Shoulder dystocia--a clinical study of 56 cases

A retrospective analysis of 17,127 singleton vaginal deliveries revealed 56 cases of shoulder dystocia giving an incidence of 0.3%. Although an increasing incidence of shoulder dystocia was noted as the infant birth-weight increased, 41% of shoulder dystocia occurred in infants of average birth-weight (2,500-3,999g). Diabetes mellitus, postmaturity, maternal weight above 90 kg were each factors associated with a large sized infant which should signal the possible occurrence of shoulder dystocia. In the present series shoulder dystocia occurred in 2.7% of all infants weighing 4,000 g or more. Diabetic women experienced shoulder dystocia more often than non-diabetics. In the diabetics 15.7% of neonates of birth-weight 4,000 g and above sustained shoulder dystocia compared to 1.6% in the nondiabetic patients. Immediate neonatal injury was apparent in 43% of infants with shoulder dystocia, Erb palsy being the commonest injury. The perinatal mortality rate in the series was 54/1,000 deliveries. There was no maternal death. To avoid the potentially lethal and dangerous complications of shoulder dystocia, all clinical and technological methods available should be utilized to detect the excessive sized infants so that abdominal delivery may be performed before it is too late.

Vaginal dystocia in a patient with a double uterus and a longitudinal vaginal septum

A case of a breech straddling a vaginal septum requiring urgent division is reported. This case demonstrates some of the obstetric complications associated with congenital genital tract anomalies.

Unexpected dystocia secondary to a fetal sacrococcygeal teratoma: a successful outcome

Sacrococcygeal teratoma is a rare cause of dystocia. With recent advances in perinatal care, particularly the increasing use of maternal ultrasound, it is unlikely that unexpected dystocia secondary to this tumor will be seen by many physicians. Recent reports of this type of dystocia are rare and infant mortality secondary to it is high. However, if and when encountered, such dystocia need not imply a bad prognosis for either mother or infant. This is a report of successful management of one case as well as a presentation of recently reported cases and recommendations for management.

Obstetric complications of macrosomic babies in African women

A prospective analysis has been made on 145 consecutive deliveries resulting in babies weighing 4.5 kg and above delivered at the University of Nigeria Teaching Hospital (U.N.T.H.), Enugu, over a 1-year period (1985). Babies weighing 4.5 kg and over are regarded as macrosomic babies. The incidence of macrosomic babies in this study is 11 per thousand deliveries or 1 in 90. Factors that predisposed to the birth of macrosomic babies include: excessive weight gain during the course of pregnancy, tall height of the woman, multiparity and prolonged gestation. Diabetes mellitus was not a significant factor. Complications include prolonged labor, post-partum hemorrhage, ruptured uterus, shoulder dystocia and an increased perinatal mortality rate. Maternal mortality was also increased. Ninety percent of the multiparous women achieved spontaneous vaginal delivery while only 42% of the primigravidae achieved vaginal delivery. The implications are discussed.

Risk factors for Erb-Duchenne palsy

The risk factors associated with the occurrence of Erb-Duchenne palsy were examined. Of 22 palsies, 18 were noted among 32,088 nondiabetic gravidas (0.56 per 1000) compared with four among 380 diabetic gravidas (10.5 per 1000), a statistically significant difference. One in six infants of diabetic gravidas who sustained shoulder dystocia experienced an Erb-Duchenne palsy. The incidence of precipitate second-stage labors was high (31.8%) among those infants who experienced the neurologic complication. This labor abnormality is not preventable and may contribute, in many ways, to the neurologic complication. Although recently graduated (less than four years' postresidency training) obstetricians, especially if placed in a high-volume practice, were more likely to experience this adverse outcome than more experienced physicians, even the most senior clinicians delivered infants who were affected.

Shoulder dystocia: its incidence and associated risk factors

A case-control study (73 cases, 146 controls) was conducted to evaluate maternal, obstetrical and fetal factors associated with shoulder dystocia. Several factors were identified that were associated with a higher incidence of shoulder dystocia. However, none of them accurately predict those deliveries that will be complicated by shoulder dystocia. Among the 73 shoulder dystocia cases there were no perinatal deaths and all birth-related injuries associated with shoulder dystocia were temporary except for two cases of mild muscular weakness among 12 brachial palsy cases.

Factors affecting dystocia and birth weight in Grati cattle in Pujon, East Java

This paper discusses factors affecting dystocia and birth weight in Grati cattle in three villages in the Pujon district, East Java. Records of birth weight, dystocia score, village, season, parity, sex, artificial versus natural service, and age and weight of dam, were obtained from 268 parturitions. Village and weight of the dam had a significant effect on birth weight but not on dystocia. Parity had a significant effect on dystocia score. More abnormal births occurred with AI using exotic bulls. Calves from an abnormal birth were on average more than three kg heavier. First parity births combined with Al with exotic bulls had a particularly high incidence of dystocia. It is concluded that farmers in Pujon can reduce the incidence of dystocia in heifers by using local bulls only.

Uterine torsion followed by jejunal incarceration in a partially everted urinary bladder of a cow

A case of bladder eversion with intestinal entrapment in a cow is described. The condition occurred in conjunction with a 180 degrees right side uterine torsion. The cow responded well to corrective surgery.

Cellular and molecular bases for dystocia

In this review I have briefly outlined some of the cellular and molecular reasons for dystocia. I have described the myogenic, that may control the normal progression of labor and explain inadequate uterine contractility associated with dystocia. I have placed particular emphasis on our studies of gap junctions and their regulation. These studies show that there are specific physiologic mechanisms for regulating structural and functional coupling between myometrial cells during labor. The integration of these control mechanisms probably operates to ensure appropriate activation and maintenance of synchronous contractility of the myometrium and effective delivery.

