Shoulder dystocia: definitions and incidence

Stratification of outcome of shoulder dystocia according to maneuver used for delivery, retrospective cohort and meta-analysis

BACKGROUND

Shoulder dystocia is an unpredictable obstetric condition with potential long-term neonatal complications. The risk of neonatal injury might be related to the condition itself as well as to the obstetrics maneuvers used for its release.

OBJECTIVES

To examine the available evidence to assess current management and possible improvement of outcomes.

SEARCH STRATEGY

A comprehensive search of MEDLINE, EMBASE, EMCARE, and The Cochrane Library database was performed, all studies reporting on neonatal outcomes in cases of shoulder dystocia stratified by obstetric maneuvers used for delivery were included. Data abstraction was performed and checked by two independent reviewers.

RESULTS

McRoberts maneuver was the least associated with risk of neonatal injury (odds ratio 0.6, 95% confidence interval 0.4-0.9), followed by delivery of posterior arm.

CONCLUSION

Delivery of posterior arm might be prioritized in cases of shoulder dystocia after failed McRoberts. Neonatal hypoxic injury correlates with the duration of dystocia rather than the maneuver used.

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.

Impact of COVID-19 mandatory lockdown on maternal gestational weight gain and neonatal macrosomia rate at an academic medical center in Israel

BACKGROUND

In an effort to prevent the spread of coronavirus disease 2019 (COVID-19), governments restricted outdoor activities and imposed lockdown quarantine. This change in lifestyle probably affected individuals' eating habits and physical activity.

OBJECTIVE

To examine the effect of lockdown due to the COVID-19 pandemic on maternal antenatal weight gain, neonatal macrosomia, and other maternal and neonatal outcomes of women delivering at an academic medical center in Israel.

METHOD

A retrospective, two-period cohort study conducted at a university teaching medical center in Afula, Israel. The study period was between April and September 2020. This period signifies worsening in pandemic situations, during which citizens experienced strict prolonged lockdown measures. The parallel unexposed period (control period) was between April and September 2019. Singleton pregnancies delivered at >24 weeks were eligible. Primary outcome was incidence of macrosomia. Secondary outcomes included gestational weight gain, body mass index (BMI) at delivery, rates of gestational diabetes mellitus (GDM), mode of delivery, postpartum hemorrhage (PPH), and neonatal outcomes reflecting neonatal birth weight and condition at delivery.

RESULTS

A total of 4,765 women were included, 2,442 in the study group and 2,323 in the control group. The incidence of macrosomia was significantly higher in 2020 (6.2%) than in 2019 (4.9%), (p = .048; OR: 1.29; 95% CI: 1.002- 1.65). Women gained significantly more weight (median 1 kg more), weighed more at delivery (median 1 kg), and had higher BMI at delivery in 2020 compared with those in 2019 (p < .01). The incidence of GDM was 9.5% and 8.5% in the study and control groups respectively (p = .26; OR: 1.12; 95% CI: 0.92-1.37). Greater percentage of women did not perform the glucose challenge test in 2020 (9.9%) compared with those in 2019 (7.5%) (p = .003, OR: 1.36; 95% CI: 1.11-1.67). The incidence of any hypertension related to pregnancy was significantly higher in 2020 compared to 2019 (5.8% vs 4.4% respectively, (p = .042; OR: 1.32; 95% CI: 1.02-1.71). The proportion of women who smoked during pregnancy was also significantly higher in 2020 than in 2019 (5.1% vs 3.7%, respectively, p = .02; OR: 1.40; 95% CI: 1.06-1.86). Delivery mode did not differ, while the incidence of PPH was significantly higher in 2020 than in 2019 (5.6% vs 3.4%, respectively, p = .001; OR: 1.65; 95% CI: 1.25-2.19). Neonatal condition at delivery was comparable.

CONCLUSION

COVID-19-related lockdown was associated with the increased rate of macrosomic infants. This indirect effect of the pandemic is probably related to poorer maternal antenatal metabolic health status. Long-term consequences should be further examined.

