The relationship of fetal position and ethnicity with shoulder dystocia and birth injury

Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996 to 2012

OBJECTIVE

This study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics.

STUDY DESIGN

We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions.

RESULTS

The incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time.

CONCLUSION

Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers.

KEY POINTS

· The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..

Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries

PURPOSE

Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb's and Klumpke's palsy and the use of ICD-10 code 066.0.

METHODS

A retrospective, register-based case-control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006-2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes.

RESULTS

The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb's palsy and increasing use of ICD-10 code O66.0.

CONCLUSION

There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb's palsy and improved coding of shoulder dystocia.

Maternal postures for fetal malposition in labour for improving the health of mothers and their infants

BACKGROUND

Fetal malposition (occipito-posterior and persistent occipito-transverse) in labour is associated with adverse maternal and infant outcomes. Whether use of maternal postures can improve these outcomes is unclear. This Cochrane Review of maternal posture in labour is one of two new reviews replacing a 2007 review of maternal postures in pregnancy and labour.

OBJECTIVES

To assess the effect of specified maternal postures for women with fetal malposition in labour on maternal and infant morbidity compared to other postures.  SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (13 July 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or cluster-RCTs conducted among labouring women with a fetal malposition confirmed by ultrasound or clinical examination, comparing a specified maternal posture with another posture. Quasi-RCTs and cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, risk of bias, and performed data extraction. We used mean difference (MD) for continuous variables, and risk ratios (RRs) for dichotomous variables, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight eligible studies with 1766 women.  All studies reported some form of random sequence generation but were at high risk of performance bias due to lack of blinding. There was a high risk of selection bias in one study, detection bias in two studies, attrition bias in two studies, and reporting bias in two studies. Hands and knees The use of hands and knees posture may have little to no effect on operative birth (average RR 1.14, 95% CI 0.87 to 1.50; 3 trials, 721 women; low-certainty evidence) and caesarean section (RR 1.34, 95% CI 0.96 to 1.87; 3 trials, 721 women; low-certainty evidence) but the evidence is uncertain; and very uncertain for epidural use (average RR 0.74, 95% CI 0.41 to 1.31; 2 trials, 282 women; very low-certainty evidence), instrumental vaginal birth (average RR 1.04, 95% CI 0.57 to 1.90; 3 trials, 721 women; very low-certainty evidence), severe perineal tears (average RR 0.88, 95% CI 0.03 to 22.30; 2 trials, 586 women; very low-certainty evidence), maternal satisfaction (average RR 1.02, 95% CI 0.68 to 1.54; 3 trials, 350 women; very low-certainty evidence), and Apgar scores less than seven at five minutes (RR 0.71, 95% CI 0.21 to 2.34; 2 trials, 586 babies; very low-certainty evidence).  No data were reported for the hands and knees comparisons for postpartum haemorrhage, serious neonatal morbidity, death (stillbirth or death of liveborn infant), admission to neonatal intensive care, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy.  Lateral postures The use of lateral postures may have little to no effect on reducing operative birth (average RR 0.72, 95% CI 0.43 to 1.19; 4 trials, 871 women; low-certainty evidence), caesarean section (average RR 0.78, 95% CI 0.44 to 1.39; 4 trials, 871 women; low-certainty evidence), instrumental vaginal birth (average RR 0.73, 95% CI 0.39 to 1.36; 4 trials, 871 women; low-certainty evidence), and maternal satisfaction (RR 0.96, 95% CI 0.84 to 1.09; 2 trials, 451 women; low-certainty evidence), but the evidence is uncertain. The evidence is very uncertain about the effect of lateral postures on severe perineal tears (RR 0.66, 95% CI 0.17 to 2.48; 3 trials, 609 women; very low-certainty evidence), postpartum haemorrhage (RR 0.90, 95% CI 0.48 to 1.70; 1 trial, 322 women; very low-certainty evidence), serious neonatal morbidity (RR 1.41, 95% CI 0.64 to 3.12; 3 trials, 752 babies; very low-certainty evidence), Apgar scores less than seven at five minutes (RR 0.25, 95% CI 0.03 to 2.24; 1 trial, 322 babies; very low-certainty evidence), admissions to neonatal intensive care (RR 1.41, 95% CI 0.64 to 3.12; 2 trials, 542 babies; very low-certainty evidence) and neonatal death (stillbirth or death of liveborn) (1 trial, 210 women and their babies; no events).  For the lateral posture comparisons, no data were reported for epidural use, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy. We were not able to estimate the outcome death (stillbirth or death of liveborn infant) due to no events (1 trial, 210 participants).  AUTHORS' CONCLUSIONS: We found low- and very low-certainty evidence which indicated that the use of hands and knees posture or lateral postures in women in labour with a fetal malposition may have little or no effect on health outcomes of the mother or her infant. If a woman finds the use of hands and knees or lateral postures in labour comfortable there is no reason why they should not choose to use them. Further research is needed on the use of hands and knees and lateral postures for women with a malposition in labour. Trials should include further assessment of semi-prone postures, same-side-as-fetus lateral postures with or without hip hyperflexion, or both, and consider interventions of longer duration or that involve the early second stage of labour.

