Intrapartum interventions for preventing shoulder dystocia

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used, and overall rates are increasing globally. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (26 September 2022), and reference lists of the retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs. Trials were eligible for inclusion if women were diagnosed with GDM during pregnancy and the trial compared tighter and less-tight glycaemic targets during management. We defined tighter glycaemic targets as lower numerical glycaemic concentrations, and less-tight glycaemic targets as higher numerical glycaemic concentrations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for carrying out data collection, assessing risk of bias, and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated risk of bias, and extracted data for the four included studies. We assessed the certainty of evidence for selected outcomes using the GRADE approach. Primary maternal outcomes included hypertensive disorders of pregnancy and subsequent development of type 2 diabetes. Primary infant outcomes included perinatal mortality, large-for-gestational-age, composite of mortality or serious morbidity, and neurosensory disability.

MAIN RESULTS

This was an update of a previous review completed in 2016. We included four RCTs (reporting on 1731 women) that compared a tighter glycaemic control with less-tight glycaemic control in women diagnosed with GDM. Three studies were parallel RCTs, and one study was a stepped-wedged cluster-RCT. The trials took place in Canada, New Zealand, Russia, and the USA. We judged the overall risk of bias to be unclear. Two trials were only published in abstract form. Tight glycaemic targets used in the trials ranged between ≤ 5.0 and 5.1 mmol/L for fasting plasma glucose and ≤ 6.7 and 7.4 mmol/L postprandial. Less-tight targets for glycaemic control used in the included trials ranged between < 5.3 and 5.8 mmol/L for fasting plasma glucose and < 7.8 and 8.0 mmol/L postprandial. For the maternal outcomes, compared with less-tight glycaemic control, the evidence suggests a possible increase in hypertensive disorders of pregnancy with tighter glycaemic control (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.80 to 1.69, 2 trials, 1491 women; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. Tighter glycaemic control likely results in little to no difference in caesarean section rates (RR 0.98, 95% CI 0.82 to 1.17, 3 studies, 1662 women; moderate certainty evidence) or induction of labour rates (RR 0.96, 95% CI 0.78 to 1.18, 1 study, 1096 women; moderate certainty evidence) compared with less-tight control. No data were reported for the outcomes of subsequent development of type 2 diabetes, perineal trauma, return to pre-pregnancy weight, and postnatal depression. For the infant outcomes, it was difficult to determine if there was a difference in perinatal mortality (RR not estimable, 2 studies, 1499 infants; low certainty evidence), and there was likely no difference in being large-for-gestational-age (RR 0.96, 95% CI 0.72 to 1.29, 3 studies, 1556 infants; moderate certainty evidence). The evidence suggests a possible reduction in the composite of mortality or serious morbidity with tighter glycaemic control (RR 0.84, 95% CI 0.55 to 1.29, 3 trials, 1559 infants; low certainty evidence); however, the 95% CI is compatible with a wide range of effects that encompass both benefit and harm. There is probably little difference between groups in infant hypoglycaemia (RR 0.92, 95% CI 0.72 to 1.18, 3 studies, 1556 infants; moderate certainty evidence). Tighter glycaemic control may not reduce adiposity in infants of women with GDM compared with less-tight control (mean difference -0.62%, 95% CI -3.23 to 1.99, 1 study, 60 infants; low certainty evidence), but the wide CI suggests significant uncertainty. We found no data for the long-term outcomes of diabetes or neurosensory disability. Women assigned to tighter glycaemic control experienced an increase in the use of pharmacological therapy compared with women assigned to less-tight glycaemic control (RR 1.37, 95% CI 1.17 to 1.59, 4 trials, 1718 women). Tighter glycaemic control reducedadherence with treatment compared with less-tight glycaemic control (RR 0.41, 95% CI 0.32 to 0.51, 1 trial, 395 women). Overall the certainty of evidence assessed using GRADE ranged from low to moderate, downgraded primarily due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

This review is based on four trials (1731 women) with an overall unclear risk of bias. The trials provided data on most primary outcomes and suggest that tighter glycaemic control may increase the risk of hypertensive disorders of pregnancy. The risk of birth of a large-for-gestational-age infant and perinatal mortality may be similar between groups, and tighter glycaemic targets may result in a possible reduction in composite of death or severe infant morbidity. However, the CIs for these outcomes are wide, suggesting both benefit and harm. There remains limited evidence regarding the benefit of different glycaemic targets for women with GDM to minimise adverse effects on maternal and infant health. Glycaemic target recommendations from international professional organisations vary widely and are currently reliant on consensus given the lack of high-certainty evidence. Further high-quality trials are needed, and these should assess both short- and long-term health outcomes for women and their babies; include women's experiences; and assess health services costs in order to confirm the current findings. Two trials are ongoing.