Sensitivity, specificity, and diagnostic accuracy of WHO 2013 criteria for diagnosis of gestational diabetes mellitus in low risk early pregnancies: international, prospective, multicentre cohort study

Objective

To evaluate the predictability of gestational diabetes mellitus wth a 75 g oral glucose tolerance test (OGTT) in early pregnancy, based on the 2013 criteria of the World Health Organization, and to test newly proposed cut-off values.

Design

International, prospective, multicentre cohort study.

Setting

Six university or cantonal departments in Austria, Germany, and Switzerland, from 1 May 2016 to 31 January 2019.

Participants

Low risk cohort of 829 participants aged 18-45 years with singleton pregnancies attending first trimester screening and consenting to have an early 75 g OGTT at 12-15 weeks of gestation. Participants and healthcare providers were blinded to the results.

Main outcome measures

Fasting, one hour, and two hour plasma glucose concentrations after an early 75 g OGTT (12-15 weeks of gestation) and a late 75 g OGTT (24-28 weeks of gestation).

Results

Of 636 participants, 74 (12%) developed gestational diabetes mellitus, according to World Health Organization 2013 criteria, at 24-28 weeks of gestation. Applying WHO 2013 criteria to the early OGTT with at least one abnormal value gave a low sensitivity of 0.35 (95% confidence interval 0.24 to 0.47), high specificity of 0.96 (0.95 to 0.98), positive predictive value of 0.57 (0.41 to 0.71), negative predictive value of 0.92 (0.89 to 0.94), positive likelihood ratio of 10.46 (6.21 to 17.63), negative likelihood ratio of 0.65 (0.55 to 0.78), and diagnostic odds ratio of 15.98 (8.38 to 30.47). Lowering the postload glucose values (75 g OGTT cut-off values of 5.1, 8.9, and 7.8 mmol/L) improved the detection rate (53%, 95% confidence interval 41% to 64%) and negative predictive value (0.94, 0.91 to 0.95), but decreased the specificity (0.91, 0.88 to 0.93) and positive predictive value (0.42, 0.32 to 0.53) at a false positive rate of 9% (positive likelihood ratio 5.59, 4.0 to 7.81; negative likelihood ratio 0.64, 0.52 to 0.77; and diagnostic odds ratio 10.07, 6.26 to 18.31).

Conclusions

The results of this prospective low risk cohort study indicated that the 75 g OGTT as a screening tool in early pregnancy is not sensitive enough when applying WHO 2013 criteria. Postload glucose values were higher in early pregnancy complicated by diabetes in pregnancy. Lowering the postload cut-off values identified a high risk group for later development of gestational diabetes mellitus or those who might benefit from earlier treatment. Results from randomised controlled trials showing a beneficial effect of early intervention are unclear.

Trial registration

ClinicalTrials.gov NCT02035059.

Incidence of obstetric brachial plexus palsy after a training program in shoulder dystocia

INTRODUCTION

Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis.

MATERIAL AND METHODS

Retrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008-2016).

RESULTS

In the 2017-2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation).

CONCLUSION

These results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.

Induction of labour for predicted macrosomia: study protocol for the 'Big Baby' randomised controlled trial

INTRODUCTION

Large-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected to be macrosomic may mitigate the risk of shoulder dystocia. The Big Baby Trial aims to find if induction of labour at 38⁺⁰-38⁺⁴ weeks' gestation, in pregnancies with suspected LGA fetuses, reduces the incidence of shoulder dystocia.