Accuracy of Fetal Biacromial Diameter and Derived Ultrasonographic Parameters to Predict Shoulder Dystocia: A Prospective Observational Study

Background and Objectives: Shoulder dystocia (ShD) is one of most dangerous obstetric complication. The objective of this study was to determine if the ultrasonographic fetal biacromial diameter (BA) and derived parameters could predict ShD in uncomplicated term pregnancies. Materials and Methods: We conducted a prospective observational study in a tertiary care university hospital from March 2021 to February 2022. We included all full-term pregnancies accepted for delivery that received an accurate ultrasonography (USG) scan before delivery. USG biometry and estimated fetal weight (EFW) were collected. Therefore, we evaluated the diameter of the mid-arm, the transverse thoracic diameter (TTD) and the biacromial diameter (BA). BA was estimated using Youssef’s formula: TTD + 2 mid-arm diameters. The primary outcome was the evaluation of BA and its related parameters (BA/biparietal diameter (BPD), BA/head circumference (HC) and BA–BPD in fetuses with ShD versus fetuses without ShD. Diagnostic accuracy for ShD of BA, BA/BPD, BA/HC and BA–BPD was evaluated using receiver operator curve (ROC) analysis. Results: 90 women were included in the analysis, four of these had ShD and required extra maneuvers after head delivery. BA was increased in fetuses with ShD (150.4 cm; 95% CI 133.2 cm to 167.6 cm) compared to no-ShD (133.5 cm; 95% CI 130.1 cm to 137.0 cm; p = 0.04). Significant differences were also found between ShD and no-ShD groups for BA/BPD (1.66 (95% CI 1.46 to 1.86) vs. 1.44 (95% CI 1.41 to 1.48); p = 0.04), BA/HC (0.45 (95% CI 0.40 to 0.49) vs. 0.39 (95% CI 0.38 to 0.40); p = 0.01), BA–BPD (60.0 mm (95% CI 42.4 to 77.6 cm) vs. 41.4 (95% CI 38.2 to 44.6); p = 0.03), respectively. ROC analysis showed an overall good accuracy for ShD, with an AUC of 0.821 (p = 0.001) for BA alone and 0.881 (p = 0.001), 0.857 (p = 0.016) and 0.867 (p = 0.013) for BA/BPD, BA–BPD and BA/HC, respectively. Conclusions: BA alone, as well as BA/BPD, BA/HC and BA–BPD might be useful predictors of ShD in uncomplicated term pregnancies. However, such evidence needs extensive confirmation by means of additional studies with large sample sizes, especially in case of pregnancies at high risk for ShD (i.e., gestational diabetes).