Obstetric Paralysis: Who is to blame? A systematic literature review

Obstetric palsy is classically defined as the brachial plexus injury due to shoulder dystocia or to maneuvers performed on difficult childbirths. In the last 2 decades, several studies have shown that half of the cases of Obstetric palsy are not associated with shoulder dystocia and have raised other possible etiologies for Obstetric palsy. The purpose of the present study is to collect data from literature reviews, classic articles, sentries, and evidence-based medicine to better understand the events involved in the occurrence of Obstetric palsy. A literature review was conducted in the search engine PubMed (MeSH - Medical Subject Headings) with the following keywords: shoulder dystocia and obstetric palsy , completely open, boundless regarding language or date. Later, the inclusion criterion was defined as revisions. A total of 21 review articles associated with the themes described were found until March 8, 2018. Faced with the best available evidence to date, it is well-demonstrated that Obstetric palsy occurs in uncomplicated deliveries and in cesarean deliveries, and there are multiple factors that can cause it, relativizing the responsibility of obstetricians, nurses, and midwives. The present study aims to break the paradigms that associate Obstetric palsy compulsorily with shoulder dystocia, and that its occurrence necessarily implies negligence, malpractice or recklessness of the team involved.

Shoulder dystocia and range of head-body delivery interval (HBDI): The association between prolonged HBDI and neonatal outcomes: Protocol for a systematic review

OBJECTIVE

Shoulder dystocia (SD) is an obstetric emergency which if not carefully diagnosed and managed, can contribute to lifelong neonatal morbidities. Despite current guidelines on the definition of SD (impaction of the fetal shoulder behind the maternal symphysis pubis and need for ancillary manoeuvres or head-body delivery interval (HBDI) >60 s) its accurate diagnosis requires clinical expertise as well as overall consideration of feto-maternal condition. Based on the literature available, our study aims to determine (1) the range of HBDI as an indicator of SD and (2) the neonatal complications occurring following prolonged HBDI in normal or SD-complicated births.

STUDY DESIGN

A comprehensive literature search will be conducted in the following databases MEDLINE, CINAHL and Scopus (Elsevier) as well as international obstetric guidelines to find English language published data since 1970 that evaluate HBDI, prolonged HBDI and associated neonatal outcomes. Retrospective/prospective observational studies and randomized controlled trials will be recruited. As heterogeneity in definitions of SD among studies is expected, we will categorize our results according to the following two definitions: 1-Bony obstruction of fetal shoulder behind the maternal symphysis pubis or less commonly, posterior shoulder on sacral promontory and need for ancillary manoeuvres or 2- Head-body delivery interval (HBDI)> 60 s). Two reviewers will independently identify eligible studies, assess risk of bias and extract data based on predefined checklists. Outcomes of interest will be the HBDI in normal and SD-complicated births and associated neonatal consequences.

DISCUSSION

Findings of this systematic review will provide reliable information regarding (1) the interval between birth of the head and birth of the shoulders and (2) neonatal outcomes attributed to either true SD or prolonged HBDI. Our findings will add to the knowledge of whether prolonged HBDI is an appropriate definition for SD and whether/what level of prolongation of HBDI results in adverse neonatal outcomes. This increased understanding will better inform the clinical practice of midwives and obstetricians.

Changing Labor and Delivery Practice: Focus on Achieving Practice and Documentation Standardization with the Goal of Improving Neonatal Outcomes

OBJECTIVE

To establish multifactorial shoulder dystocia response and management protocol to promote sustainable practice change.

DATA SOURCES/STUDY SETTING

Primary data collection was conducted over 3 years. Implementation of the protocol spanned 13 months. Data collection occurred at five sites, which were chosen for their diversity in both patient mix and geographical location.