METHODS AND ANALYSIS

The Big Baby Trial is a multicentre, prospective, individually randomised controlled trial of induction of labour at 38⁺⁰ to 38⁺⁴ weeks' gestation vs standard care as per each hospital trust (median gestation of delivery 39⁺⁴) among women whose fetuses have an estimated fetal weight >90th customised centile according to ultrasound scan at 35⁺⁰ to 38⁺⁰ weeks' gestation. There is a parallel cohort study for women who decline randomisation because they opt for induction, expectant management or caesarean section. Up to 4000 women will be recruited and randomised to induction of labour or to standard care. The primary outcome is the incidence of shoulder dystocia; assessed by an independent expert group, blind to treatment allocation, from delivery records. Secondary outcomes include birth trauma, fractures, haemorrhage, caesarean section rate and length of inpatient stay. The main trial is ongoing, following an internal pilot study. A qualitative reporting, health economic evaluation and parallel process evaluation are included.

ETHICS AND DISSEMINATION

The study received a favourable opinion from the South West-Cornwall and Plymouth Health Research Authority on 23/03/2018 (IRAS project ID 229163). Study results will be reported in the National Institute for Health Research journal library and published in an open access peer-reviewed journal. We will plan dissemination events for key stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN18229892.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: an observational study

OBJECTIVE

To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI).

DESIGN

Retrospective observational study.

SETTING

Helsinki University Women's Hospital, Finland.

SAMPLE

Deliveries with SD.

METHODS

Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed.

RESULTS

During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm.

CONCLUSIONS

Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

Overview of techniques to manage shoulder dystocia during vaginal birth

Shoulder dystocia is an obstetric emergency which is unpredictable and complicates approximately 0.5-1% of vaginal births. This article discusses the risk factors and the associated fetal and maternal complications, while it is also an overview of techniques and algorithms to handle shoulder dystocia.

Large-for-gestational-age or macrosomia as a classifier for risk of adverse perinatal outcome: a retrospective cross-sectional study

OBJECTIVE

Small for gestational age (SGA) fetuses and neonates are of great interest, while those who are too big are much less studied. The aim was to analyze the classifiers described by ACOG "Fetal macrosomia" practice bulletin as predictors of adverse perinatal outcomes for overgrown fetuses and their mothers.

MATERIALS

From a database of 53,586 singleton term births, appropriate-for-gestational-age (AGA), large for gestational age (LGA), and macrosomic deliveries were selected. AGA served as a control. The crude and adjusted odds ratios (aORs) were calculated for large-for-gestational-age >90th centile, and macrosomia >4000 g, >4250 g, and >4500 g. Patients with and without diabetes were analyzed separately.

RESULTS

Macrosomia >4000 g performed poorer than other classifiers. LGA performed comparably to other definitions of macrosomia. Diabetes carries a severe risk of complications for overgrown neonates, but those non-diabetic also have increased risk.

CONCLUSIONS

Definition of macrosomia as weight >4000 g should be reconsidered. LGA >90th centile should be used as a definition of fetal overgrowth along with other definitions of macrosomia.

Risk factors for neonatal brachial plexus palsy: a systematic review and meta-analysis

AIM

To provide a comprehensive update on the most prevalent, significant risk factors for neonatal brachial plexus palsy (NBPP).

METHOD

Cochrane CENTRAL, MEDLINE, Web of Science, Embase, and ClinicalTrials.gov were searched for relevant publications up to March 2019. Studies assessing risk factors of NBPP in relation to typically developing comparison individuals were included. Meta-analysis was performed for the five most significant risk factors, on the basis of the PRISMA statement and MOOSE guidelines. Pooled odds ratios (ORs), 95% confidence intervals (CIs), and across-study heterogeneity (I² ) were reported. Reporting bias and quality of evidence was rated. In addition, we assessed the incidence of NBPP.

RESULTS

Twenty-two observational studies with a total sample size of 29 419 037 live births were selected. Significant risk factors included shoulder dystocia (OR 115.27; 95% CI 81.35-163.35; I² =92%), macrosomia (OR 9.75; 95% CI 8.29-11.46; I² =70%), (gestational) diabetes (OR 5.33; 95% CI 3.77-7.55; I² =59%), instrumental delivery (OR 3.8; 95% CI 2.77-5.23; I² =77%), and breech delivery (OR 2.49; 95% CI 1.67-3.7; I² =70%). Caesarean section appeared as a protective factor (OR 0.13; 95% CI 0.11-0.16; I² =41%). The pooled overall incidence of NBPP was 1.74 per 1000 live births. It has decreased in recent years.