Maternal body-mass-index and neonatal brachial plexus palsy in a California cohort

OBJECTIVE

To evaluate risk factors and describe the association between maternal pre-pregnancy body-mass-index (BMI) and neonatal brachial plexus palsy (BPP) in vaginal deliveries with and without shoulder dystocia.

METHODS

This is a retrospective cohort study of singleton, non-anomalous, term vaginal deliveries in California (2007-2011). Deliveries were classified as with or without shoulder dystocia. Our primary outcome was BPP and the independent variable of interest was maternal pre-pregnancy BMI, which was categorized as underweight (<18.5 kg/m²), normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obesity I (30-34.9 kg/m²), obesity II (35-39.9 kg/m²) and obesity III (≥40 kg/m²). We evaluated demographics, maternal, labor, and neonatal characteristics using chi-squared tests and assessed the association of pre-pregnancy BMI with BPP using multivariable logistic regression models.

RESULTS

In our cohort of 1,395,761 women, there were 21,463 deliveries with shoulder dystocia and 1,374,298 deliveries without shoulder dystocia. Among deliveries with shoulder dystocia, BPP was observed more frequently in neonates born to women with BMI categorized as overweight (32% vs. 29%; p < .001), obesity I (22% vs. 14%; p < .001), obesity II (10% vs. 6%; p < .001), and obesity III (8% vs. 3%; p < .001). After adjusting for confounders, the odds of BPP in deliveries with shoulder dystocia was significantly higher for women who were overweight (aOR = 1.65; 95% CI: 1.35-2.01), obesity I (aOR = 2.33; 95% CI: 1.86-2.90), obesity II (aOR = 2.56; 95% CI: 1.92-3.40), and obesity III (aOR = 3.80; 95% CI: 2.75-5.25). In deliveries without shoulder dystocia, BPP was more common in women with a BMI that was overweight (29% vs. 25%; p < .001), obesity I (17% vs. 11%; p < .001), obesity II (9% vs. 4%; p < .001), and obesity III (8% vs. 2%; p < .001). In this cohort, multivariable regression model showed similar results in women with a BMI that was overweight (aOR = 1.47; 95% CI: 1.19-1.81), obesity I (aOR = 1.99; 95% CI: 1.55-2.54), obesity II (aOR = 2.79; 95% CI: 2.04-3.83), and obesity III (aOR = 5.05; 95% CI: 3.63-7.03).

CONCLUSION

Rising maternal pre-pregnancy BMI is associated with an increased risk of BPP in vaginal deliveries with and without shoulder dystocia. Preconception interventions targeting weight management may be beneficial in reducing BPP in all deliveries.

Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia

OBJECTIVE

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).

METHODS

At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.

RESULTS

Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).

CONCLUSIONS

Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

The association of vacuum-assisted delivery and shoulder dystocia among macrosomic newborns: a retrospective study

PURPOSE

Although shoulder dystocia (ShD) is associated with fetal macrosomia and vacuum-assisted delivery (VAD), the independent role of the latter in the occurrence of ShD is yet to be completely elucidated, as it is difficult to study its true independent contribution to ShD formation in the presence of many confounding factors. Therefore, we aimed to study whether VAD is independently associated with an increased risk for ShD among macrosomic newborns.

METHODS

A retrospective cohort study from a single tertiary medical center including all women who delivered vaginally a macrosomic infant during 2011-2020. We allocated the study cohort into two groups: (1) VAD (2) spontaneous vaginal deliverys, and analyzed risk factors for ShD. A multivariate regression analysis was performed to identify determinants independently associated with ShD occurrence.

