier if designation is by station and position at the time of instrumentation (e.g. left OP at +3) rather than simply mid, low or outlet IVD [ 11 , 14 ]. Choice of instruments: forceps or ventouse The choice of instrument depends on the operator’s experience, familiarity with the instrument, station and position of the vertex. Therefore, knowledge of the station and the position of the vertex is essential. The fetus in an OA position in the mid/low cavity can be delivered using non‐rotational, long or short‐handled forceps or a vacuum device: silicone, plastic or anterior metal cups (with suction tubing arising from the dorsum of the cup) are all suitable. For the fetus lying OT at mid‐ or low‐cavity, or lying OP position mid‐cavity, Kielland’s forceps or vacuum devices can be used to correct the malposition. Manual rotation is another technique to consider. Low‐cavity direct OP positions can be delivered ‘face to pubis’ but this may cause signifcant perineal trauma as the occiput delivers. For this reason, an OP vacuum cup (with the suction tubing arising from the edge of the cup) may be preferred. The cup will promote flexion and late rotation to OA often occurs on the perineum just prior to delivery. The Kiwi OmniCup® is an all‐purpose disposable vacuum delivery system with a plastic cup and in‐built PalmPump™ suitable for use in all positions of the vertex. Later models also display force traction to help the accoucheur avoid cup slippage ( http://clinicalinnovations.com/portfolio‐items/kiwi‐complete‐vacuum‐delivery‐system/ ) Forceps delivery Forceps come in pairs and most have fenestrated blades with a cephalic and pelvic curve between the heel and toe (distal end) of each blade. The heel continues as a shank which ends in the handle. The handles of the two blades sit together and meet at the lock. The cephalic curve fits along either side of the fetal head with the blades lying on the maxilla or malar eminences in the line of the mento‐vertical diameter ( Fig. 26.8 a). When correctly attached, uniform pressure is applied to the head, with the main traction force applied over the malar eminences. The shanks are over the flexion point, allowing effective traction in the correct direction. Non‐rotational forceps (the longer‐handled Neville Barnes or Simpson, and the shorter‐handled Wrigley’s) have a distinct pelvic curve that allows the blades to lie in the line of the pelvic axis whilst the handles remain horizontal. Kielland’s forceps have a minimal pelvic curve to allow rotation within the pelvis to correct malposition. Fig. 26.8 (a) Malar forceps application showing mento‐vertical diameter; (b) forceps traction (Pajot’s manoeuvre). Prior to applying forceps, the blades should be assembled to check whether they fit together as a pair. All forceps have matching numbers imprinted on the handles or shanks and these should also be checked. Non‐rotational forceps can be applied when the vertex is no more than 45° either side of the direct OA position (i.e. right OA to left OA). Application and delivery in a direct OP position is also possible but not routinely recommended because of increased perineal trauma. The left blade is inserted first using a light ‘pencil grip’, negotiating the pelvic and cephalic curves with a curved movement of the blade between the fetal head and the operator’s right hand, which is kept along the left vaginal wall for protection. Hands are swapped to insert the right blade using the same technique. Correct application results in the handles lying horizontally, right on top of left, and locking should be easy. Before applying traction, correct application must be confirmed: (i) the sagittal suture is lying midline, equidistant from and parallel to the blades; (ii) the occiput is no more than 2–3 cm above the level of the shanks (i.e. head well‐flexed); and (iii) no more than a fingertip passes into the fenestration at the heel of the blade. From mid‐ and low‐cavity, Pajot’s maneouvre should be used, balancing outward traction with one hand with downward pressure on the shanks with the other ( Fig. 26.8 b, white arrow). The handles are kept horizontal to avoid trauma to the anterior vaginal wall from the toes of the blades. Traction is synchronized with contractions and maternal effort, and the resultant movement is outwards down the line of the pelvic axis until the head is crowning. An episiotomy is usually needed as the perineum stretches up. The direction of traction is now upwards once the biparietal eminences emerge under the pubic arch and the head is born by extension. The mother will usually ask to have her baby handed to her immediately (unless active resuscitation is required). After completing the third stage, any perineal trauma is repaired and a full surgical count completed. The procedure, including plans for analgesia and bladder care, should be fully documented. Rotational forceps Kielland’s forceps have a minimal pelvic curve allowing rotation of the head at mid‐cavity. They are powerful forceps requiring a skilled accoucheur who is willing to abandon the procedure if progress is not as expected. The number of units able to teach use of Kielland’s forceps to the point of independent practice is declining in the UK. The forceps should match and are applied so that the knobs on the handles face the fetal occiput. Kielland’s are used to correct both OT and OP positions using two methods of application. Direct application involves sliding each blade along the side of the head if space permits, and is more easily achieved with OP positions. Wandering application is useful in OT positions. The first blade is applied in front of the fetal face, from where it is gently ‘wandered’ around to lie in the usual position alongside the malar bone. The posterior blade is applied directly using the space in the pelvic sacral curve. If application is difficult or the blades do not easily lock, the procedure should be abandoned. Correct application should be confirmed. Once locked, it is essential to hold the handles at a relatively steep angle downwards in the line of the mid‐pelvic axis in order to achieve easy rotation. Asynclitism is corrected using the sliding lock, moving the shanks over each other until the knobs are aligned. Rotation should take place between contractions, using only gentle force. Rotation may require the fetal head to be gently disimpacted, either upwards or downwards but no more than 1‐cm displacement is needed. Correct application should be checked again after rotation. Traction should result in progressive descent and an episiotomy is usually required. At the point of delivery, the handles of Kielland’s are only just above the horizontal because of the lack of pelvic curve. If there is no descent with traction during three contractions with maternal effort, the procedure should be abandoned. Whether Kielland’s delivery takes place in the delivery room or in obstetric theatre requires careful assessment of fetal and maternal condition, analgesia and labour progress. If there is any doubt, a formal trial of forceps should be arranged. Vacuum delivery Ventouse or vacuum delivery is increasingly favoured over forceps delivery for similar indications in the second stage of labour. The prerequisites to be satisfied before vacuum delivery are the same as for all forms of IVD. Vacuum delivery is contraindicated below 34 +0 weeks and should be used with caution between 34 +0 to 36 +0 weeks [11] . Overall it is contraindicated for fetuses with possible haemorrhagic tendencies (risk of subgaleal haemorrhage) and before full dilatation [11] . Experienced practitioners may consider vacuum after 8 cm in a multigravid patient in some circumstances. There are many types of vacuum cup in regular use, made of different materials and of differing shapes. Whichever cup is used, the aim is to ensure that the centre of the cup is directly over the flexion point. The flexion point is 3 cm in front of the occiput in the midline and is the point where the mento‐vertical diameter exits the fetal skull [15] . Traction on this point promotes flexion, presenting the smallest diameters for descent through the pelvis: this is the optimum flexing median application ( Fig. 26.9 a). Other applications increase the risk of cup detachment, failed vacuum delivery and scalp trauma. In decreasing order of effectiveness, these are the flexing paramedian application ( Fig. 26.9 b), the deflexing median application ( Fig. 26.9 c) and the deflexing paramedian application ( Fig. 26.9 d). Fig. 26.9 Placement of the vacuum cup, from most favourable (a) to unfavourable (d). (a) Flexing median; (b) flexing paramedian; (c) deflexing median; (d) deflexing paramedian. It is vitally important to select the correct cup and this will vary depending on both the position and attitude of the fetus. The soft Silc, Silastic or anterior metal cups (where the tubing is attached on the dorsum of the cup) are not suitable for OT or OP positions, as their shape and configuration do not allow application over the flexion point. They are suitable for OA positions where the flexion point is accessible in the midline. Metal cups come in different sizes, usually 4, 5 or 6 cm in diameter. In a systematic review they were more likely to result in successful vaginal birth than soft cups (RR 1.63, 95% CI 1.17–2.28), but with more cases of scalp injury (RR 0.67, 95% CI 0.53–0.86) and cephalhaematoma (RR 0.61, 95% CI 0.39–0.95) [16] . A specially designed cup should be used for OT and OP positions: metal OP cups have tubing emerging from the lateral aspect of the cup and the Kiwi OmniCup has a groove in the dorsum of the cup to accommodate the flexible stem. These cups can be manoeuvred more laterally or posteriorly to reach the flexion point. Hand‐held vacuum is associated with more failures than metal ventouse [16] , although a larger study suggested that the OmniCup has an overall failure rate of 12.9% [11] . Aldo Vacca (1941–2014) was the doyen of vacuum delivery and (with reference to the flexion point and cup application) his favourite quote was ‘It’s always more posterior than you think’. After ensuring flexion point application, the cup must be held firmly on the fetal scalp, and a finger should be run around the rim to ensure that no maternal tissue is entrapped. A vacuum of 0.2 bar (150 mmHg or 0.2 kg/cm 2 negative pressure) is created using a hand‐held or mechanical pump, before rechecking the position over the flexion point and confirming maternal tissue is not trapped. The vacuum is increased to 0.7–0.8 bar (500–600 mmHg or 0.8 kg/cm 2 ) in one step, waiting 2 min where possible to develop the ‘chignon’ within the cup. Axial traction in the line of the pelvic axis should be timed with uterine contractions and maternal pushing. A thumb should be placed on the cup, with the index finger on the scalp at the edge of the cup allowing the operator to feel any potential detachment before it is heard (by which point it is often too late to prevent detachment). Descent promotes auto‐rotation of the head to the OA position and episiotomy is often not required. Parents should be reassured that the ‘chignon’ will settle over 2–3 days. Manual rotation Manual rotation for persistent OP position is an alternative to IVD. The procedure requires insertion of one hand into the posterior vagina to encourage flexion and rotation. Careful patient selection is essential and the operator must ensure that effective analgesia is in place. The right hand is inserted for a left OP position (insert left hand for right OP). Four fingers are placed behind the fetal occiput to act as the ‘gutter’ on which the head will rotate, with the thumb placed alongside the anterior fontanelle. When the mother pushes with a contraction, the thumb applies pressure to flex the head and rotation to an OA position should occur with minimal effort. In a series ( N  = 61) where OP position was managed in two groups, the spontaneous delivery rate increased from 27% to 77% in the group offered digital rotation ( P <0.0001) [17] . Complications of IVD In a Cochrane review of 32 studies ( N  = 6597), forceps were less likely to fail to achieve a vaginal birth compared with ventouse (RR 0.65, 95% CI 0.45–0.94) [16] . Vaginal and perineal lacerations, including third‐ and fourth‐degree tears, are more common with forceps than with vacuum. Infra‐levator haematomas may occur occasionally and these should be drained if large or symptomatic. The risk of flatus incontinence or altered continence is also higher. Follow‐up of women who have had low or outlet IVD confirms normal physical and neourological outcomes for the vast majority of the newborn. In terms of neonatal outcome, cephalhaematoma is more common with vacuum but risk of facial injury is less. Facial and scalp abrasions are usually minor and heal in a few days. Unilateral facial nerve palsy is rare and resolves within days or weeks and is not usually related to poor technique. Skull fracture is rare and most need no treatment unless depressed, when surgical elevation may be indicated. Vacuum delivery may result in retinal haemorrhages, haematoma confined to one of the skull bones and neonatal jaundice. Severe scalp lacerations imply poor technique and are fortunately rare. Subgaleal haemorrhage may cause minor or severe morbidity and rarely mortality [18] . In reviewing morbidity associated with IVD, it is important to remember that the alternative option of second‐stage CS is also associated with increased morbidity for both mother and baby. Safe practice: sequential intrumentation and trial of instrumental delivery For all IVDs, the procedure should be abandoned if there is ‘no evidence of progressive descent with moderate traction during each contraction, or where delivery is not imminent following three contractions of a correctly applied instrument by an experienced operator’ [11] . Sequential instrumentation is associated with increased neonatal morbidity and the decision to proceed must take into account the relative risks of delivery by second‐stage CS from deep in the pelvis. It can be difficult to judge whether to proceed with IVD, especially in cases with mid‐cavity malposition at the level of the ischial spines. In such cases a trial of instrumental delivery should be undertaken in theatre under regional anaesthesia, with the full theatre team and neonatal practitioner present. The estimated incidence of trial of instrumental delivery is 2–5%. It is vital to maintain awareness of the situation, with a clear willingness to abandon the attempt if progress is not as expected, proceeding immediately to CS. The couple should be advised of this strategy and appropriate consent obtained prior to the procedure, which should be undertaken by the most senior obstetrician available. In the presence of fetal compromise, it is prudent to consider delivery by emergency CS, rather than proceeding with a potentially difficult IVD. Paired cord blood samples should be taken and results recorded after every attempted IVD. Contemporary developments in IVD New methods are being developed to achieve IVD and include disposable plastic forceps with the ability to measure traction force (see http://www.medipex.co.uk/success‐stories/pro‐nata‐yorkshire‐obstetric‐forceps/ and Fig. 26.10 ) and the Odon device where traction is applied using a plastic bag placed around the fetal head and neck. This device is undergoing trials led by the World Health Organization (see http://www.who.int/reproductivehealth/topics/maternal_perinatal/odon_device/en/ ). Fig. 26.10 Pro‐Nata Yorkshire obstetric forceps. Reproduced with permission of Mark Jessup.