INTERPRETATION

The incidence of NBPP is decreasing. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are risk factors for NBPP. Caesarean section appears as a protective factor.

WHAT THIS PAPER ADDS

The overall incidence of neonatal brachial plexus palsy is 1.74 per 1000 live births. The incidence has declined significantly. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are the main risk factors. Prevention is difficult owing to unpredictability and often labour-related risk.

Perinatal Outcomes in a Longitudinal Birth Cohort of First Nations Mothers With Pregestational Type 2 Diabetes and Their Offspring: The Next Generation Study

OBJECTIVES

There is emerging evidence that First Nations women with diabetes in pregnancy and their offspring have poorer health outcomes than non-First Nations women. The aim of this study was to describe the perinatal outcomes of pregnancies complicated by type 2 diabetes.

METHODS

The Next Generation longitudinal study is a First Nations birth cohort of children born to mothers diagnosed in childhood with type 2 diabetes. Pregnant women were prospectively enrolled in the birth cohort, and a review of medical records (including stored fetal ultrasound images) was performed to determine perinatal outcomes for 112 child-mother pairs between 2005 and 2015. Maternal demographics, antenatal variables, fetal ultrasound findings, obstetric and delivery information and neonatal birth outcomes were collected and analyzed.

RESULTS

Mothers in our cohort were young and most were overweight at the start of pregnancy. Most had suboptimal glycemic control in the first trimester (median glycated hemoglobin, 9.3%). The cesarean section rate was high at 41%. Over one-half of newborns had macrosomia at birth, and almost 1 in 5 were born with a structural anomaly, mainly renal. Fetal ultrasound significantly underestimated the proportion of infants born with macrosomia (p<0.05) and missed 3 of 7 cardiac defects in this cohort.

CONCLUSIONS

High rates of anomalies, macrosomia and cesarean deliveries provide insight into pregnancy management and disease processes for First Nations women with pregestational type 2 diabetes and their offspring, and highlights opportunities for improvement in prenatal care of these women.

Delivery room emergencies due to birth injuries

Delivery room emergencies due to birth injuries are serious, usually unexpected, and can be distressing situations that necessitate immediate action to reduce neonatal morbidity and prevent neonatal mortality. Birth injuries requiring immediate, urgent care in the delivery room are uncommon, hence knowledge of obstetric risk factors and prenatal conditions linked to birth injury is an important first step in the management of affected neonates. Furthermore, immediate recognition of injury and quick action upon delivery is essential in order to achieve the best possible outcomes. This chapter briefly reviews the known risk factors associated with birth injury, and then discusses the identification and management of specific injuries that may require immediate treatment in the delivery room, or hasty management within hours after birth.

Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study

Introduction

Brachial plexus birth injury is one of the challenges associated with maternal delivery, with varying prevalence between countries. Brachial plexus birth injury poses negative health implications to children and also has socio-economic implications on families and the community as a whole. To treat brachial plexus birth injury, a multi-disciplinary treatment approach is recommended. Brachial plexus birth palsy (BPBP) is categorised into two-upper plexus injury (Erb's palsy) and lower plexus injury (Klumpke's palsy). These categories present with various degrees of injuries, with less severe injuries responding well to treatment and in most instances may resolve on their own, but serious and complicated injuries will require a multi-disciplinary treatment approach to treat and/or manage. Effective treatment and management depends on adequate knowledge of the disease condition. These include the risk factors and prevalence of brachial plexus birth palsy within a particular population at a specific period in time. The aim of this study was to determine the risk factors and the prevalence of a hospital based brachial plexus birth palsy within a five-year period (2013-2017).

Methods

A five-year retrospective study design was used. The study involved selection of all clients' diagnosed with brachial plexus birth palsy, where their gender, birth weight, complications at birth, type of brachial plexus suffered, mothers' diabetes status, mother's age, birth attendant, side of affectation, presentation at birth and mode of delivery were recorded.