RESULTS

Of 2,664 deliveries who met the study inclusion criteria, 118 (4.4%) were VAD. The rate of ShD in the entire cohort was 108/2664 (4.1%). The following factors were more frequent among the VAD group: no previous vaginal delivery [odds ratio (OR) 2.4 (95% confidence interval (CI) 1.4-4.0, p < 0.001)], prolonged second stage (OR 11.9; 95% CI 8.1-17.6, p < 0.01), induction of labor (OR 2.4; 95% CI 1.5-3.8, p < 0.01) and ShD (OR 2.0; 95% CI 1.0-4.1, p = 0.04). ShD was associated with higher rates of maternal height < 160 cm (OR 2.0; 95% CI 1.3-3.1, p < 0.01), pregestational diabetes (OR 7.2; 95% CI 2.0-26.8, p = 0.01), hypertensive disorder (OR 2.6; 95% CI 1.1-6.2, p = 0.02) and higher birthweight (mean 4,124 vs. 4,167 g, p < 0.01). On multivariate regression analysis, the following factors remained independently associated with ShD occurrence: increased birthweight (aOR 1.0; 95% CI 1.0-1.0, p < 0.01), pregestational diabetes (aOR 5.3; 95% CI 1.1-25.0, p = 0.03), while maternal height was negatively associated with ShD (aOR 0.9; 95% CI 0.9-0.9, p < 0.01).

CONCLUSION

In deliveries of neonates above 4000 g, VAD did not independently increase the risk of ShD occurrence. Therefore, when expeditious delivery of a macrosomic infant is required, VAD is a viable option.

Rising trends in the incidence of shoulder dystocia and development of a novel shoulder dystocia risk score tool: a nationwide population-based study of 800 484 Finnish deliveries

INTRODUCTION

Shoulder dystocia has remained an unpredictable and feared emergency in obstetrics. Some risk factors have been identified but nevertheless there is a lack of risk evaluation tools in clinical practice. The aim of this study was to evaluate the incidence and risk factors of shoulder dystocia in the Finnish population and to develop a shoulder dystocia risk score tool.

MATERIAL AND METHODS

This retrospective, population-based study included all deliveries in Finland between 2004 and 2017 (n = 800 484). The annual numbers of shoulder dystocia diagnoses were gathered from nationwide Finnish Medical Birth Register and Hospital Discharge Register. The incidence of shoulder dystocia was calculated in subgroups according to the mode of delivery, maternal diabetes status, body mass index (BMI), age, parity and gestational age. Based on these numbers, a shoulder dystocia risk score tool was created.

RESULTS

The overall incidence of shoulder dystocia was 0.18%. It increased significantly during the study period from 0.10% to 0.32% (P < .001). More specifically, the incidence increased significantly in all analyzed subgroups except for women with BMI <18.5 or age <20 years. To evaluate the importance of risk factors, practical and simple shoulder dystocia risk score tool was created. Instrumental vaginal delivery, maternal diabetes of any kind, BMI ≥25, age ≥40 years and gestational age ≥41 weeks were associated with higher shoulder dystocia risk compared with non-diabetic, non-obese and younger women with spontaneous deliveries before 41 weeks of gestation. In our risk score tool, cases with shoulder dystocia had a significantly higher number of risk points than those without it (15.2 vs 10.4, P < .001). The risk was significantly high when the scores were ≥18 points (relative risk 9.54, 95% confidence interval 8.61-10.57).

CONCLUSIONS

The incidence of shoulder dystocia in Finland increased during the study period but it is still low compared with previous studies from other countries. In clinical daily practice, the new shoulder dystocia risk score tool helps to evaluate the individual risk profile of the parturient. According to this risk score tool, the highest risk was found with the combination of instrumental vaginal delivery, maternal diabetes, BMI ≥25, age ≥40 years and gestational age ≥41 weeks.

Effect of upright and ambulant positions versus lying down during the active first stage of labor on birth outcomes among nulliparous women: randomized controlled clinical trial

Objective

To examine the effect of upright and ambulant positions versus lying down during the active first stage of labor on birth outcomes for nulliparous women.

Methods

This is a randomized controlled clinical trial conducted at the delivery department of Damanhour Educational Institute, El Behira Governorate, Egypt. The study sample involved 150 parturient women equally divided into intervention and control groups using randomization block technique. The researchers used four tools for data collection: Demographic data interview schedule, World Health Organization Partograph, Apgar's score, to evaluate neonatal outcomes, and visual analogue pain intensity scale. For the study group, the parturient women were encouraged to assume one of the upright positions or ambulating around the bed so as to maintain the pelvis in vertical plane as far as possible for 20–25 min for every 1 h. The control group received routine hospital care, which includes lying down in bed. IBM SPSS 23.0 was used to analyze the data.