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

• Subfertility
• The Law and the Obstetrician and Gynaecologist
• Assisted Reproduction
• Ambulatory Gynaecology, Hysteroscopy and Laparoscopy

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

Adhesive Capsulitis (Frozen Shoulder) Clinical Presentation

• Author: Jefferson R Roberts, MD; Chief Editor: Herbert S Diamond, MD  more...
• Sections Adhesive Capsulitis (Frozen Shoulder)
• Practice Essentials
• Epidemiology
• Presentation
• Surgical Indications
• Relevant Anatomy
• Contraindications
• Pathophysiology
• Physical Examination
• Approach Considerations
• Laboratory Studies
• Imaging Studies
• Histologic Findings
• Medical Therapy
• Extracorporeal Shockwave Therapy
• Surgical Therapy
• Postoperative Details
• Complications
• Outcome and Prognosis
• Future and Controversies
• Long-Term Monitoring
• Questions & Answers

Patients in the initial (freezing) stage of frozen shoulder syndrome (FSS) will describe the following:

• Insidious onset of vague, dull pain at the deltoid insertion
• Pain with shoulder movement
• Nagging pain at night, with sleep deprivation and the inability to sleep on the affected side
• Marked limitation of active and passive shoulder rotation, particularly external rotation

The pain of FSS can be described as dull or aching.  The pain leads to significant disability, affecting the activities of daily living, work, and leisure. [ 31 ]

During the second (frozen) stage, patients will complain of stiffness and severe loss of shoulder motion. The pain will be less pronounced. Patients will endorse the inability to reach over their head, to their side, and across their chest with the affected arm, or to scratch their back or put on a coat. The contralateral shoulder often becomes symptomatic years after FSS develops in the first shoulder. [ 12 ]

The patient's posture should be observed while he or she is wearing a gown and sitting on a stool. The examiner should note whether the patient is listing to one side because of pain, or holding the neck to one side because of spasm or pain. Such initial observations help determine whether a cervical condition may be contributing to the patient's symptomatology.

On examination, the patient will have tenderness at the deltoid insertion and over the anterior capsule and posterior capsule with deep palpation. Compensatory scapulothroacic motion can create pain around the medial scapula. Forward flexion, abduction, and internal and external rotation of the shoulder should be assessed. Active and passive range of motion at the glenohumeral joint will be reduced, compared with the unaffected shoulder. Limitation of external rotation and abduction will be the most prominent findings.

Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg . 2011 Mar. 20 (2):322-5. [QxMD MEDLINE Link] .

Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl . 1969. 119:1-59. [QxMD MEDLINE Link] .

Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis . 1984 Jun. 43(3):361-4. [QxMD MEDLINE Link] . [Full Text] .

Binder AI, Bulgen DY, Hazleman BL, Tudor J, Wraight P. Frozen shoulder: an arthrographic and radionuclear scan assessment. Ann Rheum Dis . 1984 Jun. 43(3):365-9. [QxMD MEDLINE Link] . [Full Text] .

Lloyd-Roberts GC, French PR. Periarthritis of the shoulder. A study of the disease and its treatment. Br Med J . 1959. 1:1569-71.

Tveita EK, Sandvik L, Ekeberg OM, Juel NG, Bautz-Holter E. Factor structure of the Shoulder Pain and Disability Index in patients with adhesive capsulitis. BMC Musculoskelet Disord . 2008 Jul 17. 9:103. [QxMD MEDLINE Link] . [Full Text] .

Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc . 2007 Dec. 15(4):216-21. [QxMD MEDLINE Link] .

Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg . 2008 Mar-Apr. 17(2):231-6. [QxMD MEDLINE Link] .

Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br . 2007 Jul. 89(7):928-32. [QxMD MEDLINE Link] .

Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med . 2018 Jul 12. [QxMD MEDLINE Link] . [Full Text] .

Codman EA. The shoulder . Boston, Mass: Thomas Todd; 1934.

Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive capsulitis. J Shoulder Elbow Surg . 2011 Apr. 20(3):502-14. [QxMD MEDLINE Link] .

Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J . 2016 May 19. 6 (1):26-34. [QxMD MEDLINE Link] . [Full Text] .

Duplay ES. De la periarthritis scapulohumerale et des raiderus de l'epaule qui en son la consequence. Arch Gen Med . 1872. 20:513-42.

Bulgen DY, Binder A, Hazleman BL, et al. Immunological studies in frozen shoulder. J Rheumatol . 1982 Nov-Dec. 9(6):893-8. [QxMD MEDLINE Link] .

Bulgen DY, Hazleman BL, Voak D. HLA-B27 and frozen shoulder. Lancet . 1976 May 15. 1(7968):1042-4. [QxMD MEDLINE Link] .

DePalma AF. Loss of scapulohumeral motion (frozen shoulder). Ann Surg . 1952. 135:193-204.

Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis . 1972 Jan. 31(1):69-71. [QxMD MEDLINE Link] . [Full Text] .

Chang YT, Chang WN, Tsai NW, Cheng KY, Huang CC, Kung CT, et al. Clinical Features Associated with Frozen Shoulder Syndrome in Parkinson's Disease. Parkinsons Dis . 2015. 2015:232958. [QxMD MEDLINE Link] . [Full Text] .

Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum . 1987 Aug. 30(8):936-9. [QxMD MEDLINE Link] .

Bruckner FE, Nye CJ. A prospective study of adhesive capsulitis of the shoulder ("frozen shoulder'') in a high risk population. Q J Med . 1981 Spring. 50(198):191-204. [QxMD MEDLINE Link] .

Sharma SP, Bærheim A, Moe-Nilssen R, Kvåle A. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC Musculoskelet Disord . 2016 May 26;. 17: [QxMD MEDLINE Link] .