Results

The prevalence rate of brachial plexus birth palsy was 14.7% out of a total of three hundred and twenty (320) cases reviewed over the study period in the Volta Regional Hospital. Erb's palsy was found to be the modal type of BPBP in this population (93.6%).

Conclusion

There is the need to provide a nationwide education on the risk factors that predispose babies to brachial plexus birth palsy. There is also the need for frequent antenatal visit by pregnant women; this will help in the provision of best antenatal history, diagnostic investigation in determining the birth weight and safe mode of delivery.

The Association of Clavicle Fracture With Brachial Plexus Birth Palsy

PURPOSE

Shoulder dystocia is the strongest known risk factor for brachial plexus birth palsy (BPBP). Fractures of the clavicle are known to occur in the setting of shoulder dystocia. It remains unknown whether a clavicle fracture that occurs during a birth delivery with shoulder dystocia increases the risk of BPBP or, alternatively, is protective. The purpose of this study was to use a large, national database to determine whether a clavicle fracture in the setting of shoulder dystocia is associated with an increased or decreased risk of BPBP.

MATERIALS AND METHODS

The 1997 to 2012 Kids' Inpatient Database (KID) was analyzed for this study. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify newborns diagnosed with shoulder dystocia and BPBP as well as a concurrent fracture of the clavicle. Newborns with shoulder dystocia were stratified into 2 groups: dystocia without a clavicle fracture and dystocia with a clavicle fracture. Multivariable logistic regression was used to quantify the risk for BPBP among shoulder dystocia subgroups.

RESULTS

The dataset included 5,564,628 sample births extrapolated to 23,385,597 population births over the 16-year study period. A BPBP occurred at a rate of 1.2 per 1,000 births. Shoulder dystocia complicated 18.8% of births with a BPBP. A total of 7.84% of newborns with a BPBP also sustained a clavicle fracture. Births with shoulder dystocia and a clavicle fracture incurred BPBP at a rate similar to that for newborns with shoulder dystocia and no fracture (9.82% vs 11.77%). Shoulder dystocia without a concurrent clavicle fracture was an independent risk factor for BPBP (odds ratio, 112.1; 95% confidence interval, 103.5-121.4). Those with shoulder dystocia and clavicle fracture had a risk for BPBP comparable with those with shoulder dystocia but no fracture (odds ratio, 126.7 vs 112.1).

CONCLUSIONS

This population-level investigation suggests that, among newborns with shoulder dystocia, clavicle fracture is not associated with a significant change in the risk of BPBP.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

BACKGROUND

In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee.

AIMS

To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event.

MATERIALS AND METHODS

Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens.

RESULTS

Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation.

CONCLUSIONS

There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Accuracy of immediate antepartum ultrasound estimated fetal weight and its impact on mode of delivery and outcome - a cohort analysis

Background

The aim of the study was to investigate the accuracy of ultrasound-derived estimated fetal weight (EFW) and to determine its impact on management and outcome of delivery.

Methods

In this single-center cohort analysis, women with a singleton term pregnancy in the beginning stages of labor were included. Women with immediately antepartum EFW (N = 492) were compared to women without ultrasound (N = 515).

Results

EFW was correct (deviation from birth weight ≤ 10%) in 72.2% (355/492) of patients with fetal biometry; 19.7% (97/492) were underestimated, and 8.1% (40/492) were overestimated. Newborns with a lower birth weight were more frequently overestimated, and newborns with higher birth weight were more frequently underestimated. The mean difference between EFW and real birth weight was − 114.5 g (standard deviation ±313 g, 95% confidence interval 87.1–142.0). The rate of non-reassuring fetal heart tracing (9.8% vs. 1.9%, P < 0.001) and of caesarean delivery (9.1% vs. 5.0%, P = 0.013) was higher in women with EFW. Overestimation was associated with an increased risk for delivery by caesarean section (odds ratio 2.80; 95% confidence interval 1.2–6.5, P = 0.017). After adjustment, EFW remained associated with increased non-reassuring fetal heart tracing (odds ratio 4.73; 95% confidence interval 2.3–9.6) and caesarean delivery (odds ratio 1.86; 95% confidence interval 1.1–3.1). The incidence of perineal tears of grade 3/4, shoulder dystocia, postnatal depression and neonatal acidosis did not differ between groups.

