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Manske MC, Wilson MD, Wise BL, James MA, Melnikow J, Hedriana HL, Tancredi DJ. Association of Parity and Previous Birth Outcome With Brachial Plexus Birth Injury Risk. Obstet Gynecol 2023; 142:1217-1225. [PMID: 37797333 PMCID: PMC10592124 DOI: 10.1097/aog.0000000000005394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/20/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk. METHODS We conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined. RESULTS Of 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury. CONCLUSIONS Parity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.
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Affiliation(s)
- M. Claire Manske
- Assistant Professor, Department of Orthopaedic Surgery, University of California Davis, Sacramento, California, United States
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California, United States
| | - Machelle D. Wilson
- Principal Biostatistician, Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California, United States
| | - Barton L. Wise
- Professor, Department of Internal Medicine, University of California Davis, Sacramento, California, United States
| | - Michelle A. James
- Assistant Professor, Department of Orthopaedic Surgery, University of California Davis, Sacramento, California, United States
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California, United States
| | - Joy Melnikow
- Professor Emeritus, Department of Family and Community Medicine, University of California Davis, Sacramento, California, United States
| | - Herman L. Hedriana
- Professor and Chief, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of California Davis, Sacramento, California, United States
| | - Daniel J. Tancredi
- Professor in Residence, Department of Pediatrics, University of California Davis, Sacramento, California, United States
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Jaufuraully S, Lakshmi Narasimhan A, Stott D, Attilakos G, Siassakos D. A systematic review of brachial plexus injuries after caesarean birth: challenging delivery? BMC Pregnancy Childbirth 2023; 23:361. [PMID: 37198580 DOI: 10.1186/s12884-023-05696-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 05/10/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. METHODS Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. MAIN RESULTS 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. CONCLUSIONS In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.
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Affiliation(s)
- Shireen Jaufuraully
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| | | | - Daniel Stott
- Elizabeth Garrett Anderson Wing, University College Hospital, London, UK
| | - George Attilakos
- Elizabeth Garrett Anderson Wing, University College Hospital, London, UK
| | - Dimitrios Siassakos
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre (BRC), London, UK
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Diack B, Pierre F, Gachon B. Impact of fetal manipulation on maternal and neonatal severe morbidity during shoulder dystocia management. Arch Gynecol Obstet 2023; 307:501-509. [PMID: 36149510 DOI: 10.1007/s00404-022-06783-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/28/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE There are few data on maternal and neonatal morbidities associated with shoulder dystocia (SD), depending on the use of fetal manipulation (FM). A prior 5-year study was conducted in our center in 2012 for this purpose. Our objective was to compare severe maternal and neonatal morbidities according to FM execution in a larger cohort. METHODS We conducted a retrospective study between 2007 and 2020. SD was considered when additional maneuvers were required to complete a delivery. Severe maternal morbidity was defined as the occurrence of obstetric anal sphincter injury (OASI). Severe neonatal morbidity was defined as Apgar < 7 at 5 min and/or cord arterial pH < 7.1 and/or or a permanent brachial plexus palsy. We studied these data in the FM group compared to the non- FM group. RESULTS FM was associated with increased OASI rates (21.1% vs. 3.8%, OR = 6.72 [2.7-15.8]). We found no significant difference in severe neonatal morbidity. Maternal age > 35 and FM appear to be associated with the occurrence of OASI, with ORa = 13.3 [1.5-121.8] and ORa = 5.3 [2.2-12.8], respectively. FM was the only factor associated with the occurrence of severe neonatal morbidity (ORa = 2.3 [1.1-4.8]. The rate of episiotomy was significantly decreased (20% versus 5% p < 0.05) and there was an increase in the rate of SD managed with FM in our center. CONCLUSION FM is the only factor associated with an increased risk of OASI. In case of failure of non-FM maneuvers, the rapid implementation of FM maneuvers resulted in no difference regarding severe neonatal morbidity.
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Affiliation(s)
- Bineta Diack
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Miletrie, 86000, Poitiers, France.
| | - Fabrice Pierre
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Miletrie, 86000, Poitiers, France
| | - Bertrand Gachon
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Miletrie, 86000, Poitiers, France
- Université de Poitiers, INSERM CIC 1402, CHU de Poitiers, Poitiers, France
- Université de Nantes, EA 4334 MIP, Nantes, France
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McNeely MM, Chang KWC, Smith BW, Justice D, Daunter AK, Yang LJS, McGillicuddy JE. Knowledge of neonatal brachial plexus palsy among medical professionals in North America. Childs Nerv Syst 2021; 37:3797-3807. [PMID: 34406450 DOI: 10.1007/s00381-021-05310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.
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Affiliation(s)
- Molly M McNeely
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Brandon W Smith
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Alecia K Daunter
- Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Pulos N, Shaughnessy WJ, Spinner RJ, Shin AY. Brachial Plexus Birth Injuries: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202106000-00003. [PMID: 34102666 DOI: 10.2106/jbjs.rvw.20.00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births. » The gold standard for predicting the need for early intervention remains serial examination. » Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers. » Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Narendran LM, Mendez-Figueroa H, Chauhan SP, Folh KL, Grobman WA, Chang K, Yang L, Blackwell SC. Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia. J Matern Fetal Neonatal Med 2021; 35:5443-5449. [PMID: 33541167 DOI: 10.1080/14767058.2021.1882982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Leena M Narendran
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kendra L Folh
- Quality and Safety Department, Children's Memorial Herman Hospital, Houston, TX, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - Kate Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Lynda Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Doty MS, Chauhan SP, Chang KWC, Al-Hafez L, McGovern C, Yang LJS, Blackwell SC. Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia. AJP Rep 2020; 10:e42-e48. [PMID: 32140291 PMCID: PMC7056399 DOI: 10.1055/s-0040-1705140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/15/2019] [Indexed: 11/23/2022] Open
Abstract
Objective The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.