Saeidian SR, Hemmati AA, Haghighi MH. Pain relieving effect of short-course, pulse prednisolone in managing frozen shoulder. J Pain Palliat Care Pharmacother . 2007. 21(1):27-30. [QxMD MEDLINE Link] .

Flannery O, Mullett H, Colville J. Adhesive shoulder capsulitis: does the timing of manipulation influence outcome?. Acta Orthop Belg . 2007 Feb. 73(1):21-5. [QxMD MEDLINE Link] .

Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther . 2006 Mar. 86(3):355-68. [QxMD MEDLINE Link] .

Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study. Physiotherapy . 2013 Oct 3. [QxMD MEDLINE Link] .

Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg . 2004 Sep-Oct. 13 (5):499-502. [QxMD MEDLINE Link] .

De Ponti A, Viganò MG, Taverna E, et al. Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy. J Shoulder Elbow Surg . 2006 Mar-Apr. 15(2):188-90. [QxMD MEDLINE Link] .

Ryan V, Brown H, Minns Lowe CJ, Lewis JS. The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review. BMC Musculoskelet Disord . 2016 Aug 15. 17(1):340. [QxMD MEDLINE Link] .

Ozaki J, Nakagawa Y, Sakurai G, et al. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am . 1989 Dec. 71(10):1511-5. [QxMD MEDLINE Link] .

Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. Am J Sports Med . 2010 Jan 28. [QxMD MEDLINE Link] .

Kim YS, Kim JM, Lee YG, Hong OK, Kwon HS, Ji JH. Intercellular adhesion molecule-1 (ICAM-1, CD54) is increased in adhesive capsulitis. J Bone Joint Surg Am . 2013 Feb 20. 95(4):e181-8. [QxMD MEDLINE Link] .

Rodeo SA, Hannafin JA, Tom J, Warren RF, Wickiewicz TL. Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder. J Orthop Res . 1997 May. q5(3):427-36. [QxMD MEDLINE Link] .

Song A, Higgins LD, Newman J, Jain NB. Glenohumeral corticosteroid injections in adhesive capsulitis: a systematic search and review. PM R . 2014 Dec. 6(12):1143-56. [QxMD MEDLINE Link] .

Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop . 2015 Mar 18. 6(2):263-8. [QxMD MEDLINE Link] .

Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis: a sticky issue. Am Fam Physician . 1999 Apr. 59(7):1843-52. [QxMD MEDLINE Link] .

Thomas SJ, McDougall C, Brown ID, Jaberoo MC, Stearns A, Ashraf R, et al. Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus. J Shoulder Elbow Surg . 2007 Nov-Dec. 16(6):748-51. [QxMD MEDLINE Link] .

Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy . 2017 Mar;. 103(1):40-47. [QxMD MEDLINE Link] .

Uddin MM, Khan AA, Haig AJ, Uddin MK. Presentation of frozen shoulder among diabetic and non-diabetic patients. J Clin Orthop Trauma . 2014 Dec. 5(4):193-8. [QxMD MEDLINE Link] .

Lamplot JD, Lillegraven O, Brophy RH. Shoulder activity level in patients with idiopathic adhesive capsulitis. J Shoulder Elbow Surg . 2017 Mar 31. S1058-2746(17):30064-2. [QxMD MEDLINE Link] .

Koh KH. Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials. Singapore Med J . 2016 Dec. 57(12):646-657. [QxMD MEDLINE Link] .

Zappia M, Di Pietto F, Aliprandi A, Pozza S, De Petro P, Muda A, et al. Multi-modal imaging of adhesive capsulitis of the shoulder. Insights Imaging . 2016 Jun. 7(3):365-71. [QxMD MEDLINE Link] .

Sanja MR, Mirjana ZS. Ultrasonographic study of the painful shoulder in patients with rheumatoid arthritis and patients with degenerative shoulder disease. Acta Reumatol Port . 2010 Jan-Mar. 35(1):50-8. [QxMD MEDLINE Link] .

Milena C, Patrick O, Ahmed L, Daniel M, Anne P, Lecouvet FE, et al. CT arthrography of adhesive capsulitis of the shoulder: Are MR signs applicable?. Eur J Radiol Open . 2017 Apr 2. 4:40-44. [QxMD MEDLINE Link] .

Duchstein LDL, Jakobsen JR, Marker L, Okholm M, Friberg L, Simonsen L, et al. The role of 18 F-FDG PET/CT in the diagnosis of frozen shoulder. Knee Surg Sports Traumatol Arthrosc . 2020 Mar 13. [QxMD MEDLINE Link] .

Song KD, Kwon JW, Yoon YC, Choi SH. Indirect MR Arthrographic Findings of Adhesive Capsulitis. AJR Am J Roentgenol . 2011 Dec. 197(6):W1105-9. [QxMD MEDLINE Link] .

Carbone S, Napoli A, Gumina S. MRI of adhesive capsulitis of the shoulder: Distension of the bursa in the superior subscapularis recess is a suggestive sign of the pathology. Eur J Radiol . 2013 Oct 29. [QxMD MEDLINE Link] .

Chi AS, Kim J, Long SS, Morrison WB, Zoga AC. Non-contrast MRI diagnosis of adhesive capsulitis of the shoulder. Clin Imaging . 2017 Apr 7. 44:46-50. [QxMD MEDLINE Link] .

Erber B, Hesse N, Glaser C, Baur-Melnyk A, Goller S, Ricke J, et al. MR imaging detection of adhesive capsulitis of the shoulder: impact of intravenous contrast administration and reader's experience on diagnostic performance. Skeletal Radiol . 2022 Sep. 51 (9):1807-1815. [QxMD MEDLINE Link] . [Full Text] .

Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Park JS, et al. Systematic review and meta-analysis of magnetic resonance imaging features for diagnosis of adhesive capsulitis of the shoulder. European Radiology . 2018 Jul 5. [QxMD MEDLINE Link] . [Full Text] .

Park S, Lee DH, Yoon SH, Lee HY, Kwack KS. Evaluation of Adhesive Capsulitis of the Shoulder With Fat-Suppressed T2-Weighted MRI: Association Between Clinical Features and MRI Findings. AJR Am J Roentgenol . 2016 Jul. 207(1):135-41. [QxMD MEDLINE Link] .

Mertens MG, Meert L, Struyf F, Schwank A, Meeus M. Exercise Therapy Is Effective for Improvement in Range of Motion, Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil . 2022 May. 103 (5):998-1012.e14. [QxMD MEDLINE Link] . [Full Text] .

Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med . 2018 Jul. 6 (7):2325967118785169. [QxMD MEDLINE Link] . [Full Text] .

Mitra R, Harris A, Umphrey C, Smuck M, Fredericson M. Adhesive capsulitis: a new management protocol to improve passive range of motion. PM R . 2009 Dec. 1(12):1064-8. [QxMD MEDLINE Link] .

Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil . 2008 Jun. 22(6):503-12. [QxMD MEDLINE Link] .

Tveita EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord . 2008 Apr 19. 9:53. [QxMD MEDLINE Link] . [Full Text] .

Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev . 2006 Oct 18. CD006189. [QxMD MEDLINE Link] .

Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy . 2010 Jun. 96(2):95-107. [QxMD MEDLINE Link] .

Roh YH, Yi SR, Noh JH, Lee SY, Oh JH, Gong HS, et al. Intra-articular corticosteroid injection in diabetic patients with adhesive capsulitis: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc . 2011 Nov 24. [QxMD MEDLINE Link] .

Goyal T, Singh A, Negi P, Kharkwal B. Comparative functional outcomes of patients with adhesive capsulitis receiving intra-articular versus sub-acromial steroid injections: case-control study. Musculoskelet Surg . 2018 May 23. [QxMD MEDLINE Link] . [Full Text] .

Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil . 2009 Dec. 90(12):1997-2002. [QxMD MEDLINE Link] .

Xiao RC, Walley KC, DeAngelis JP, Ramappa AJ. Corticosteroid Injections for Adhesive Capsulitis: A Review. Clin J Sport Med . 2017 May. 27(3:308-320. [QxMD MEDLINE Link] .

Tucker ME. Shock-Wave Therapy May Ease 'Frozen Shoulder' in Diabetes. Medscape Medical News. Available at https://www.medscape.com/viewarticle/872990 . December 08, 2016; Accessed: December 12, 2016.

Chen CY, Hu CC, Weng PW, Huang YM, Chiang CJ, Chen CH, et al. Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis. J Shoulder Elbow Surg . 2014 Dec. 23 (12):1843-51. [QxMD MEDLINE Link] .

Santoboni F, Balducci S, D'Errico V, Haxhi J, Vetrano M, Piccinini G, et al. Extracorporeal Shockwave Therapy Improves Functional Outcomes of Adhesive Capsulitis of the Shoulder in Patients With Diabetes. Diabetes Care . 2016 Nov 29. [QxMD MEDLINE Link] . [Full Text] .

Rymaruk S, Peach C. Indications for hydrodilatation for frozen shoulder. EFORT Open Rev . 2017 Nov. 2 (11):462-468. [QxMD MEDLINE Link] . [Full Text] .

Mun SW, Baek CH. Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study. J Shoulder Elbow Surg . 2016 Dec. 25(12):1937-1943. [QxMD MEDLINE Link] .

Bidwai AS, Mayne AI, Nielsen M, Brownson P. Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder. Shoulder Elbow . 2016 Jan. 8(1):9-13. [QxMD MEDLINE Link] .

Saltychev M, Laimi K, Virolainen P, Fredericson M. Effectiveness of Hydrodilatation in Adhesive Capsulitis of Shoulder: A Systematic Review and Meta-Analysis. Scand J Surg . 2018 Dec. 107 (4):285-293. [QxMD MEDLINE Link] .