Conclusions

Antepartum ultrasound-derived EFW does not improve maternal and fetal outcome and is therefore not recommended.

Sonographic Estimated Fetal Weight among Diabetics at ≥ 34 Weeks and Composite Neonatal Morbidity

Objectives  The objective was to assess the composite neonatal morbidity (CNM) among diabetic women with sonographic estimated fetal weight (SEFW) at 10 to 90th versus >90th percentile for gestational age (GA). Study Design  The inclusion criteria for this retrospective study were singleton pregnancies at 34 to 41 weeks, complicated by diabetes, and that had SEFW within 4 weeks of delivery. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated. Results  Among the 140 cohorts that met the inclusion criteria, 72% had SEFW at 10th to 90th percentile for GA, and 28% at >90th percentile. Compared with women with diabetes with last SEFW at 10th to 90th percentile, those with estimate > 90th percentile for GA had a significantly higher rate of CNM (13 vs. 28%; OR, 2.65; 95% CI, 1.07-6.59). Among 109 diabetic women who labored, the rate of shoulder dystocia was significantly higher with SEFW at >90th percentile for GA than those at 10th to 90th percentile (25 vs. 2%; p  = 0.002); the corresponding rate of CNM was 29 versus 10% ( p  = 0.02). Conclusion  Among diabetic women with SEFW > 90th percentile for GA, CNM was significantly higher than in women with estimate at 10 to 90th percentile. Despite the increased risk of CNM, these newborns did not have long-term morbid sequela.

Mechanical birth-related trauma to the neonate: An imaging perspective

Mechanical birth-related injuries to the neonate are declining in incidence with advances in prenatal diagnosis and care. These injuries, however, continue to represent an important source of morbidity and mortality in the affected patient population. In the United States, these injuries are estimated to occur among 2.6% of births. Although more usual in context of existing feto-maternal risk factors, their occurrence can be unpredictable. While often superficial and temporary, functional and cosmetic sequelae, disability or even death can result as a consequence of birth-related injuries. The Agency for Healthcare research and quality (AHRQ) in the USA has developed, through expert consensus, patient safety indicators which include seven types of birth-related injuries including subdural and intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, peripheral and cranial nerve injuries and other types of specified and non-specified birth trauma. Understandably, birth-related injuries are a source of great concern for the parents and clinician. Many of these injuries have imaging manifestations. This article seeks to familiarize the reader with the clinical spectrum, significance and multimodality imaging appearances of neonatal multi-organ birth-related trauma and its sequelae, where applicable.

Teaching points

• Mechanical trauma related to birth usually occurs with pre-existing feto-maternal risk factors.

• Several organ systems can be affected; neurologic, musculoskeletal or visceral injuries can occur.

• Injuries can be mild and transient or disabling, even life-threatening.

• Imaging plays an important role in injury identification and triage of affected neonates.

Strategies to Improve Management of Shoulder Dystocia Under the AHRQ Safety Program for Perinatal Care

OBJECTIVE

To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units.

DESIGN

Mixed-methods implementation evaluation.

SETTING/LOCAL PROBLEM

Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action.

PARTICIPANTS

Key informants were labor and delivery unit staff who implemented SPPC safety strategies.

INTERVENTION/MEASUREMENTS

The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation.

RESULTS

Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation.

CONCLUSION

Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.