STUDY DESIGN

Case study evaluation methodology was used to examine clinician engagement and protocol adoption.

DATA COLLECTION METHODS

The training completion for all practice engagement team activities was collected by the site project manager and entered into a flat file. Data from the labor and delivery notes, medical records, and interviews with labor and delivery teams were gathered and analyzed by the senior investigator.

PRINCIPAL FINDINGS

In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements and in subsequent years, 98 percent completed the follow-up training. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.

CONCLUSIONS

System and site management teams implemented a standardized shoulder dystocia protocol that fostered effective teamwork and obstetric team readiness for managing shoulder dystocia emergencies.

Different intensities of glycaemic control for women with gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) has major short- and long-term implications for both the mother and her baby. GDM is defined as a carbohydrate intolerance resulting in hyperglycaemia or any degree of glucose intolerance with onset or first recognition during pregnancy from 24 weeks' gestation onwards and which resolves following the birth of the baby. Rates for GDM can be as high as 25% depending on the population and diagnostic criteria used and rates are increasing globally. Risk factors associated with GDM include advanced maternal age, obesity, ethnicity, family history of diabetes, and a previous history of GDM, macrosomia or unexplained stillbirth. There is wide variation internationally in glycaemic treatment target recommendations for women with GDM that are based on consensus rather than high-quality trials.

OBJECTIVES

To assess the effect of different intensities of glycaemic control in pregnant women with GDM on maternal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 February 2016) and reference lists of the retrieved studies.

SELECTION CRITERIA

We included one randomised controlled trial. Cluster-randomised and quasi-randomised controlled trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently assessed trial eligibility for inclusion, evaluated methodological quality and extracted data for the one included study. We sought additional information from one trial author but had no response. We assessed the quality of evidence for selected outcomes using the GRADE approach.

MAIN RESULTS

We included one Canadian trial of 180 women, recruited between 20 to 32 weeks' gestation, who had been diagnosed with GDM. Data from 171 of the 180 women were published as a conference abstract and no full report has been identified. The overall risk of bias of the single included study was judged to be unclear.The included trial did not report on any of this review's primary outcomes. For the mother, these were hypertension disorders of pregnancy or subsequent development of type 2 diabetes. For the infant, our primary outcomes were (perinatal (fetal and neonatal) mortality; large-for-gestational age; composite of death or severe morbidity or later childhood neurosensory disability).The trial did report data relating to some of this review's secondary outcomes. There was no clear difference in caesarean section rates for women assigned to using strict glycaemic targets (pre-prandial 5.0 mmol/L (90 mg/L) and at one-hour postprandial 6.7 mmol/L (120 mg/dL)) (28/85, 33%) when compared with women assigned to using liberal glycaemic targets (pre-prandial 5.8 mmol/L (103 mg/dL) and at one-hour postprandial 7.8 mmol/L (140 mg/dL)) (21/86, 24%) (risk ratio (RR) 1.35, 95% confidence interval (CI) 0.83 to 2.18, one trial, 171 women; very low quality). Using the GRADE approach, we found the quality of the evidence to bevery low for caesarean section due to poor reporting of risk of bias, imprecision and publication bias. Strict glycaemic targets were associated with an increase in the use of pharmacological therapy (identified as the use of insulin in this study) (33/85; 39%) compared with liberal glycaemic targets (18/86; 21%) (RR 1.85, 95% CI 1.14 to 3.03; one trial, 171 women). CIs are wide suggesting imprecision and caution is required when interpreting the data. No other secondary maternal outcome data relevant to this review were reported. For the infant, there were no clear differences between the groups of women receiving strict and liberal glycaemic targets for macrosomia (birthweight greater than 4000 g) (RR 1.35, 95% CI 0.31 to 5.85, one trial, 171 babies); small-for-gestational age (RR 1.12, 95% CI 0.48 to 2.63, one trial, 171 babies); birthweight (mean difference (MD) -92.00 g, 95% CI -241.97 to 57.97, one trial, 171 babies) or gestational age (MD -0.30 weeks, 95% CI -0.73 to 0.13, one trial, 171 babies). Adverse effects data were not reported. No other secondary neonatal outcomes relevant to this review were reported.