Results

Significant differences (P < 0.05) were observed between the study and control groups in relation to cervical dilation, fetal head descent, uterine contractions interval, and frequency. The duration of the first stage of labor significantly reduced (P = 0.018) in the intervention group compared with control group. No significant differences (P > 0.05) were observed between both groups in term of emergency cesarean birth rates, oxytocin use, and neonatal outcomes.

Conclusions

This study proves that upright and ambulant positions significantly enhance uterine contractility, cervical dilatation, and fetal head descent and reduce the first stage duration.

Risk factors associated with neonatal brachial plexus palsy in the United States

Neonatal brachial plexus palsy (NBPP) is a birth injury that can cause severe functional loss in the affected limb. The purpose of this study was to determine the temporal changes in the national incidence of this condition and whether associated risk factors have changed over time. Children born via vaginal delivery were identified in the Kids' Inpatient Database (KID) from 1997 to 2012, and those with NBPP were identified. The trend in incidence and risk factors were assessed through the study period. The nationwide incidence of NBPP decreased during the study period. Infants with shoulder dystocia, fetal macrosomia, and gestational diabetes had the highest risk of developing NBPP, while multiple birth mates during delivery had a protective effect. Multiple risk factors, including shoulder dystocia, macrosomia, and heavy for dates became less predictive of the development of NBPP over time. Several risk factors predispose children to the development of NBPP, and the effect of these risk factors has been changing. This information can guide obstetric treatment to help prevent NBPP. Level of evidence is diagnostic, level 3.

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function

PURPOSE

To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure.

METHODS

A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions.

RESULTS

Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain.

CONCLUSIONS

OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Population-Based Risk Factors for Shoulder Dystocia

OBJECTIVE

To re-examine the risk factors for shoulder dystocia given the increasing rates of obesity and diabetes in pregnant women.

DESIGN

Retrospective observational study.

SETTING

Five hospitals located in Wisconsin, Florida, Maryland, Michigan, and Alabama.

PARTICIPANTS

We evaluated 19,236 births that occurred between April 1, 2011, and July 25, 2013.

METHODS

Data were collected from electronic medical records and used to evaluate the risk of shoulder dystocia. Data were analyzed using a generalized linear mixed model, which controlled for clustering due to site.

RESULTS

When insulin was prescribed, gestational diabetes was associated with an increased risk of shoulder dystocia (odds ratio = 2.10, 95% confidence interval [1.01, 4.37]); however, no similar association was found with regard to gestational diabetes treated with glycemic agents or through diet. Use of epidural anesthesia was associated with an increased risk for shoulder dystocia (odds ratio = 3.47, 95% confidence interval [2.72, 4.42]). Being Black or Hispanic, being covered by Medicaid or having no insurance, infant gestational age of 41 weeks or greater, and chronic diabetes were other significant risk factors.

CONCLUSION

With the changing characteristics of pregnant women, labor and birth clinicians care for more pregnant women who have an increased risk for shoulder dystocia. Our findings may help prospectively identify women with the greatest risk.