Bell S, Coghlan J, Richardson M. Hydrodilatation in the management of shoulder capsulitis. Australas Radiol . 2003 Sep. 47 (3):247-51. [QxMD MEDLINE Link] .

Rae GC, Clark J, Wright M, Chesterton P. The effectiveness of hydrodistension and physiotherapy following previously failed conservative management of frozen shoulder in a UK primary care centre. Musculoskeletal Care . 2020 Mar. 18 (1):37-45. [QxMD MEDLINE Link] .

Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistant frozen shoulder. Manipulation versus arthroscopic release. Clin Orthop . 1995 Oct. (319):238-48. [QxMD MEDLINE Link] .

Warner JJ, Allen A, Marks PH, et al. Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am . Dec 1996. 78(12):1808-16. [QxMD MEDLINE Link] .

Warner JJ, Allen AA, Marks PH, et al. Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am . Aug 1997. 79(8):1151-8. [QxMD MEDLINE Link] .

Chen J, Chen S, Li Y, Hua Y, Li H. Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder?. Arthroscopy . 2010 Apr. 26(4):529-35. [QxMD MEDLINE Link] .

Ahn K, Jhun HJ, Choi KM, Lee YS. Ultrasound-guided interventional release of rotator interval and posteroinferior capsule for adhesive capsulitis of the shoulder using a specially designed needle. Pain Physician . 2011 Nov. 14(6):531-7. [QxMD MEDLINE Link] .

Miyazaki AN, Santos PD, Silva LA, Sella GD, Carrenho L, Checchia SL. Clinical evaluation of arthroscopic treatment of shoulder adhesive capsulitis. Rev Bras Ortop . 2016 Dec 20. 52(1):61-68. [QxMD MEDLINE Link] .

Warner JJ, Greis PE. The treatment of stiffness of the shoulder after repair of the rotator cuff. Instr Course Lect . 1998. 47:67-75. [QxMD MEDLINE Link] .

Pearsall AW, Osbahr DC, Speer KP. An arthroscopic technique for treating patients with frozen shoulder. Arthroscopy . Feb 1999. 15(1):2-11. [QxMD MEDLINE Link] .

Haque R, Baruah RK, Bari A, Sawah A. Is Suprascapular Nerve Block Better Than Intra-articular Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder? A Randomized Controlled Study. Ortop Traumatol Rehabil . 2021 Jun 30. 23 (3):157-165. [QxMD MEDLINE Link] .

Sung JH, Lee JM, Kim JH. The Effectiveness of Ultrasound Deep Heat Therapy for Adhesive Capsulitis: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health . 2022 Feb 7. 19 (3): [QxMD MEDLINE Link] . [Full Text] .

Schröder S, Meyer-Hamme G, Friedemann T, Kirch S, Hauck M, Plaetke R, et al. Immediate Pain Relief in Adhesive Capsulitis by Acupuncture-A Randomized Controlled Double-Blinded Study. Pain Med . 2017 Nov 1. 18 (11):2235-2247. [QxMD MEDLINE Link] .

Ünlü B, Çalış FA, Karapolat H, Üzdü A, Tanıgör G, Kirazlı Y. Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder. Int Orthop . 2021 Jan. 45 (1):181-190. [QxMD MEDLINE Link] .

Thu AC, Kwak SG, Shein WN, Htun M, Htwe TTH, Chang MC. Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial. J Int Med Res . 2020 Dec. 48 (12):300060520976032. [QxMD MEDLINE Link] . [Full Text] .

Barman A, Mukherjee S, Sahoo J, Maiti R, Rao PB, Sinha MK, et al. Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study. Am J Phys Med Rehabil . 2019 Jul. 98 (7):549-557. [QxMD MEDLINE Link] .

Lee JH, Choi EJ, Han SC, Chung HS, Kwon MJ, Jayaram P, et al. Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis. Ultrasonography . 2021 Oct. 40 (4):555-564. [QxMD MEDLINE Link] . [Full Text] .

Badalamente MA, Wang ED. CORR® ORS Richard A. Brand Award: Clinical Trials of a New Treatment Method for Adhesive Capsulitis. Clin Orthop Relat Res . 2016 Nov. 474(11):2327-2336. [QxMD MEDLINE Link] .

Fitzpatrick J, Richardson C, Klaber I, Richardson MD. Clostridium histolyticum (AA4500) for the Treatment of Adhesive Capsulitis of the Shoulder: A Randomised Double-Blind, Placebo-Controlled Study for the Safety and Efficacy of Collagenase - Single Site Report. Drug Des Devel Ther . 2020. 14:2707-2713. [QxMD MEDLINE Link] . [Full Text] .

Dupeyron A, Dénarié M, Richard D, Dobija L, Castelli C, Petiot S, et al. Analgesic gas for rehabilitation of frozen shoulder: Protocol for a randomized controlled trial. Ann Phys Rehabil Med . 2018 Aug 9. [QxMD MEDLINE Link] . [Full Text] .

• True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
• Table. 1 Stages of Frozen Shoulder Syndrome 
• Table 2 MRI findings according to clinical stage of FSS
• Table 3. Prednisone Dosing in Patients With Refractory Frozen Shoulder Syndrome

Contributor Information and Disclosures

Jefferson R Roberts, MD Chief of Rheumatology Service, Tripler Army Medical Center; Assistant Clinical Professor of Medicine, Uniformed Services University of the Health Sciences Jefferson R Roberts, MD is a member of the following medical societies: American College of Physicians , American College of Rheumatology , Society for Simulation in Healthcare Disclosure: Nothing to disclose.

Mary L Lan, MD, MPH Resident Physician, Department of Medicine, Tripler Army Medical Center Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons Disclosure: Nothing to disclose.

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Physicians , American College of Rheumatology , American Medical Association , Phi Beta Kappa Disclosure: Nothing to disclose.

Albert W Pearsall, IV, MD Associate Professor, Department of Orthopedic Surgery, University of South Alabama College of Medicine; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center Disclosure: Nothing to disclose.

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• Adhesive Capsulitis (Frozen Shoulder)
• Adhesive Capsulitis in Physical Medicine and Rehabilitation
• Accessory Nerve Injury
• Shoulder Joint Anatomy
• Ultrasonography for Rotator Cuff Injury
• Rotator Cuff Pathology
• Arthritis as a Manifestation of Systemic Disease
• Watchful Waiting Less Expensive, as Effective as Physical Therapy for Frozen Shoulder
• Platelet-Rich Plasma in the Management of Shoulder Disorders

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2002326828-overviewDiseases & Conditions Diseases & Conditions Adhesive Capsulitis in Physical Medicine and Rehabilitation

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

[Management of shoulder presentation]

• PMID: 13270389

PubMed Disclaimer

Similar articles

• [MANAGEMENT DURING LABOR IN TRANSVERSE POSITIONS (SHOULDER PRESENTATION)]. CABALLERO A, FERNANDEZ-BOLANOS J. CABALLERO A, et al. Rev Fr Gynecol Obstet. 1964 Dec;59:785-804. Rev Fr Gynecol Obstet. 1964. PMID: 14250304 French. No abstract available.
• Shoulder presentation a commentary. HAMMOND GL. HAMMOND GL. Guys Hosp Gaz. 1951 Sep 8;65(1647):332-3. Guys Hosp Gaz. 1951. PMID: 14880028 No abstract available.
• [Diagnosis of shoulder presentation]. MAGGIORA-VERGANO T. MAGGIORA-VERGANO T. Clin Ostet Ginecol. 1955 Apr;57(2):108-10. Clin Ostet Ginecol. 1955. PMID: 13250740 Italian. No abstract available.
• Shoulder presentation. WEBSTER A, GEITTMANN WF. WEBSTER A, et al. Am J Obstet Gynecol. 1956 Jul;72(1):34-9. doi: 10.1016/s0002-9378(16)37508-1. Am J Obstet Gynecol. 1956. PMID: 13326968 No abstract available.
• Essay on the Mechanism and Management of Parturition, in the Shoulder Presentation. [No authors listed] [No authors listed] West J Med Surg. 1853 Nov-Dec;12(5-6):450-451. West J Med Surg. 1853. PMID: 38211052 Free PMC article. Review. No abstract available.
• Search in MeSH
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Am J Transl Res
• v.13(12); 2021

Application of natural shoulder delivery combined with free position delivery in maternal delivery

Objective: This research was designed to probe into the influences of natural shoulder delivery combined with free position delivery on pregnant outcome and genital tract of puerperants. Methods: Totally 128 puerperants who gave birth in our hospital from May 2018 to November 2019 were selected as the research objects. Among them, 66 in traditional position combined with traditional shoulder delivery were assigned to a conventional group (CG), and 62 in free position combined with natural shoulder delivery were assigned to a research group (RG). Their psychological mood, pain degree, pregnancy outcome, labor time, postpartum recovery and genital tract injury were compared. Results: Compared with the CG, the scores of visual analogue scale (VAS) pain, postpartum self-rating depression scale (SDS) and self-rating anxiety scale (SAS) in the RG during delivery were lower ( P <0.05); the first, second, third and total labor stages in the RG were shorter ( P <0.05). What’s more, in the RG, the incidences of lateral episiotomy, urinary retention, stress urinary incontinence, transit cesarean section, shoulder dystocia and neonatal asphyxia were lower, while the perineum integrity and natural delivery rates were higher ( P <0.05); the postpartum height of uterus, lochia discharge and blood loss were lower, while milk yield was higher ( P <0.05). Conclusion: Natural shoulder delivery combined with free position delivery can effectively improve the pregnancy outcome, benefit the postpartum recovery, shorten the labor process and reduce the degree of genital tract injury. Hence, it is worthy of clinical application.