AUTHORS' CONCLUSIONS

This review is based on a single study (involving 180 women) with an unclear risk of bias. The trial (which was only reported in a conference abstract) did not provide data for any of this review's primary outcomes but did provide data for a limited number of our secondary outcomes. There is insufficient evidence to guide clinical practice for targets for glycaemic control for women with GDM to minimise adverse effects on maternal and fetal health. Glycaemic target recommendations from international professional organisations for maternal glycaemic control vary widely and are reliant on consensus given the lack of high-quality evidence.Further high-quality trials are needed, and these should compare different glycaemic targets for guiding treatment of women with GDM, assess both short-term and long-term health outcomes for women and their babies, include women's experiences and assess health services costs. Four studies are ongoing.

Six-year incidence and some features of cases of brachial plexus injury in a tertiary referral center

Objective:

To present some features and incidence of cases of brachial plexus injury in deliveries at the Department of Obstetrics and Gynecology of Zeynep Kamil Maternity and Children’s Training and Research Hospital, from January 2010 through December 2014.

Materials and Methods:

In total, 38.896 deliveries in the Department of Obstetrics and Gynecology of Zeynep Kamil Maternity and Children’s Training and Research Hospital, from January 2010 through December 2014 were screened from a prospectively collected database. We recorded gravidity, parity, body mass index, maternal diabetes, labor induction, gestational age at delivery, operative deliveries, malpresentations, prolonged second stage of deliveries, shoulder dystocies, clavicle and humerus fructures, estimated fetal weight, biparietal diameter, abdominal circumference, femur length, fetal sex, route of delivery, maternal age, and fetal anomalies.

Results:

There were 28 (72/100.000) cases of brachial plexus injury among 38.896 deliveries. In the 6-year study period, there were 18.363 deliveries via c-section, whereas 20.533 were vaginal deliveries.

Conclusion:

Sonographic fetal weight estimation and clinical examination performed by experienced obstetricians, and active appropriate management of shoulder dystocias seemed to attenuate the incidence of brachial plexus injury in the at risk population in our tertiary referral center.

Assessment of bony pelvis and vaginally assisted deliveries

Objective. To evaluate whether pelvic measurements have any association with operative vaginal deliveries and the duration of the second stage of the delivery. Study design. A retrospective study of pregnant women at an increased risk of fetal-pelvic disproportion during 2000-2008 in North-Carelian Central Hospital. The mode of the vaginal delivery was chosen to represent the reference standard. The target condition was spontaneous vaginal delivery. Patients were divided into subgroups according to the size of the fetus and also by the parity to evaluate the variability reflecting differences in patient groups. Receiver operating characteristic (ROC) curves were established. Results. A total of 226 participants with fetal cephalic presentation delivered vaginally; of these, 184 women delivered spontaneously, and 42 women required operative vaginal delivery with vacuum extraction. There were no clinically or statistically significant differences between the size of the maternal pelvic outlet and the different modes of delivery types within these subgroups. With respect to the pelvic inlet and outlet, the areas under the curve in ROC were 0.566 with the P value of 0.18 and 95% confidence interval (CI) of 0.465-0.667 and 0.573 (95% CI: 0.484-0.622; P = 0.14). Conclusions. The maternal bony pelvic dimensions exhibited virtually no correlation with the need for operative vaginal deliveries.

Abdominal Access for Shoulder Dystocia as a Last Resort - a Case Report

Shoulder dystocia is the term used to describe failure to progress in labour after the head has been delivered due to insufficient rotation of the shoulders. It is unpredictable and cannot be prevented by the midwife or the obstetrician. We report here on a severe case of shoulder dystocia, where delivery of the shoulder was finally achieved through direct pressure on the anterior shoulder after laparotomy and uterotomy with concurrent vaginal Woods screw manoeuvre and was followed by vaginal delivery. The patient presented risk factors like maternal obesity and administration of labour-inducing drugs. After different manoeuvres like McRoberts manoeuvre and several manoeuvres for internal rotation were carried out unsuccessfully, an emergency laparotomy was performed. The newborn was in need for reanimation and artifical ventilation postpartum but recovered fast during the following days. An Erb's palsy of the posterior arm improved during the hospital stay. The German Guideline of the DGGG 8 recommends a risk management plan and regular training to all birth attendants for obstetric clinics. Beside the vaginal manoeuvres one should have at least theoretical expertise in operative manoeuvres to be able to perform them in emergency cases.