Sonographic Examination of The Fetus Vis-à-Vis Shoulder Dystocia: A Vexing Promise

Since antepartum and intrapartum risk factors are poor at identifying women whose labor is complicated by shoulder dystocia, sonographic examination of the fetus holds promise. Though there are several measurements of biometric parameters to identify the parturient who will have shoulder dystocia, none are currently clinically useful. Three national guidelines confirm that sonographic measurements do not serve as appropriate diagnostic tests to identify women who will have shoulder dystocia with or without concurrent injury. In summary, biometric measurements of the fetus should not be used to alter clinical management with the aim of averting shoulder dystocia.

Implementation of a multicenter shoulder dystocia injury prevention program

Although the evidence for supporting the effectiveness of many patient safety practices has increased in recent years, the ability to implement programs to positively impact clinical outcomes across multiple institutions is lagging. Shoulder dystocia simulation has been shown to reduce avoidable patient harm. Neonatal injury from shoulder dystocia contributes to a significant percentage of liability claims. We describe the development and the process of implementation of a shoulder dystocia simulation program across five academic medical centers and their affiliated hospitals united by a common insurance carrier. Key factors in successful roll out of this program included the following: involvement of physician and nursing leadership from each academic medical center; administrative and logistic support from the insurer; development of consensus on curriculum components of the program; conduct of gap and barrier analysis; financial support from insurer to close necessary gaps and mitigate barriers; and creation of dashboards and tracking performance of the program.

Shoulder Dystocia: Quality, Safety, and Risk Management Considerations

Shoulder dystocia is a term that evokes terror and fear among many physicians, midwives, and health care providers as they recollect at least 1 episode of shoulder dystocia in their careers. Shoulder dystocia can result in significant maternal and neonatal complications. Because shoulder dystocia is an urgent, unanticipated, and uncommon event with potentially catastrophic consequences, all practitioners and health care teams must be well-trained to manage this obstetric emergency. Preparation for shoulder dystocia in a systematic way, through standardization of process, practicing team-training and communication, along with technical skills, through simulation education and ongoing quality improvement initiatives will result in improved outcomes.

Effect of high-fidelity shoulder dystocia simulation on emergency obstetric skills and crew resource management skills among residents

OBJECTIVE

To determine the effect of a simulation training program for residents in obstetrics and gynecology in terms of technical and nontechnical skills for the management of shoulder dystocia.

METHODS

A prospective study was performed at a center in Italy in April-May 2015. Thirty-two obstetrics and gynecology residents were divided into two groups. Residents in the control group were immediately exposed to an emergency shoulder dystocia scenario, whereas those in the simulation group completed a 2-hour training session with the simulator before being exposed to the scenario. After 8weeks, the residents were again exposed to the shoulder dystocia scenario and reassessed. Participants were scored on their demonstration of technical and nontechnical skills.

RESULTS

In the first set of scenarios, the mean score was higher in the simulation group than the control group in terms of both technical skills (P=0.008) and nontechnical skills (P<0.001). This difference was retained after 8weeks.

CONCLUSION

High-fidelity simulation programs could be used for the training of residents in obstetrics and gynecology to diagnose and manage obstetric emergencies such as shoulder dystocia.

The role of episiotomy in prevention and management of shoulder dystocia: a systematic review

IMPORTANCE

Shoulder dystocia is an obstetric emergency with potential catastrophic outcomes.

OBJECTIVE

To perform a systematic literature review examining the effectiveness of episiotomy in the prevention and management of shoulder dystocia during vaginal birth.

EVIDENCE ACQUISITION

Search was conducted by a research librarian in MEDLINE, Web of Science, Cochrane Library, and SCOPUS databases using the terms "episiotomy" and "shoulder dystocia," with no language or time restrictions. Two investigators independently selected original researches examining the effects of episiotomy on shoulder dystocia and its neonatal andmaternal outcomes. Relevant articles were accessed in full text, including manual search of the references. We contacted authors of studies with insufficient or unclear data. Because of clinical and methodological diversity of the studies, meta-analysis was not performed.