Introduction

Cesarean section (CS) is a surgical operation to deliver a child by cutting the mother’s abdomen and uterine wall. It was originally used as a surgical solution to solve the problems related to dystocia [ 1 , 2 ]. There are many adverse consequences. For instance, it restricts children’s physical and mental health development, increases hospitalization and recovery time and economic burden, and damages mother-infant relationship; it also causes higher risk of complications such as infection, hysterectomy and organ damage [ 3 - 5 ]. Because of fear, pain etc., many women hope to take CS without medical indications [ 6 ]. However, under the condition of good health, natural childbirth is preferred by clinicians. Therefore, seeking effective measures to reduce CS rate and promote natural delivery has become the research goal and direction of obstetricians and gynecologists.

Supine delivery is a commonly used position. Although it is convenient for medical staff to observe the progress of maternal labor and carry out related examinations, there are still many drawbacks. For one thing, it reduces the pelvic outlet diameter, thereby increasing the resistance of fetal descent and prolonging the labor process. For another, it reduces the effect of uterine contraction, thus decreasing uterine blood flow and increasing maternal discomfort, etc. [ 7 , 8 ]. Free position delivery refers to the method that a woman can freely choose squatting, kneeling, lying, sitting, standing, lying and other positions to give birth in view of her own situation during the labor process. Past clinical experience shows that taking free position to deliver has many benefits, such as relieving pain during childbirth, shortening labor process, improving uterine contraction and reducing maternal genital tract injury [ 9 - 11 ]. In the process of delivery, after the fetal head is delivered, the anterior shoulder of some fetuses is embedded with the pubic bone of the puerperants, which makes it difficult to give birth to both shoulders, resulting in shoulder dystocia [ 12 ]. Shoulder dystocia usually occurs suddenly and cannot be effectively prevented and controlled. Once it occurs, it may lead to incalculable consequences and even neonatal death [ 13 ]. Thus, how to prevent shoulder dystocia is one of the difficulties in childbirth. Previously, a research has shown that natural shoulder delivery after waiting for contractions can adapt to the frequency, speed and interval of contractions, thus preventing shoulder dystocia to the utmost extent [ 14 ]. At the moment, although there are many researches on free position delivery and natural shoulder delivery, the research data of combining these two methods are still rare.

This research explored the effects of free position delivery combined with natural shoulder delivery on pregnancy outcome and postpartum recovery of puerperants, aiming at finding an optimal delivery mode. It manifested that compared with the traditional delivery mode, this combination therapy has better benefits for patients. For example, it reduces pain during delivery, relieves adverse psychological emotions, and decreases the incidence of genital tract injury and postpartum complications; it also improves pregnancy outcome, promotes postpartum recovery, and enhances service satisfaction.

Data and methods

Recruitment of subjects.

Totally 128 puerperants who gave birth in the First People’s Hospital of Taizhou City from May 2018 to November 2019 were selected as the research objects. Thereinto, 66 in traditional position combined with traditional shoulder delivery were assigned to a conventional group (CG), and 62 in free position combined with natural shoulder delivery were assigned to the research group (RG).

Inclusion criteria: Singleton and full-term delivery; physical examination signified that the uterus developed normally, the fetus developed well, and the pelvis was normal in size and shape, which were suitable for vaginal delivery; complete clinical data; age ≥20 years. Exclusion criteria: Those with mental illness or communication disorder; those complicated with major organ dysfunction such as heart, liver and kidney; those complicated with high risk factors and complications during pregnancy; those who had a history of induced labor, repeated urinary system infection, genitourinary system abnormality and pelvic floor injury. With the consent of the medical ethics committee of our hospital (TZ (2019) Lunxue (125 preparation)), all the subjects understood the purpose and method of the research and sign the informed consent form.

Mode of delivery

In the CG, puerperants gave birth in supine position. After the fetal head was delivered, the traditional method of shoulder delivery was adopted.

In the RG, they gave birth in free position. After the fetal head was delivered, the natural shoulder delivery method was adopted. The specific methods are as follows: In view of the comfort and individuation of puerperants, puerperants choose standing position (they stand against the wall and grasp the handrails with both hands), sitting position (they sit on the delivery ball, grasp the handrails, and step on the bracket, shaking left and right or bouncing up and down), kneeling position (they kneel on the soft cushion, leaning forward, holding the delivery ball with both hands and shaking around the delivery ball), squatting position (the head of the bed is raised to 90°, and they lie with their back against the head of the bed), or supine position (the delivery ball is put on the bed, and they lies on the ball with the waist shaking back and forth). Based on the individual situation and the needs at that time, the body position was randomized and changed. Under different body positions, when the cervix is fully open and the mother can exert her own strength, a lateral position with a supine position or a semi-sitting position should be considered. After the fetal head is delivered, the puerperants are instructed not to rush to deliver the fetal shoulder but wait for the next contraction, and guided to force the fetal head to perform natural reduction and external rotation. The shoulder of the fetus can be rotated in different directions to assist the delivery. After the delivery of the shoulders, a lateral position can be considered to assist the delivery of the fetal body and lower limbs.

Note: According to the perineum condition of the puerperants and the size of the fetus, the doctors consider whether to perform perineum incision or not. If necessary, they choose the appropriate incision method, and local or perineum nerve block anesthesia.

Outcome measures

Professional medical staff should record the first, second and third stages and the total time of labor.

The degree of perineum injury between both groups was compared: The first degree perineal laceration is the tearing of perineal skin and vaginal entrance mucosa, and there is not much bleeding; the second has reached the fascia and muscle layer of perineum, involving the mucosa of posterior vaginal wall and bleeding more; the third is that the laceration extends to the deep perineum, the external anal sphincter has broken, and the rectal mucosa is still intact; the fourth is complete penetration of anus, rectum and vagina, exposure of rectal cavity and serious tissue damage.

The value of the most severe pain in the process of uterus dilation was observed by visual analogue scale pain score (VAS) [ 15 ]. The score can be divided into 11 values, and the patient chooses the corresponding one according to the pain situation; 10 indicate the most severe pain and 0 indicates no pain. The anxiety and depression of patients after delivery were evaluated by self-rating anxiety scale (SAS) [ 16 ] and self-rating depression scale (SDS) [ 17 ]. The total score is 100 points; the higher the score, the more serious the anxiety is.

The incidences of postpartum complications, including urinary retention, stress urinary incontinence, anemia, constipation and metritis, were recorded in the two groups. The amount of postpartum hemorrhage was measured by weighing method 2 h after delivery. The height of uterine fundus, lochia discharge and lactation volume were recorded. The pregnancy outcomes were recorded, including natural delivery, transit cesarean section, shoulder dystocia, neonatal asphyxia and forceps delivery.

One day after delivery, patients’ satisfaction with the mode of delivery was evaluated by the self-made Delivery Mode Satisfaction Questionnaire in our hospital. There are 20 questions, each of which scores 5 points; score <70 denotes dissatisfied, 70-89 denotes basically satisfied, and ≥90 denotes satisfied. Satisfaction = (satisfaction + basic satisfaction)/total cases × 100%.

Statistical analysis

SPSS 21.0 was employed for statistical analysis, and the pictures were drawn by GraphPad Prism 7. The counting data were compared by Chi-square test, marked as χ 2 . The measurement data were assessed by t test. Independent-samples t test was used for comparison between groups, and paired t test was used for comparison within groups. P <0.05 means the difference was statistically remarkable.

Comparison of general data

There was no marked difference between the two groups in general data, such as maternal age, BMI before pregnancy, gestational age, dietary preference, working, marital status, history of smoking and drinking, painless delivery, educational level and parity ( P >0.05) ( Table 1 ).

Comparison of general data ([n (%)], means ± sd)

Comparison of labor pain and postpartum psychological emotion between the two groups

After evaluating the pain during childbirth and postpartum psychological emotion, we found that compared with the CG, the VAS score in the RG during childbirth was lower, and the SDS and SAS scores after childbirth were also lower ( P <0.05) ( Figure 1 ).

Comparison of pain during childbirth and postpartum psychological mood. A: Comparison of pain scores during labor. B: Comparison of postpartum SDS scores. C: Comparison of postpartum SAS scores. Note: * P <0.05.

Comparison of labor time between the two groups

The first, second, third and total labor time in the RG were shorter than those in the CG, with statistically significant differences ( P <0.05) ( Figure 2 ).

Comparison of labor time. A: Comparison of time of the first stage of labor. B: Comparison of time of the second stage of labor. C: Comparison of time of the third stage of labor. D: Comparison of total labor time. Note: * P <0.05.

Comparison of perineum injury between the two groups

After comparing the perineum of both groups, we found that the lateral episiotomy rate of the RG was lower than that of the CG (9.68% vs. 25.76%), and the perineum integrity rate of the former was higher than that of the latter (24.19% vs. 7.58%), with statistical significance ( P <0.05). There was no obvious difference in perineal laceration between them ( P >0.05) ( Table 2 ).

Comparison of perineum between the two groups [n (%)]

Comparison of postpartum complications and blood loss in both groups

The incidence of postpartum complications was recorded. It was found that the incidence of urinary retention and stress urinary incontinence in the RG was remarkably lower than that in the CG, and the postpartum blood loss in 2 h of the former group was obviously less ( P >0.05), while the incidence of anemia, constipation and metritis showed no remarkable difference between the two groups ( P <0.05) ( Table 3 ).