A comparison of obstetric maneuvers for the acute management of shoulder dystocia

OBJECTIVE

To assess the efficacy of obstetric maneuvers for resolving shoulder dystocia and the effect that these maneuvers have on neonatal injury when shoulder dystocia occurs.

METHODS

Using an electronic database encompassing 206,969 deliveries, we identified all women with a vertex fetus beyond 34 0/7 weeks of gestation who incurred a shoulder dystocia during the process of delivery. Women whose fetuses had a congenital anomaly and women with an antepartum stillbirth were excluded. Medical records of all cases were reviewed by trained abstractors. Cases involving neonatal injury (defined as brachial plexus injury, clavicular or humerus fracture, or hypoxic-ischemic encephalopathy or intrapartum neonatal death attributed to the shoulder dystocia) were compared with those without injury.

RESULTS

Among 132,098 women who delivered a term cephalic liveborn fetus vaginally, 2,018 incurred a shoulder dystocia (1.5%), and 101 (5.2%) of these incurred a neonatal injury. Delivery of the posterior shoulder was associated with the highest rate of delivery when compared with other maneuvers (84.4% compared with 24.3-72.0% for other maneuvers; P<.005 to P<.001) and similar rates of neonatal injury (8.4% compared with 6.1-14.0%; P=.23 to P=.7). The total number of maneuvers performed significantly correlated with the rate of neonatal injury (P<.001).

CONCLUSION

Delivery of the posterior shoulder should be considered following the McRoberts maneuver and suprapubic pressure in the management of shoulder dystocia. The need for additional maneuvers was associated with higher rates of neonatal injury.

Shoulder dystocia: an Evidence-Based approach

Shoulder Dystocia (SD) is the nightmare of obstetricians. Despite its low incidence, SD still represents a huge risk of morbidity for both the mother and fetus. Even though several studies showed the existence of both major and minor risk factors that may complicate a delivery, SD remains an unpreventable and unpredictable obstetric emergency. When it occurs, SD is difficult to manage due to the fact that there are not univocal algorithms for its management.Nevertheless, even if it is appropriately managed, SD is one of the most litigated cause in obstetrics, because it is frequently associated with permanent birth-related injuries and mother complications.All the physicians should be prepared to manage this obstetric emergency by attending periodic training, even if SD is difficult to teach for its rare occurrence and because in clinical practice it is often handled by experienced obstetricians.THE PURPOSE OF THIS STUDY IS TO REVIEW THE LITERATURE CONCERNING THE EVERLASTING PROBLEMS OF SD: identification of risk factors for the early detection of delivery at high risk of SD and a systematic management of this terrifying obstetric emergency in order to avoid the subsequent health, medico-legal and economic complications.

Women with gestational diabetes mellitus in the ACHOIS trial: risk factors for shoulder dystocia

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with increased risk of fetal macrosomia and shoulder dystocia. However, not all women with GDM and fetal macrosomia have shoulder dystocia.

AIMS

To identify the risk factors for shoulder dystocia in women with gestational diabetes using data from women recruited into the routine care group of the ACHOIS trial.

METHODS

A secondary analysis was performed on data collected from women enrolled in the ACHOIS trial. Bivariate analyses were performed using the Fisher exact test. Variables found to be significantly associated with shoulder dystocia and previously identified risk factors were used as explanatory variables in multivariate analyses.

RESULTS

A positive relationship was found between the severity of maternal fasting hyperglycaemia and the risk of shoulder dystocia, with a 1 mmol increase in fasting oral glucose-tolerance test leading to a relative risk (RR) of 2.09 (95% CI 1.03-4.25). Shoulder dystocia occurred more often in births requiring operative vaginal delivery (RR 9.58, 95% CI 3.70-24.81, P < 0.001). Macrosomic and large-for-gestational-age infants were more likely to have births complicated by shoulder dystocia (RR 6.27, 95% CI 2.33-16.88, P < 0.001 and RR 4.57, 95% CI 1.74-12.01, P < 0.005, respectively). Fetal macrosomia was the only variable to maintain its significance in all multivariate analyses.

CONCLUSIONS

Fetal macrosomia is the strongest independent risk factor for shoulder dystocia. Effective preventative strategies are needed.