RESULTS

Fourteen articles met the inclusion criteria, encompassing a total of 9769 shoulder dystocia cases. Only 1 study effectively evaluated the role of episiotomy in shoulder dystocia prevention, yielding a nonsignificant result. Three articles assessed neonatal consequences of shoulder dystocia, one of them linking episiotomy to higher risk of neonatal injury. Two of the 3 studies evaluating maternal outcomes showed that episiotomy is related to increased risk of advanced perineal tears. Overall quality of evidence was rated as very low.

CONCLUSIONS AND RELEVANCE

Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue.

[The Jacquemier's maneuver: An overview of midwives knowledge and practices in a third level maternity hospital]

OBJECTIVES

Shoulder dystocia is an uncommon but serious complication occurring in 0.2 to 3% of deliveries. We carried out a study in order to assess the midwives experience, knowledge and practices on shoulder dystocia, at the maternity hospital of Saint-Denis, Reunion Island.

METHODS

The first part is a confidential questionnaire addressed to midwives working in the delivery unit. The second part is a retrospective desk review of shoulders dystocia which occurred from 2004 to 2014.

RESULTS

(1) The population was made up of 28 midwives, having between 1 to 27 years of experience. Seventy-five percent of them had been faced with shoulder dystocia, and 62% had realized Jacquemier's maneuver. However, only 25% received this maneuver training. Less than a third of them answered correctly to at least 7 from the 8 theoretical questions about the Jacquemier's maneuver. (2) We studied 34 shoulders dystocia, occurring between 36+5 to 41+2 gestational weeks, mostly with no risk factors found. Mac Roberts' maneuver is used as first-line in 88% of situations. Jacquemier's maneuver is used in 52.9% of cases (5.9% as first-line, 47% as second-line). In 26.4% of situations, the midwife is not able to reduce the dystocia. She usually carries out a combination of maneuvers. The gynecologist is asked only for 23.5% of dystocia and he usually uses Jacquemier's maneuver (70% of situations).

CONCLUSION

The Jacquemier's maneuver is rarely practiced (uncommon situation, lack of training). Simulation trainings should be put in place, because neonatal sequels can be avoided.

Shoulder dystocia in primary midwifery care in the Netherlands

INTRODUCTION

In the Netherlands, low-risk pregnancies are managed by midwives in primary care. Despite strict definitions of low risk, obstetric complications can occur. Midwives seldom encounter uncommon labour complications, but are sufficiently trained to manage these. We assessed neonatal and maternal outcome after management of shoulder dystocia in primary midwifery care.

MATERIALS AND METHODS

In this 2-year prospective cohort study from April 2008 to April 2010, primary-care midwives, who participated in an obstetric emergency course, reported all obstetric complications. Main outcome was neonatal and maternal outcome.

RESULTS

In sixty-four cases of shoulder dystocia McRoberts was the first maneuver in 42/64 (65.6%) cases with a success rate of 23.8%. All-fours maneuver was most frequently used as the second maneuver (24/45; 53.3%). No neonatal mortality occurred, none of the infants suffered from hypoxic ischemic injury, two (3.1%) had transient brachial plexus injuries, two (3.1%) had fractured clavicles and one (1.6%) had a fractured humerus. Eight (12.5%) neonates were successfully resuscitated because of birth asphyxia. All infants fully recovered. In neonates with immediate adverse outcome significantly more maneuvers were used compared with those without adverse neonatal outcome (p = 0.02). Postpartum hemorrhage occurred in 2/64 (3.1%) women, deep vaginal lacerations in 2/64 (3.1%), perineal tears in 23/64 (35.9%). No anal sphincter injuries occurred.

CONCLUSIONS

McRoberts and all-fours maneuvers are widely used by primary-care midwives in the management of shoulder dystocia. Low rates of adverse neonatal and maternal outcomes were observed in cases of shoulder dystocia up to 6 weeks postpartum.

Clinical assessment of the infant and child following perinatal brachial plexus injury

STUDY DESIGN

Literature review.

INTRODUCTION

After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome.

PURPOSE

To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians.

METHODS

We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians.

DISCUSSION

With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.