Comparison of postpartum complications between the two groups ([n (%)], means ± sd)

Comparison of postpartum height of uterine fundus, lochia discharge and lactation

Compared with the CG, the postpartum height of uterine fundus and amount of lochia in the RG were lower, while the lactation was higher, and the differences were statistically significant ( P <0.05) ( Figure 3 ).

Comparison of postpartum height of uterine fundus, lochia discharge and lactation. A: Comparison of postpartum height of uterine fundus. B: Comparison of postpartum lochia discharge. C: Comparison of postpartum lactation. Note: * P <0.05.

Comparison of pregnancy outcomes between the two groups

Compared with the CG, the natural delivery rate in the RG increased, while the transit cesarean section rate, shoulder dystocia and neonatal asphyxia rates decreased ( P <0.05). However, there was no marked difference in the incidence of forceps delivery between the two groups ( P >0.05) ( Table 4 ).

Comparison of pregnancy outcomes between the two groups [n (%)]

Comparison of satisfaction of delivery mode between the two groups

After evaluating the satisfaction of both groups on delivery mode, we discovered that the total satisfaction rate of the RG was markedly higher than that of the CG (79.03% vs. 60.61%), and the difference was statistically significant ( P <0.05). In addition, we found that many of the puerperants in the CG experienced severe pain during delivery, uncomfortable posture and poor experience ( Table 5 ).

Comparison of satisfaction of delivery mode between the two groups [n (%)]

Childbirth is a natural physiological process. Natural childbirth is the best choice beneficial to both mothers and babies. How to effectively avoid and reduce the occurrence of birth injury is a problem that obstetricians and gynecologists have been discussing. This research analyzed the application value of natural shoulder delivery combined with free position delivery in natural delivery.

Positive delivery experience can improve maternal health and promote the connection between mothers and infants, while negative experience may lead to psychological distress and serious diseases, such as depression, post-traumatic stress disorder, impaired mother-infant bond and fear of the next birth [ 18 , 19 ]. There are many factors that affect the normal delivery, among which pain and its related negative emotions are crucial [ 20 , 21 ]. In the process of delivery in traditional position, puerperants need to keep a posture, which not only increases their fatigue, but also may affect their psychological state, thereby bringing poor cooperation and ultimately affecting the smooth delivery. The puerperants can not only distract their attention and relieve their nervousness, but also enhance the quality of uterine contraction and relieve the pain of childbirth by adjusting their body position, thus improving the treatment compliance and the confidence of successful childbirth [ 22 , 23 ]. It revealed that the VAS score of the RG during delivery was lower than that of the CG, and the SDS and SAS scores of the former after delivery were also lower. This showed that free position could relieve the pain and negative emotions of puerperants, which is beneficial to the delivery.

A recent research has suggested that prolonged labor process is a crucial reason for the obviously increased postpartum disease rate of puerperants and newborns [ 24 ]. During delivery, uterine inertia and abnormal fetal position are vital reasons for prolonging the second stage of labor [ 25 ]. In the process of delivery in traditional posture, the direction of the fetal axis is inconsistent with that of the pelvis of puerperants, so gravity cannot be used, which increases the difficulty and time of delivery [ 26 ]. When they change from lying position to upright position, sitting position or squatting position, the pressure in the uterine cavity is increased and the uterine contractility is strengthened, thus speeding up the delivery process by making full use of gravity [ 27 , 28 ]. What’s more, free body delivery can slowly and fully expand the perineum, so as to reduce the damage to it. Shoulder dystocia is a serious obstetric emergency. If it can’t be treated promptly and effectively, it can lead to serious complications of mothers and children. Some studies have shown that natural shoulder delivery after waiting for contraction can prevent shoulder dystocia to a certain extent [ 29 ]. This study signified that the first, second, third and total labor time in the RG were shorter than those in the CG; the incidences of lateral episiotomy, urinary retention, stress urinary incontinence, transit cesarean section, shoulder dystocia and neonatal asphyxia in the RG were lower than those in the CG, and the blood loss in 2 h after delivery was markedly lower. Besides, the perineum integrity and natural delivery rates in the RG were higher than those in the CG. Compared with the CG, the height of uterine fundus and lochia amount in the RG were lower, while the lactation output was higher. And this is consistent with the results of previous studies [ 30 ]. This shows that natural shoulder delivery combined with free position delivery can reduce the incidence of maternal genital tract injury and postpartum complications, and improve pregnancy outcome and postpartum recovery.

Women’s satisfaction with delivery is a crucial indicator to measure the quality of maternal reproductive health services. At the end of this study, the satisfaction of both groups on delivery mode was evaluated; it was found that the total satisfaction rate of the RG was markedly higher than that of the CG, and many puerperants in the latter group had severe pain during delivery, uncomfortable posture, poor experience, and wanted a more comfortable mode. This shows that the traditional body position can no longer meet the needs of the puerperants nowadays. Hence, it’s necessary to find a more comfortable mode of production, which will be beneficial to the popularization of natural shoulder delivery combined with free body position delivery.

Nevertheless, this study still has certain limitations. First of all, as a retrospective study, we did not conduct a randomized controlled experiment, and the results we obtained may be biased. Secondly, our sample size is relatively small. Therefore, we hope to increase our sample size in subsequent studies and carry out forward-looking studies to improve the conclusions we have obtained.

To sum up, natural shoulder delivery combined with free position delivery can effectively improve maternal pregnancy outcome, facilitate postpartum recovery, shorten the labor process and reduce the degree of genital tract injury, and thus is worthy of clinical application.

Disclosure of conflict of interest

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Reliability of pressure pain threshold (ppt) and conditioned pain modulation (cpm) in participants with and without chronic shoulder pain.

1. Introduction

2. materials and methods, 2.1. study design, 2.2. participants, 2.3. raters, 2.4. pressure pain threshold, 2.5. conditioned pain modulation, 2.6. self-reported outcome measures, 2.7. before the testing procedure, 2.8. during the testing procedure, 2.9. statistical analysis, 3.1. descriptive statistics, 3.2. pressure pain threshold, intra-rater and inter-rater reliability, 3.3. conditioned pain modulation, 3.4. correlations between self-reported questionnaires and ppts, 3.5. correlations between self-reported questionnaires and cpm, 4. discussion, 4.1. pressure pain threshold, 4.2. conditioned pain modulation, 4.3. self-reported questionnaires’ associations with ppts and cpm, 4.4. limitations and strengths, 4.5. implications in clinical practice, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