Fetal dystocia

Fetal dystocia is the result of an unfortunate relationship between fetal anatomy and maternal pelvic capacity. Most commonly, arrest of labor progress occurs at a point at which the problem is solved without significant risk to maternal-fetal welfare by abdominal delivery. This article has, in part, focused upon some rare exceptions and on how to anticipate and deal with them as well as possible.

Soft tissue and pelvic dystocia

This article has considered the subject of bony pelvic dystocia and soft tissue dystocia. Dystocia most often results from a combination of fetal and pelvic factors. However, on many occasions the size and shape of the pelvis is the initial problem, which encourages the fetus to take up a malposition such as occiput-posterior, and this in turn results in a dysfunctional contraction pattern that may or may not be corrected by oxytocin augmentation--a vicious circle that can only be broken by performance of a cesarean section. With minor degrees of pelvic dystocia, asynclitism and molding of the fetal head can often make a safe vaginal delivery possible. Clinically all pelvises can be categorized into adequate, questionable, and too small. The latter group is the least common and generally includes the congenitally or developmentally abnormal pelvises, and in most cases primary cesarean section should be the mode of delivery. In all other pelvises with a vertex presentation, a trial of labor is indicated because the fetal head is an excellent pelvimeter. With proper fetal monitoring with an intrauterine pressure catheter, with the use of a partograph to assist in the diagnosis of an active-phase arrest, followed by a cesarean section at the appropriate time, there is no increase in fetal or maternal morbidity. If the breech is the presenting part, then there are only two types of pelvis--very adequate and inadequate--and x-ray pelvimetry should be used to help in the classification.(ABSTRACT TRUNCATED AT 250 WORDS)

Symphysis-fundus height, maternal height, labor pattern, and mode of delivery

Fetal growth was monitored with use of symphysis-fundus charts in 920 consecutive term singleton pregnancies with cephalic presentation. There were 402 primigravid and 518 multigravid patients. The symphysis-fundus charts were divided into four zones and the patients allocated into groups according to the zone of the last symphysis-fundus height measurement before the onset of labor. A highly significant increase was noted in the incidence of abnormal labor and operative delivery in group A primigravid women (symphysis-fundus height above the ninetieth centile), which was even more pronounced when the effect of epidural analgesia was excluded. Conversely, there was a significant progressive increase in the proportion of operative deliveries for fetal distress from group A through group D (symphysis-fundus height below the tenth centile). Similar trends were significant but less pronounced among multigravid women. The relationship between maternal height, symphysis-fundus height, and operative delivery for dystocia in primigravid women was examined. High operative delivery rates were present in group A primigravid patients regardless of maternal height. In groups B and C, however, increased maternal height was associated with lower operative delivery rates.

Shoulder dystocia: predictors and outcome. A five-year review

Shoulder dystocia is an uncommon complication of delivery with a high morbidity rate. Ninety-one cases were coded for shoulder dystocia at the Toronto General Hospital from 1980 through 1985. True shoulder dystocia was found in 24 cases, an incidence of 0.23%. There was no significant difference in average weight and percentage of macrosomia between cases of true shoulder dystocia and those merely coded as such. True shoulder dystocia was associated with a neonatal morbidity rate of 42%, consisting of a respiratory arrest and neurological and orthopedic damage. Fundal pressure, in the absence of other maneuvers, resulted in a 77% complication rate and was strongly associated with orthopedic and neurologic damage. Delivery of the posterior shoulder and the corkscrew maneuver were associated with good fetal outcome.

The influence of high level feeding on the duration of parturition and the incidence of dystocia in dairy cows

Dairy cows on high and controlled feed levels were observed to determine the duration of the parturition process and the incidence of dystocia. Maternal and foetal mass ratio at calving were recorded. The duration of parturition in cows on high level feeding was significantly prolonged to 5.2 +/- 2.8 hours as compared to 1.34 +/- 0.89 hours in cows on controlled feeding. The incidence of dystocia was significantly higher in over-fed cows. While maternal mass on high level feeding increased by 27.3%, foetal mass increased by only 5.4%.

[Obstetric outcome of the malformed uterus. Study of 155 pregnancies]

Gynecological and obstetrical pathologies are considered in 155 pregnancies involving uterine deformity. Evaluation of their relative importance shows that maintenance of pregnancy is more important than pregnancy per se. Certain rules are proposed for treatment and obstetrical management of such pregnancies.

Risk factors for shoulder dystocia in the average-weight infant

Almost half (47.6%) of all deliveries with shoulder dystocia occurred in association with the delivery of an average-weight infant (under 4000 g). Of 4294 nondiabetic gravidas delivering infants of birth weight 3500 to 3999 g, 94 (2.2%) experienced a shoulder dystocia. Protraction and arrest disorders were associated with a statistically significant increase in the incidence of shoulder dystocia, and this effect was further augmented by low forceps delivery. Among 6252 infants weighing 3000 to 3499 g, there were 40 instances of shoulder dystocia (0.6%). Only arrest disorders were associated with an increased rate.

Risk factors for shoulder dystocia

The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.

The role of ultrasound in the aggressive management of obstructed labor secondary to fetal malformations

Eleven cases of major congenital anomalies were diagnosed in conjunction with arrest of dilatation or descent. In three cases, the diagnosis of fetal death was made. In the remainder, despite extensive counseling, the mothers refused cesarean section for an anomalous fetus. Fetal decompression resulted in prompt vaginal delivery in 10 of 11 cases.