Risk Factors for Shoulder Dystocia: the Impact of Mother's Race and Ethnicity

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

Pregnancy, parturition and preeclampsia in women of African ancestry

Maternal and associated neonatal mortality rates in sub-Saharan Africa remain unacceptably high. In Mulago Hospital (Kampala, Uganda), 2 major causes of maternal death are preeclampsia and obstructed labor and their complications, conditions occurring at the extremes of the birthweight spectrum, a situation encapsulated as the obstetric dilemma. We have questioned whether the prevalence of these disorders occurs more frequently in indigenous African women and those with African ancestry elsewhere in the world by reviewing available literature. We conclude that these women are at greater risk of preeclampsia than other racial groups. At least part of this susceptibility seems independent of socioeconomic status and likely is due to biological or genetic factors. Evidence for a genetic contribution to preeclampsia is discussed. We go on to propose that the obstetric dilemma in humans is responsible for this situation and discuss how parturition and birthweight are subject to stabilizing selection. Other data we present also suggest that there are particularly strong evolutionary selective pressures operating during pregnancy and delivery in Africans. There is much greater genetic diversity and less linkage disequilibrium in Africa, and the genes responsible for regulating birthweight and placentation may therefore be easier to define than in non-African cohorts. Inclusion of African women into research on preeclampsia is an essential component in tackling this major disparity of maternal health.

Precipitous and difficult deliveries

Any delivery in the emergency department is considered a precipitous birth and is an anxiety-producing event. Many deliveries proceed without incident. However, the emergency physician must be prepared for several dreaded scenarios, such as nuchal cord, shoulder dystocia, and breech birth. This article reviews the basics, complications, and management of such deliveries.

Severe chronic morbidity following childbirth

Three special, chronic morbidities of childbirth are reviewed with the most up-to-date knowledge in this article. Firstly, obstetric fistulas secondary to prolonged obstructed labour are still prevalent tragedies in underdeveloped countries. The damage is not only physical but psychosexual and social. The surgical skill and technology required to prevent and to treat obstetric fistulas are simple, but culture-social antagonism, geographic distance, political instability and financial constraint have to be overcome before effective management can take place. Congenital brachial plexus palsy is associated with shoulder dystocia and macrosomia, and both excessive exogenous traction and strong endogenous pushing forces contribute to its occurrence. As shoulder dystocia and macrosomia are not easily predictable, regular training and drill is essential to ensure proper management of shoulder dystocia. Most of the babies with brachial palsy will recover in 3 months but a minority of patients will suffer a more severe degree of damage, requiring early micro-neurosurgical intervention. Finally, although birth asphyxia is not the major cause of cerebral palsy, brain injury resulting from acute intrapartum hypoxic-ischemic insult is potentially alleviated by early neonatal hypothermic therapy. Both clinical and radiological assessments are essential in selecting suitable candidates for this innovative neuroprotective strategy.

[Severe shoulder dystocia: study of 14 cases treated by Jacquemier's maneuver]

OBJECTIVE

Shoulder dystocia is a dreadful complication of vaginal deliveries since it can be responsible of brachial plexus palsies and even neonatal deaths. Unlike most studies, we defined shoulder dystocia as the enclosing of fetal shoulders above the superior strait (cavity station of 1cm) and situations being resolved only by delivery of the posterior arm (Jacquemier's maneuver). The purpose of this study was to analyze cases of shoulder dystocia in terms of maternal and neonatal complications and to compare risk factors with those identified in the literature.

MATERIAL AND METHODS

We conducted a retrospective study of 14 cases of severe shoulder dystocia (SSD) which occurred at our hospital between January 1995 and January 2007. TSD was diagnosed in the absence of engagement of both fetal shoulders requiring recourse to Jacquemier's maneuver for delivery. Any gestational diabetes, abnormal progression of labour, suspicion or existence of fetal macrosomia, instrumental delivery, and neonatal complications were noted.

RESULTS

The incidence of SSD was around 1 per thousand. Multiparity, weight gain greater than 15kg and gestational diabetes were moderately present in our study group. Only 20% of neonates were macrosomic and 50% had a birth-weight of less than 4000g. In 80% of cases, an instrumental extraction was practised. Brachial plexus injuries affected 20% of neonates, no fracture was observed, one child died following an unresolved SSD.

CONCLUSION

This series shows that the incidence of SSD is rare and difficultly predictable even though identified risk factors exist. However, an instrumental extraction seems frequently associated with SSD and any extraction should take into account the presence of known risk factors. In spite of the severity of our cases of shoulder dystocia, complications found seemed to be similar to those observed in the literature.