• Sanchis, M.N.; Lluch, E.; Nijs, J.; Struyf, F.; Kangasperko, M. The role of central sensitization in shoulder pain: A systematic literature review. Semin. Arthritis Rheum. 2015 , 44 , 710–716. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nijs, J.; George, S.Z.; Clauw, D.J.; Fernández-de-Las-Peñas, C.; Kosek, E.; Ickmans, K.; Fernández-Carnero, J.; Polli, A.; Kapreli, E.; Huysmans, E.; et al. Central sensitisation in chronic pain conditions: Latest discoveries and their potential for precision medicine. Lancet Rheumatol. 2021 , 3 , e383–e392. [ Google Scholar ] [ CrossRef ]
• Alagappan, T.R.; Senthilkumar, S.N.; Dhanani, D.P.; Vashi, R.H.; Barot, D.N.; Savani, M.N. Recognition of central nervous system sensitization and its risk factors in patients with unilateral musculoskeletal shoulder pain. Physiother.-J. Indian Assoc. Physiother. 2019 , 13 , 102–108. [ Google Scholar ] [ CrossRef ]
• Bilika, P.; Nijs, J.; Fandridis, E.; Dimitriadis, Z.; Strimpakos, N.; Kapreli, E. In the Shoulder or in the Brain? Behavioral, Psychosocial and Cognitive Characteristics of Unilateral Chronic Shoulder Pain with Symptoms of Central Sensitization. Healthcare 2022 , 10 , 1658. [ Google Scholar ] [ CrossRef ]
• Woolf, C.J. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 2011 , 152 , S2–S15. [ Google Scholar ] [ CrossRef ]
• Glare, P.; Aubrey, K.R.; Myles, P.S. Transition from acute to chronic pain after surgery. Lancet 2019 , 393 , 1537–1546. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nijs, J.; Lahousse, A.; Kapreli, E.; Bilika, P.; Saraçoğlu, İ.; Malfliet, A.; Coppieters, I.; De Baets, L.; Leysen, L.; Roose, E.; et al. Nociplastic Pain Criteria or Recognition of Central Sensitization? Pain Phenotyping in the Past, Present and Future. J. Clin. Med. 2021 , 10 , 3203. [ Google Scholar ] [ CrossRef ]
• Kosek, E.; Clauw, D.; Nijs, J.; Baron, R.; Gilron, I.; Harris, R.E.; Mico, J.A.; Rice, A.S.C.; Sterling, M. Chronic nociplastic pain affecting the musculoskeletal system: Clinical criteria and grading system. Pain 2021 , 162 , 2629–2634. [ Google Scholar ] [ CrossRef ]
• Uddin, Z.; MacDermid, J.C. Quantitative Sensory Testing in Chronic Musculoskeletal Pain. Pain Med. 2016 , 17 , 1694–1703. [ Google Scholar ] [ CrossRef ]
• Previtali, D.; Bordoni, V.; Filardo, G.; Marchettini, P.; Guerra, E.; Candrian, C. High Rate of Pain Sensitization in Musculoskeletal Shoulder Diseases: A Systematic Review and Meta-analysis. Clin. J. Pain 2021 , 37 , 237–248. [ Google Scholar ] [ CrossRef ]
• Yarnitsky, D.; Arendt-Nielsen, L.; Bouhassira, D.; Edwards, R.R.; Fillingim, R.B.; Granot, M.; Hansson, P.; Lautenbacher, S.; Marchand, S.; Wilder-Smith, O. Recommendations on terminology and practice of psychophysical DNIC testing. Eur. J. Pain 2010 , 14 , 339. [ Google Scholar ] [ CrossRef ]
• Arendt-Nielsen, L.; Morlion, B.; Perrot, S.; Dahan, A.; Dickenson, A.; Kress, H.G.; Wells, C.; Bouhassira, D.; Drewes, A.M. Assessment and manifestation of central sensitisation across different chronic pain conditions. Eur. J. Pain 2018 , 22 , 216–241. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Bannister, K.; Dickenson, A.H. What the brain tells the spinal cord. Pain 2016 , 157 , 2148–2151. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Wang, R.; King, T.; De Felice, M.; Guo, W.; Ossipov, M.H.; Porreca, F. Descending facilitation maintains long-term spontaneous neuropathic pain. J. Pain 2013 , 14 , 845–853. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Lewis, G.N.; Rice, D.A.; McNair, P.J. Conditioned pain modulation in populations with chronic pain: A systematic review and meta-analysis. J. Pain 2012 , 13 , 936–944. [ Google Scholar ] [ CrossRef ]
• Muhsen, A.; Moss, P.; Gibson, W.; Walker, B.; Jacques, A.; Schug, S.; Wright, A. The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia. Clin. J. Pain 2019 , 35 , 435–442. [ Google Scholar ] [ CrossRef ]
• Cornelius, M.; Edwards, R. (480) Conditioned pain modulation and treatment response in patients with knee osteoarthritis. J. Pain 2014 , 15 , S96. [ Google Scholar ] [ CrossRef ]
• Bruehl, S.; France, C.R.; Stone, A.L.; Gupta, R.; Buvanendran, A.; Chont, M.; Burns, J.W. Greater Conditioned Pain Modulation Is Associated With Enhanced Morphine Analgesia in Healthy Individuals and Patients With Chronic Low Back Pain. Clin. J. Pain 2021 , 37 , 20–27. [ Google Scholar ] [ CrossRef ]
• Georgopoulos, V.; Akin-Akinyosoye, K.; Zhang, W.; McWilliams, D.F.; Hendrick, P.; Walsh, D.A. Quantitative sensory testing and predicting outcomes for musculoskeletal pain, disability, and negative affect: A systematic review and meta-analysis. Pain 2019 , 160 , 1920–1932. [ Google Scholar ] [ CrossRef ]
• Cruz-Almeida, Y.; Fillingim, R.B. Can quantitative sensory testing move us closer to mechanism-based pain management? Pain Med. 2014 , 15 , 61–72. [ Google Scholar ] [ CrossRef ]
• Alburquerque-Sendín, F.; Camargo, P.R.; Vieira, A.; Salvini, T.F. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: A blinded, controlled study. Clin. J. Pain 2013 , 29 , 478–486. [ Google Scholar ] [ CrossRef ]
• Coronado, R.A.; Simon, C.B.; Valencia, C.; George, S.Z. Experimental pain responses support peripheral and central sensitization in patients with unilateral shoulder pain. Clin. J. Pain 2014 , 30 , 143–151. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Gwilym, S.E.; Oag, H.C.; Tracey, I.; Carr, A.J. Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery. J. Bone Jt. Surg. Br. Vol. 2011 , 93 , 498–502. [ Google Scholar ] [ CrossRef ]
• Haik, M.N.; Evans, K.; Smith, A.; Henríquez, L.; Bisset, L. People with musculoskeletal shoulder pain demonstrate no signs of altered pain processing. Musculoskelet. Sci. Pract. 2019 , 39 , 32–38. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hidalgo-Lozano, A.; Fernández-de-las-Peñas, C.; Calderón-Soto, C.; Domingo-Camara, A.; Madeleine, P.; Arroyo-Morales, M. Elite swimmers with and without unilateral shoulder pain: Mechanical hyperalgesia and active/latent muscle trigger points in neck-shoulder muscles. Scand. J. Med. Sci. Sports 2013 , 23 , 66–73. [ Google Scholar ] [ CrossRef ]
• Kuppens, K.; Hans, G.; Roussel, N.; Struyf, F.; Fransen, E.; Cras, P.; Van Wilgen, C.P.; Nijs, J. Sensory processing and central pain modulation in patients with chronic shoulder pain: A case-control study. Scand. J. Med. Sci. Sports 2018 , 28 , 1183–1192. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Paul, T.M.; Soo Hoo, J.; Chae, J.; Wilson, R.D. Central hypersensitivity in patients with subacromial impingement syndrome. Arch. Phys. Med. Rehabil. 2012 , 93 , 2206–2209. [ Google Scholar ] [ CrossRef ]
• Valencia, C.; Kindler, L.L.; Fillingim, R.B.; George, S.Z. Stability of conditioned pain modulation in two musculoskeletal pain models: Investigating the influence of shoulder pain intensity and gender. BMC Musculoskelet. Disord. 2013 , 14 , 182. [ Google Scholar ] [ CrossRef ]
• Yan, C.Q.; Zhang, S.; Li, Q.Q.; Zhang, L.W.; Wang, X.R.; Fu, Q.N.; Shi, G.X.; Liu, C.Z. Detection of peripheral and central sensitisation at acupoints in patients with unilateral shoulder pain in Beijing: A cross-sectional matched case-control study. BMJ Open 2017 , 7 , e014438. [ Google Scholar ] [ CrossRef ]
• Nascimento, J.; Alburquerque-Sendín, F.; Vigolvino, L.P.; Oliveira, W.F.; Sousa, C.O. Absolute and Relative Reliability of Pressure Pain Threshold Assessments in the Shoulder Muscles of Participants With and Without Unilateral Subacromial Impingement Syndrome. J. Manip. Physiol. Ther. 2020 , 43 , 57–67. [ Google Scholar ] [ CrossRef ]
• Suzuki, H.; Tahara, S.; Mitsuda, M.; Izumi, H.; Ikeda, S.; Seki, K.; Nishida, N.; Funaba, M.; Imajo, Y.; Yukata, K.; et al. Current Concept of Quantitative Sensory Testing and Pressure Pain Threshold in Neck/Shoulder and Low Back Pain. Healthcare 2022 , 10 , 1485. [ Google Scholar ] [ CrossRef ]
• Bilika, P.; Paliouras, A.; Savvoulidou, K.; Arribas-Romano, A.; Dimitriadis, Z.; Billis, E.; Strimpakos, N.; Kapreli, E. Psychometric properties of quantitative sensory testing in healthy and patients with shoulder pain: A systematic review. J. Musculoskelet. Neuronal Interact. 2023 , 23 , 145–164. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Cathcart, S.; Winefield, A.H.; Rolan, P.; Lushington, K. Reliability of temporal summation and diffuse noxious inhibitory control. Pain Res. Manag. 2009 , 14 , 433–438. [ Google Scholar ] [ CrossRef ]
• Alsouhibani, A.; Vaegter, H.B.; Hoeger Bement, M. Systemic Exercise-Induced Hypoalgesia Following Isometric Exercise Reduces Conditioned Pain Modulation. Pain Med. 2019 , 20 , 180–190. [ Google Scholar ] [ CrossRef ]
• Marcuzzi, A.; Wrigley, P.J.; Dean, C.M.; Adams, R.; Hush, J.M. The long-term reliability of static and dynamic quantitative sensory testing in healthy individuals. Pain 2017 , 158 , 1217–1223. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Kottner, J.; Audigé, L.; Brorson, S.; Donner, A.; Gajewski, B.J.; Hróbjartsson, A.; Roberts, C.; Shoukri, M.; Streiner, D.L. Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. J. Clin. Epidemiol. 2011 , 64 , 96–106. [ Google Scholar ] [ CrossRef ]