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Affiliation(s)
- Morgen S Doty
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Kate W-C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Leen Al-Hafez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas
| | - Connie McGovern
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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Sentilhes L, Madar H, Ducarme G, Hamel JF, Mattuizzi A, Hanf M. Outcomes of operative vaginal delivery managed by residents under supervision and attending obstetricians: a prospective cross-sectional study. Am J Obstet Gynecol 2019; 221:59.e1-59.e15. [PMID: 30807764 DOI: 10.1016/j.ajog.2019.02.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND To assess both severe maternal and neonatal mortality and morbidity after attempted operative vaginal deliveries by residents under supervision and by attending obstetricians. STUDY DESIGN Secondary analysis of a 5-year prospective study with cross-sectional analysis including 2192 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. Obstetricians who attempted or performed an operative vaginal delivery were classified into 2 groups according to their level of experience: attending obstetricians (who had 5 years or more of experience) and obstetric residents (who had less than 5 years of experience) under the supervision of an attending obstetrician. We used multivariate logistic regression and propensity score methods to compare outcomes associated with attending obstetricians and obstetric residents. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesareans, postpartum hemorrhage >1500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, or maternal death; severe neonatal morbidity was defined as a 5-minute Apgar score <7, umbilical artery pH <7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, or neonatal death. RESULTS High prepregnancy body mass index, high dose of oxytocin, manual rotation, persistent occiput posterior or transverse positions, operating room delivery, midpelvic delivery, forceps, and spatulas were significantly more frequent in deliveries managed by attending obstetricians than residents whereas a second-stage pushing phase longer than 30 minutes was significantly more frequent in deliveries managed by residents. The rate of severe maternal morbidity was 7.8% (115/1475) for residents vs 9.9% (48/484) for attending obstetricians; for severe neonatal morbidity, the rates were 8.3% (123/1475) vs 15.1% (73/484), respectively. In the univariate, multivariable, and sensitivity analyses, attempted operative vaginal delivery managed by a resident was significantly and inversely associated with severe neonatal but not maternal morbidity. After propensity score matching, delivery managed by a resident was not significantly associated with severe maternal morbidity (adjusted odds ratio, 0.74; 95% confidence interval, 0.39-1.38) and was no longer associated with neonatal morbidity (adjusted odds ratio, 0.51; 95% confidence interval, 0.25-1.04). CONCLUSION Management of attempted operative vaginal deliveries by residents under the supervision of attending obstetricians, compared with by the attending obstetricians themselves, does not appear to be associated with either maternal or neonatal morbidity. These reassuring results support the continued use of residency programs for training in operative vaginal deliveries under the supervision of attending obstetricians.
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The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors. J Pediatr Orthop 2019; 39:e134-e140. [PMID: 29016426 DOI: 10.1097/bpo.0000000000001089] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The epidemiology of brachial plexus birth palsy (BPBP) in the United States may be changing over time due to population-level changes in obstetric care. METHODS The Kids' Inpatient Database from 1997 to 2012 was analyzed. Annual estimates of BPBP incidence and disease determinant distribution were calculated for the general population and the study population with BPBP. Long-term trends were analyzed. A multivariate logistic regression model was used to quantify the risk associated with each determinant. RESULTS The database yielded a combined total of 5,564,628 sample births extrapolated to 23,385,597 population births. The population incidence of BPBP dropped 47.1% over the 16-year study period, from 1.7 to 0.9 cases per 1000 live births (P<0.001). Female, black, and Hispanic subgroups had moderately increased risks of BPBP. Among children with BPBP, 55.0% had no identifiable risk factor. Shoulder dystocia was the strongest risk factor for BPBP in the regression model [odds ratio (OR), 113.2; P<0.001], although the risk of sustaining a BPBP in the setting of shoulder dystocia decreased from 10.7% in 1997 to 8.3% in 2012 (P=0.006). Birth hypoxia was independently associated with BPBP (OR, 3.1; P<0.001). Cesarean delivery (OR, 0.16; P<0.001) and multiple gestation birth (OR, 0.45; P<0.001) were associated with lower incidence of BPBP. Notably, the rate of cesarean delivery increased by 62.8% during the study period, from 20.9% in 1997 to 34.0% in 2012 (P<0.001). CONCLUSIONS Over a 16-year period, the incidence of BPBP fell dramatically, paralleled by a significant increase in the rate of cesarean delivery. Systemic changes in obstetric practice may have contributed to these trends. As more than half of BPBP cases have no identifiable risk factor, prospective investigation of established risk factors and characterization of new disease determinants are needed to more reliably identify infants at greatest risk. Racial and geographic inequalities in disease burden should be investigated to identify interventional targets. LEVEL OF EVIDENCE Level III-case series.
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