• Cimino, R.; Farella, M.; Michelotti, A.; Pugliese, R.; Martina, R. Does the ovarian cycle influence the pressure-pain threshold of the masticatory muscles in symptom-free women? J. Orofac. Pain 2000 , 14 , 105–111. [ Google Scholar ]
• Bajaj, P.; Arendt-Nielsen, L.; Bajaj, P.; Madsen, H. Sensory changes during the ovulatory phase of the menstrual cycle in healthy women. Eur. J. Pain 2001 , 5 , 135–144. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Borg, D.N.; Bach, A.J.E.; O’Brien, J.L.; Sainani, K.L. Calculating sample size for reliability studies. PMR J. Inj. Funct. Rehabil. 2022 , 14 , 1018–1025. [ Google Scholar ] [ CrossRef ]
• Wang-Price, S.; Zafereo, J.; Brizzolara, K.; Mackin, B.; Lawson, L.; Seeger, D.; Lawson, S. Psychometric Properties of Pressure Pain Thresholds Measured in 2 Positions for Adults With and Without Neck-Shoulder Pain and Tenderness. J. Manip. Physiol. Ther. 2019 , 42 , 416–424. [ Google Scholar ] [ CrossRef ]
• Liaghat, B.; Eshoj, H.; Juul-Kristensen, B.; Arendt-Nielsen, L.; Skou, S.T. Pressure pain sensitivity in patients with traumatic first-time and recurrent anterior shoulder dislocation: A cross-sectional analysis. Scand. J. Pain 2020 , 20 , 387–395. [ Google Scholar ] [ CrossRef ]
• Rolke, R.; Magerl, W.; Campbell, K.A.; Schalber, C.; Caspari, S.; Birklein, F.; Treede, R.D. Quantitative sensory testing: A comprehensive protocol for clinical trials. Eur. J. Pain 2006 , 10 , 77–88. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Nuwailati, R.; Bobos, P.; Drangsholt, M.; Curatolo, M. Reliability of conditioned pain modulation in healthy individuals and chronic pain patients: A systematic review and meta-analysis. Scand. J. Pain 2022 , 22 , 262–278. [ Google Scholar ] [ CrossRef ]
• Martel, M.O.; Wasan, A.D.; Edwards, R.R. Sex differences in the stability of conditioned pain modulation (CPM) among patients with chronic pain. Pain Med. 2013 , 14 , 1757–1768. [ Google Scholar ] [ CrossRef ]
• Craig, C.L.; Marshall, A.L.; Sjöström, M.; Bauman, A.E.; Booth, M.L.; Ainsworth, B.E.; Pratt, M.; Ekelund, U.; Yngve, A.; Sallis, J.F.; et al. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports Exerc. 2003 , 35 , 1381–1395. [ Google Scholar ] [ CrossRef ]
• Papathanasiou, G.; Georgoudis, G.; Papandreou, M.; Spyropoulos, P.; Georgakopoulos, D.; Kalfakakou, V.; Evangelou, A. Reliability measures of the short International Physical Activity Questionnaire (IPAQ) in Greek young adults. Hell. J. Cardiol. 2009 , 50 , 283–294. [ Google Scholar ]
• Bjelland, I.; Dahl, A.A.; Haug, T.T.; Neckelmann, D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J. Psychosom. Res. 2002 , 52 , 69–77. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Michopoulos, I.; Douzenis, A.; Kalkavoura, C.; Christodoulou, C.; Michalopoulou, P.; Kalemi, G.; Fineti, K.; Patapis, P.; Protopapas, K.; Lykouras, L. Hospital Anxiety and Depression Scale (HADS): Validation in a Greek general hospital sample. Ann. Gen. Psychiatry 2008 , 7 , 4. [ Google Scholar ] [ CrossRef ]
• Mayer, T.G.; Neblett, R.; Cohen, H.; Howard, K.J.; Choi, Y.H.; Williams, M.J.; Perez, Y.; Gatchel, R.J. The development and psychometric validation of the central sensitization inventory. Pain Pract. 2012 , 12 , 276–285. [ Google Scholar ] [ CrossRef ]
• Bilika, P.; Neblett, R.; Georgoudis, G.; Dimitriadis, Z.; Fandridis, E.; Strimpakos, N.; Kapreli, E. Cross-cultural Adaptation and Psychometric Properties of the Greek Version of the Central Sensitization Inventory. Pain Pract. 2020 , 20 , 188–196. [ Google Scholar ] [ CrossRef ]
• Koo, T.K.; Li, M.Y. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J. Chiropr. Med. 2016 , 15 , 155–163. [ Google Scholar ] [ CrossRef ]
• De Groef, A.; Van Kampen, M.; Vervloesem, N.; Clabau, E.; Christiaens, M.R.; Neven, P.; Geraerts, I.; Struyf, F.; Devoogdt, N. Inter-rater reliability of shoulder measurements in middle-aged women. Physiotherapy 2017 , 103 , 222–230. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Vaegter, H.B.; Lyng, K.D.; Yttereng, F.W.; Christensen, M.H.; Sørensen, M.B.; Graven-Nielsen, T. Exercise-Induced Hypoalgesia After Isometric Wall Squat Exercise: A Test-Retest Reliabilty Study. Pain Med. 2019 , 20 , 129–137. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Jones, D.H.; Kilgour, R.D.; Comtois, A.S. Test-retest reliability of pressure pain threshold measurements of the upper limb and torso in young healthy women. J. Pain 2007 , 8 , 650–656. [ Google Scholar ] [ CrossRef ]
• Persson, A.L.; Brogårdh, C.; Sjölund, B.H. Tender or not tender: Test-retest repeatability of pressure pain thresholds in the trapezius and deltoid muscles of healthy women. J. Rehabil. Med. 2004 , 36 , 17–27. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Vanderweeën, L.; Oostendorp, R.A.; Vaes, P.; Duquet, W. Pressure algometry in manual therapy. Man. Ther. 1996 , 1 , 258–265. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ruscheweyh, R.; Weinges, F.; Schiffer, M.; Bäumler, M.; Feller, M.; Krafft, S.; Straube, A.; Sommer, J.; Marziniak, M. Control over spinal nociception as quantified by the nociceptive flexor reflex (RIII reflex) can be achieved under feedback of the RIII reflex. Eur. J. Pain 2015 , 19 , 480–489. [ Google Scholar ] [ CrossRef ]
• Rezaii, T.; Hirschberg, A.L.; Carlström, K.; Ernberg, M. The influence of menstrual phases on pain modulation in healthy women. J. Pain 2012 , 13 , 646–655. [ Google Scholar ] [ CrossRef ]
• Ruscheweyh, R.; Albers, C.; Kreusch, A.; Sommer, J.; Marziniak, M. The effect of catastrophizing self-statements on pain perception and the nociceptive flexor reflex (RIII reflex). Clin. J. Pain 2013 , 29 , 725–732. [ Google Scholar ] [ CrossRef ]
• Murphy, M.; Gibson, W.; Chivers, P.; Docking, S.; Rio, E. Considerations for multi-centre conditioned pain modulation (CPM) research; an investigation of the inter-rater reliability, level of agreement and confounders for the Achilles tendon and Triceps Surae. Br. J. Pain 2021 , 15 , 91–101. [ Google Scholar ] [ CrossRef ]
• Graeff, P.; Itter, A.; Wach, K.; Ruscheweyh, R. Inter-Individual Differences Explain More Variance in Conditioned Pain Modulation Than Age, Sex and Conditioning Stimulus Intensity Combined. Brain Sci. 2021 , 11 , 1186. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Cummins, T.M.; McMahon, S.B.; Bannister, K. The impact of paradigm and stringent analysis parameters on measuring a net conditioned pain modulation effect: A test, retest, control study. Eur. J. Pain 2021 , 25 , 415–429. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Coronado, R.A.; George, S.Z. The Central Sensitization Inventory and Pain Sensitivity Questionnaire: An exploration of construct validity and associations with widespread pain sensitivity among individuals with shoulder pain. Musculoskelet. Sci. Pract. 2018 , 36 , 61–67. [ Google Scholar ] [ CrossRef ]
• Hendriks, E.; Voogt, L.; Lenoir, D.; Coppieters, I.; Ickmans, K. Convergent Validity of the Central Sensitization Inventory in Chronic Whiplash-Associated Disorders; Associations with Quantitative Sensory Testing, Pain Intensity, Fatigue, and Psychosocial Factors. Pain Med. 2020 , 21 , 3401–3412. [ Google Scholar ] [ CrossRef ]
• Scerbo, T.; Colasurdo, J.; Dunn, S.; Unger, J.; Nijs, J.; Cook, C. Measurement Properties of the Central Sensitization Inventory: A Systematic Review. Pain Pract. 2018 , 18 , 544–554. [ Google Scholar ] [ CrossRef ]
• Yarnitsky, D.; Bouhassira, D.; Drewes, A.M.; Fillingim, R.B.; Granot, M.; Hansson, P.; Landau, R.; Marchand, S.; Matre, D.; Nilsen, K.B.; et al. Recommendations on practice of conditioned pain modulation (CPM) testing. Eur. J. Pain 2015 , 19 , 805–806. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Steimer, T. The biology of fear- and anxiety-related behaviors. Dialogues Clin. Neurosci. 2002 , 4 , 231–249. [ Google Scholar ] [ CrossRef ]
• Naugle, K.M.; Riley, J.L., 3rd. Self-reported physical activity predicts pain inhibitory and facilitatory function. Med. Sci. Sports Exerc. 2014 , 46 , 622–629. [ Google Scholar ] [ CrossRef ]
• Naugle, K.M.; Ohlman, T.; Naugle, K.E.; Riley, Z.A.; Keith, N.R. Physical activity behavior predicts endogenous pain modulation in older adults. Pain 2017 , 158 , 383–390. [ Google Scholar ] [ CrossRef ]

Click here to enlarge figure

Share and Cite

Bilika, P.; Kalamatas-Mavrikas, P.; Vasilis, N.; Strimpakos, N.; Kapreli, E. Reliability of Pressure Pain Threshold (PPT) and Conditioned Pain Modulation (CPM) in Participants with and without Chronic Shoulder Pain. Healthcare 2024 , 12 , 1734. https://doi.org/10.3390/healthcare12171734

Bilika P, Kalamatas-Mavrikas P, Vasilis N, Strimpakos N, Kapreli E. Reliability of Pressure Pain Threshold (PPT) and Conditioned Pain Modulation (CPM) in Participants with and without Chronic Shoulder Pain. Healthcare . 2024; 12(17):1734. https://doi.org/10.3390/healthcare12171734

Bilika, Paraskevi, Panagiotis Kalamatas-Mavrikas, Nikolaos Vasilis, Nikolaos Strimpakos, and Eleni Kapreli. 2024. "Reliability of Pressure Pain Threshold (PPT) and Conditioned Pain Modulation (CPM) in Participants with and without Chronic Shoulder Pain" Healthcare 12, no. 17: 1734. https://doi.org/10.3390/healthcare12171734

Article Metrics

Further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals