Shoulder dystocia by severity in families: A nationwide population study

INTRODUCTION

Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are scarce. It is unknown if shoulder dystocia tends to be passed on between generations. We aimed to assess the recurrence risk of shoulder dystocia by severity in the same woman and between generations on both the maternal and paternal side. We also assessed the likelihood of a second delivery and planned cesarean section after shoulder dystocia.

MATERIAL AND METHODS

This was a population-based cohort study, using data from the Medical Birth Registry of Norway. To study recurrence in the same mother, we identified 1 091 067 pairs of first and second, second and third, and third and fourth births in the same mother. To study intergenerational recurrence, we identified an individual both as a newborn and as a mother or father in 824 323 mother-offspring pairs and 614 663 father-offspring pairs. We used Bayesian log-binomial multilevel regression to calculate relative risks (RR) with 95% credible intervals.

RESULTS

In subsequent deliveries in the same woman the unadjusted RR of recurrence was 7.05 (95% credible interval 6.39-7.79) and 2.99 (2.71-3.31) after adjusting for possible confounders, including current birthweight. The RRs were higher with severe shoulder dystocia as exposure or outcome. With severe shoulder dystocia as both exposure and outcome, unadjusted and adjusted RR was 20.42 (14.25-29.26) and 6.29 (4.41-8.99), respectively. Women with severe and mild shoulder dystocia and those without had subsequent delivery rates of 71.1, 68.9 and 69.0%, respectively. However, the rates of planned cesarean section in subsequent deliveries for those without shoulder dystocia, mild and severe were 1.3, 5.2 and 16.0%, respectively. On the maternal side the unadjusted inter-generational RR of recurrence was 2.82 (2.25-3.54) and 1.41 (1.05-1.90) on the paternal side. Corresponding adjusted RRs were 1.90 (1.51-2.40) and 1.19 (0.88-1.61), respectively.

CONCLUSIONS

We found a strong recurrence risk of shoulder dystocia, especially severe, in subsequent deliveries in the same woman. The inter-generational recurrence risk was higher on the maternal than paternal side. Women with a history of shoulder dystocia had more often planned cesarean section.

Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study

INTRODUCTION

Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries.

MATERIAL AND METHODS

The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery.

RESULTS

During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery.

CONCLUSIONS

The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.

Predictors of maternal and neonatal outcomes in labors complicated by shoulder dystocia: a comparative analysis

INTRODUCTION

Studies investigating the risk factors associated with unfavorable maternal/neonatal outcomes in cases of shoulder dystocia are scarce. This study aims to uncover the predictive factors that give rise to unfavorable outcomes within the context of shoulder dystocia.

MATERIALS AND METHODS

Medical records of pregnancies complicated by shoulder dystocia was obtained between 2008-2022 from a single tertiary center. This study involved the comparison of sociodemographic, sonographic, and delivery characteristics among pregnancies complicated by shoulder dystocia resulting in favorable vs. unfavorable maternal/neonatal outcomes.

RESULTS

A total of 275 pregnancies were analyzed, with 111 (40.3%) classified as unfavorable outcomes and 164 (59.7%) as favorable outcomes. Employing a multivariable regression analysis, several independent associations were identified with unfavorable maternal/neonatal outcomes. Specifically, short maternal stature, pre-gestational diabetes, vacuum extraction, Wood's screw maneuver, and macrosomia merged as significant predictors of unfavorable maternal/neonatal outcomes.

CONCLUSION

Short maternal stature, pre-gestational diabetes, vacuum extraction, Wood's screw maneuver, and macrosomia may all contribute to poor maternal/neonatal outcomes in shoulder dystocia cases. This knowledge allows clinicians to improve their decision-making, patient care, and counseling.

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.

Association between Diabetes in Pregnancy and Shoulder Dystocia by Infant Birth Weight in an Era of Cesarean Delivery for Suspected Macrosomia

OBJECTIVE

 We estimated the association between diabetes and shoulder dystocia by infant birth weight subgroups (<4,000, 4,000-4,500, and >4,500 g) in an era of prophylactic cesarean delivery for suspected macrosomia.

STUDY DESIGN

 A secondary analysis from the National Institute of Child Health and Human Development U.S. Consortium for Safe Labor of deliveries at ≥24 weeks with a nonanomalous, singleton fetus with vertex presentation undergoing a trial of labor. The exposure was either pregestational or gestational diabetes compared with no diabetes. The primary outcome was shoulder dystocia and secondarily, birth trauma with a shoulder dystocia. We calculated adjusted risk ratios (aRRs) with modified Poison's regression between diabetes and shoulder dystocia and the number needed to treat (NNT) to prevent a shoulder dystocia with cesarean delivery.

RESULTS

 Among 167,589 assessed deliveries (6% with diabetes), pregnant individuals with diabetes had a higher risk of shoulder dystocia at birth weight <4,000 g (aRR: 1.95; 95% confidence interval [CI]: 1.66-2.31) and 4,000 to 4,500 g (aRR: 1.57; 95% CI: 1.24-1.99), albeit not significantly at birth weight >4,500 g (aRR: 1.26; 95% CI: 0.87-1.82) versus those without diabetes. The risk of birth trauma with shoulder dystocia was higher with diabetes (aRR: 2.29; 95% CI: 1.54-3.45). The NNT to prevent a shoulder dystocia with diabetes was 11 and 6 at ≥4,000 and >4,500 g, versus without diabetes, 17 and 8 at ≥4,000 and >4,500 g, respectively.

CONCLUSION

 Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered. Guidelines providing the option of cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.

KEY POINTS

· >Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered.. · Cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.. · These findings can inform delivery planning for providers and pregnant individuals with diabetes..

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

BACKGROUND

Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation.

OBJECTIVE

Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05.

RESULTS

Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001).

CONCLUSION

Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

Predictors of shoulder dystocia at the time of operative vaginal delivery: a prospective cohort study

Our aim was to identify factors associated with shoulder dystocia following an attempted operative vaginal delivery (aOVD) in a prospective cohort study and to evaluate whether these factors can be used to accurately predict shoulder dystocia by building a score of shoulder dystocia risk. This was a planned secondary analysis of a prospective cohort study of deliveries with aOVD at term from 2008-2013. Cases were defined as women with shoulder dystocia following an aOVD defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Multivariate logistic regression analyses were performed to determine risk factors for shoulder dystocia. Shoulder dystocia occurred in 57 (2.7%) of the 2118 women included. In the whole cohort, women with shoulder dystocia more often had a history of shoulder dystocia (3.5% vs. 0.2%, p = 0.01), and there was a significant interaction between aOVD and gestational age and the duration of the second stage of labor: women with shoulder dystocia more often had a gestational age > 40 weeks and a second stage of labor longer than 3 h specifically for midpelvic aOVD. In multivariable analysis, a history of shoulder dystocia was the only factor independently associated with shoulder dystocia following aOVD (aOR 27.00, 95% CI 4.10-178.00). The AUC for the receiver operating characteristic curve generated using a multivariate model with term interaction with head station was 0.70 (95% CI 0.62-0.77). The model failed to accurately predict shoulder dystocia.

Antenatal risk score for prediction of shoulder dystocia with focus on fetal ultrasound data

BACKGROUND

Shoulder dystocia is one of the most threatening complications during delivery, and although it is difficult to predict, individual risk should be considered when counseling for mode of delivery.

OBJECTIVE

This study aimed to develop and validate a risk score for shoulder dystocia based on fetal ultrasound and maternal data from 15,000 deliveries.

STUDY DESIGN

Data were retrospectively obtained of deliveries in 3 tertiary centers between 2014 and 2017 for the derivation cohort and between 2018 and 2020 for the validation cohort. Inclusion criteria were singleton pregnancy, vaginal delivery in cephalic presentation at ≥37+0 weeks' gestation, and fetal biometry data available within 2 weeks of delivery. Independent predictors were determined by multivariate regression analysis in the derivation cohort, and a score was developed on the basis of the effect of the predictors.

RESULTS

The derivation cohort consisted of 7396 deliveries with a 0.91% rate of shoulder dystocia, and the validation cohort of 7965 deliveries with a 1.0% rate of shoulder dystocia. Among all women, 13.8% had diabetes mellitus, and 12.1% were obese (body mass index ≥30 kg/m2). Independent risk factors in the derivation cohort were: estimated fetal weight ≥4250 g (odds ratio, 4.27; P=.002), abdominal-head-circumference ≥2.5 cm (odds ratio, 3.96; P<.001), and diabetes mellitus (odds ratio, 2.18; P=.009). On the basis of the strength of effect, a risk score was developed: estimated fetal weight ≥4250 g=2, abdominal-head-circumference ≥2.5 cm=2, and diabetes mellitus=1. The risk score predicted shoulder dystocia with moderate discriminatory ability (area under the receiver-operating characteristic curve, 0.69; P<.001; area under the receiver-operating characteristic curve, 0.71; P<.001) and good calibration (Hosmer-Lemeshow goodness-of-fit; P=.466; P=.167) for the derivation and validation cohorts, respectively. With 1 score point, 16 shoulder dystocia cases occurred in 1764 deliveries, with 0.6% shoulder dystocia incidence and a number needed to treat with cesarean delivery to avoid 1 case of shoulder dystocia of 172 (2 points: 38/1809, 2.1%, 48; 3 points: 18/336, 5.4%, 19; 4 points: 10/96, 10.5%, 10; and 5 points: 5/20, 25%, 4); 40.8% of the shoulder dystocia cases occurred without risk factors.

CONCLUSION

The presented risk score for shoulder dystocia may act as a supplemental tool for the clinical decision-making regarding mode of delivery. According to our score model, in pregnancies with a score ≤2, meaning having solely estimated fetal weight ≥4250 g, or abdominal-head-circumference ≥2.5, or diabetes mellitus, cesarean delivery for prevention of shoulder dystocia should not be recommended because of the high number needed to treat to avoid 1 case of shoulder dystocia. Conversely, in patients with a score of ≥4 with or without diabetes mellitus, cesarean delivery may be considered. However, in 40% of the shoulder dystocia cases, no risk factors had been present.

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).

Antenatal risk prediction of shoulder dystocia: influence of diabetes and obesity: a multicenter study

PURPOSE

To estimate the risk of shoulder dystocia (SD) in pregnancies with/without maternal diabetes or obesity; to identify antenatal maternal and fetal ultrasound-derived risk factors and calculate their contributions.

METHODS

A multicenter retrospective analysis of 13,428 deliveries in three tertiary hospitals (2014-2017) with fetal ultrasound data ≤ 14 days prior to delivery (n = 7396).

INCLUSION CRITERIA

singleton pregnancies in women ≥ 18 years old; vertex presentation; vaginal delivery at ≥ 37 weeks of gestation. Estimated fetal weight (EFW) and birth weight (BW) were categorized by steps of 250 g. To evaluate risk factors, a model was performed using ultrasound data with SD as the dependent variable.

RESULTS

Diabetes was present in 9.3%; BMI ≥ 30 kg/m² in 10.4% and excessive weight gain in 39.8%. The total SD rate was 0.9%, with diabetes 2.0% and with obesity 1.9%. These increased with BW 4250-4499 g compared to 4000-4249 g in women with diabetes (12.1% vs 1.9%, P = 0.010) and without (6.1% vs 1.6%, P < 0.001) and at the same BW threshold for women with obesity (9.6% vs 0.6%, P = 0.002) or without (6.4% vs 1.8%, P < 0.001). Rates increased similarly for EFW at 4250 g and for AC-HC at 2.5 cm. Independent risk factors for SD were EFW ≥ 4250 g (OR 3.8, 95% CI 1.5-9.4), AC-HC ≥ 2.5 cm (OR 3.1, 95% CI 1.3-7.5) and diabetes (OR 2.2, 95% CI 1.2-4.0). HC/AC ratio, obesity, excessive weight gain and labor induction were not significant.

CONCLUSION

Independent of diabetes, which remains a risk factor for SD, a significant increase may be expected if the EFW is ≥ 4250 g and AC-HC is ≥ 2.5 cm.

Diabetic Uterine Environment Leads to Disorders in Metabolism of Offspring

Aims

Research evidence indicates that epigenetic modifications of gametes in obese or diabetic parents may contribute to metabolic disorders in offspring. In the present study, we sought to address the effect of diabetic uterine environment on the offspring metabolism.

Methods

Type 2 diabetes mouse model was induced by high-fat diet combined with streptozotocin (STZ) administration. We maintained other effect factors constant and changed uterine environment by zygote transfers, and then determined and compared the offspring numbers, symptoms, body weight trajectories, and metabolism indices from different groups.

Result

We found that maternal type 2 diabetes mice had lower fertility and a higher dystocia rate, accompanying the increased risk of offspring malformations and death. Compared to only a pre-gestational exposure to hyperglycemia, exposure to hyperglycemia both pre- and during pregnancy resulted in offspring growth restriction and impaired metabolism in adulthood. But there was no significant difference between a pre-gestational exposure group and a no exposure group. The deleterious effects, no matter bodyweight or glucose tolerance, could be rescued by transferring the embryos from diabetic mothers into normal uterine environment.

Conclusion

Our data demonstrate that uterine environment of maternal diabetes makes critical impact on the offspring health.

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m^-2 ); low BMI (<18.5 kg.m^-2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up.

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.

Diabetes, Fetal Demise, and Shoulder Dystocia: The Importance of Glucose Screening to Prevent Catastrophic Obstetric Outcomes

Diabetes is associated with increased risk of stillbirth and shoulder dystocia. Compared with uncomplicated pregnancies, diabetic patients have a 4-6x risk of stillbirth and 2-3x risk of shoulder dystocia. A 34 yo G2P0010 presented with a 40+3 wga IUFD with nonstandard antenatal glucose screening. Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was not relieved by McRoberts, suprapubic pressure, Rubin II, Wood's Screw, or posterior arm delivery. Nitroglycerine was administered, after which Wood's Screw was successful resulting in delivery of an infant weighing 4190 grams (85th percentile for gestational age). A 31 yo G1 presented with a 37+1 wga IUFD. Her 28 wga three-hour GTT was notable for an elevated value at one hour (216 mg/dL). Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was relieved via posterior axillary sling after failure of McRoberts, suprapubic pressure, Rubin II, Wood's Screw, and Gaskin's, resulting in the delivery of an infant weighing 3590 g (92nd percentile for gestational age). We present two cases of severe shoulder dystocia in patients who both presented with term IUFD and diabetic-range hemoglobin A1c. There is minimal literature on diabetic patients with pregnancies affected by both stillbirth and shoulder dystocia. These cases underscore the importance of glucose screening and control to prevent catastrophic obstetric outcomes.

Time and mode of delivery in diabetic pregnancy: a review

The review presents some renewed data on the problem of optimal time and modes of delivery for women with various types of diabetes mellitus (DM 1 and 2, gestational diabetes). The necessity of making the universal delivery strategy algorithm for women with DM comes out of adverse outcomes high frequency, where the main cases are fetal macrosomia, fetal shoulder dystocia and perinatal mortality. Despite significant interest for this issue, there is still no common delivery tactics in the world for pregnant women with carbohydrate metabolism disorders. The main obstacle is evidence-based tests and meta-analysis insufficiency. So far, further studies are necessary to obtain high quality data concerning optimal terms and modes of delivery for women with DM.

Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis

BACKGROUND

A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes.

OBJECTIVE

We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States.

STUDY DESIGN

A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years.

RESULTS

In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time.

CONCLUSION

In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.

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.

Different insulin types and regimens for pregnant women with pre-existing diabetes

BACKGROUND

Insulin requirements may change during pregnancy, and the optimal treatment for pre-existing diabetes is unclear. There are several insulin regimens (e.g. via syringe, pen) and types of insulin (e.g. fast-acting insulin, human insulin).

OBJECTIVES

To assess the effects of different insulin types and different insulin regimens in pregnant women with pre-existing type 1 or type 2 diabetes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 October 2016), ClinicalTrials.gov (17 October 2016), the WHO International Clinical Trials Registry Platform (ICTRP; 17 October 2016), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared different insulin types and regimens in pregnant women with pre-existing diabetes.We had planned to include cluster-RCTs, but none were identified. We excluded quasi-randomised controlled trials and cross-over trials. We included studies published in abstract form and contacted the authors for further details when applicable. Conference abstracts were superseded by full publications.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

The findings in this review were based on very low-quality evidence, from single, small sample sized trial estimates, with wide confidence intervals (CI), some of which crossed the line of no effect; many of the prespecified outcomes were not reported. Therefore, they should be interpreted with caution. We included five trials that included 554 women and babies (four open-label, multi-centre, two-arm trials; one single centre, four-arm RCT). All five trials were at a high or unclear risk of bias due to lack of blinding, unclear methods of randomisation, and selective reporting of outcomes. Pooling of data from the trials was not possible, as each trial looked at a different comparison.1. One trial (N = 33 women) compared Lispro insulin with regular insulin and provided very low-quality evidence for the outcomes. There were seven episodes of pre-eclampsia in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (risk ratio (RR) 0.68, 95% CI 0.35 to 1.30). There were five caesarean sections in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (RR 0.59, 95% CI 0.25 to 1.39). There were no cases of fetal anomaly in the Lispro group and one in the regular insulin group, with no clear difference between the groups (RR 0.35, 95% CI 0.02 to 8.08). Macrosomia, perinatal deaths, episodes of birth trauma including shoulder dystocia, nerve palsy, and fracture, and the composite outcome measure of neonatal morbidity were not reported.2. One trial (N = 42 women) compared human insulin to animal insulin, and provided very low-quality evidence for the outcomes. There were no cases of macrosomia in the human insulin group and two in the animal insulin group, with no clear difference between the groups (RR 0.22, 95% CI 0.01 to 4.30). Perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy and fracture and the composite outcome measure of neonatal morbidity were not reported.3. One trial (N = 93 women) compared pre-mixed insulin (70 NPH/30 REG) to self-mixed, split-dose insulin and provided very low-quality evidence to support the outcomes. Two cases of macrosomia were reported in the pre-mixed insulin group and four in the self-mixed insulin group, with no clear difference between the two groups (RR 0.49, 95% CI 0.09 to 2.54). There were seven cases of caesarean section (for cephalo-pelvic disproportion) in the pre-mixed insulin group and 12 in the self-mixed insulin group, with no clear difference between groups (RR 0.57, 95% CI 0.25 to 1.32). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome measure of neonatal morbidity were not reported.4. In the same trial (N = 93 women), insulin injected with a Novolin pen was compared to insulin injected with a conventional needle (syringe), which provided very low-quality evidence to support the outcomes. There was one case of macrosomia in the pen group and five in the needle group, with no clear difference between the different insulin regimens (RR 0.21, 95% CI 0.03 to 1.76). There were five deliveries by caesarean section in the pen group compared with 14 in the needle group; women were less likely to deliver via caesarean section when insulin was injected with a pen compared to a conventional needle (RR 0.38, 95% CI 0.15 to 0.97). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture, and the composite outcome measure of neonatal morbidity were not reported.5. One trial (N = 223 women) comparing insulin Aspart with human insulin reported none of the review's primary outcomes: macrosomia, perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia. nerve palsy, or fracture, or the composite outcome measure of neonatal morbidity.6. One trial (N = 162 women) compared insulin Detemir with NPH insulin, and supported the outcomes with very low-quality evidence. There were three cases of major fetal anomalies in the insulin Detemir group and one in the NPH insulin group, with no clear difference between the groups (RR 3.15, 95% CI 0.33 to 29.67). Macrosomia, perinatal death, pre-eclampsia, caesarean section, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome of neonatal morbidity were not reported.

AUTHORS' CONCLUSIONS

With limited evidence and no meta-analyses, as each trial looked at a different comparison, no firm conclusions could be made about different insulin types and regimens in pregnant women with pre-existing type 1 or 2 diabetes. Further research is warranted to determine who has an increased risk of adverse pregnancy outcome. This would include larger trials, incorporating adequate randomisation and blinding, and key outcomes that include macrosomia, pregnancy loss, pre-eclampsia, caesarean section, fetal anomalies, and birth trauma.

Intrauterine fetal death and risk of shoulder dystocia at delivery

INTRODUCTION

Vaginal delivery is recommended after intrauterine fetal death. However, little is known about the risk of shoulder dystocia in these deliveries. We studied whether intrauterine fetal death increases the risk of shoulder dystocia at delivery.

MATERIAL AND METHODS

In this population-based register study using the Medical Birth Registry of Norway, we included all singleton pregnancies with vaginal delivery of offspring in cephalic presentation in Norway during the period 1967-2012 (n = 2 266 118). Risk of shoulder dystocia was estimated as absolute risk (%) and odds ratio with 95% confidence interval. Adjustment was made for offspring birthweight (in grams). We performed sub-analyses within categories of birthweight (<4000 and ≥4000 g) and in pregnancies with maternal diabetes.

RESULTS

Shoulder dystocia occurred in 1.1% of pregnancies with intrauterine fetal death and in 0.8% of pregnancies without intrauterine fetal death (p < 0.0001) (crude odds ratio 1.5, 95% confidence interval 1.2-4.9). After adjustment for birthweight, the odds ratio was 5.9 (95% confidence interval 4.7-7.4). In pregnancies with birthweight ≥4000 g, shoulder dystocia occurred in 14.6% of pregnancies with intrauterine fetal death and in 2.8% of pregnancies without intrauterine fetal death (p < 0.001) (crude odds ratio 5.9, 95% confidence interval 4.5-7.9). In pregnancies with birthweight ≥4000 g and concurrent maternal diabetes, shoulder dystocia occurred in 57.1% of pregnancies with intrauterine fetal death and 9.6% of pregnancies without intrauterine fetal death (p < 0.001) (crude odds ratio 12.6, 95% confidence interval 5.9-26.9).

CONCLUSIONS

Intrauterine fetal death increased the risk of shoulder dystocia at delivery, and the absolute risk of shoulder dystocia was particularly high if offspring birthweight was high and the mother had diabetes.

[Epidemiology of shoulder dystocia]

OBJECTIVES

To synthetize the available evidence regarding the incidence and risk factors of shoulder dystocia (SD).

METHODS

Consultation of the Medline database, and of national guidelines.

RESULTS

Shoulder dystocia is defined as a vaginal delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed. With this definition, the incidence of SD in population-based studies is about 0.5-1% of vaginal deliveries. Many risk factors have been described but most associations are not independent, or have not been constantly found. The 2 characteristics consistently found as independent risk factors for SD in the literature are previous SD (incidence of SD of about 10% in parturients with previous SD) and foetal macrosomia. Maternal diabetes and obesity also are associated with a higher risk of SD (2 to 4 folds) but these associations may be completely explained by foetal macrosomia. However, even factors independently and constantly associated with SD do not allow a valid prediction of SD because they are not discriminant; 50 to 70% of SD cases occur in their absence, and the great majority of deliveries when they are present is not associated with SD.

CONCLUSION

Shoulder dystocia is defined by the need for additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed, and complicates 0.5-1% of vaginal deliveries. Its main risk factors are previous SD and macrosomia, but they are poorly predictive. SD remains a non-predictable obstetrics emergency. Knowledge of SD risk factors should increase the vigilance of clinicians in at-risk contexts.

[Assessment of shoulder dystocia related knowledge among French obstetrics and gynecology residents]

OBJECTIVE

To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD).

MATERIALS AND METHODS

Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics.

RESULTS

Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied.

CONCLUSION

Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.

Fetal sonographic characteristics associated with shoulder dystocia in pregnancies of women with type 1 diabetes

INTRODUCTION

Shoulder dystocia is a rare but severe complication of vaginal delivery and diabetic women are at high risk. The aim of this study was to identify fetal sonographic and maternal glycemic characteristics associated with shoulder dystocia in pregnant women with type 1 diabetes.

MATERIAL AND METHODS

Twelve cases (5%) of shoulder dystocia among 241 consecutive vaginal deliveries in women with type 1 diabetes followed at Rigshospitalet University Hospital in 2009-2013 were retrospectively identified in a local database. Fetal sonographic and clinical data were compared with 69 women with type 1 diabetes and uncomplicated vaginal deliveries.

RESULTS

Women experiencing shoulder dystocia compared with women with uncomplicated deliveries had a higher glycated hemoglobin (HbA1c) in early pregnancy [median 7.0% (range 5.9-8.1) vs. 6.6% (range 5.4-10.0, P = 0.04)], whereas in late pregnancy, HbA1c in the two groups of women was comparable [6.1% (range 5.5-6.9) vs. 6.0% (range 4.7-8.4, P = 0.30)]. Fetal biometry at 36 weeks showed a higher estimated fetal weight of 3597 g (range 3051-4069) vs. 2989 g (range 2165-4025), P < 0.001, corresponding to 20% (4-41%) vs. 5% (-20 to 44%) above the mean estimated fetal weight for gestational age (P = 0.002) and a greater abdominal circumference SD score of 2.51 (range 1.56-4.20) vs. 1.33 (range -1.08 to 4.25), P = 0.001). Head circumference was comparable. Vacuum extraction was more frequent during deliveries with shoulder dystocia (58 vs. 17%, P = 0.005). Seven (58%) newborns with shoulder dystocia had brachial plexus injuries, fractures, intra-abdominal bleeding or needed resuscitation.

CONCLUSIONS

Excessive estimated fetal weight and abdominal circumference at 36 weeks' sonographic examination may help in identifying diabetic women at high risk of later shoulder dystocia.

Cerebral Palsy after Neonatal Encephalopathy: How Much Is Preventable?

OBJECTIVES

To determine the expected proportion of term cerebral palsy (CP) after neonatal encephalopathy (NE) that could theoretically be prevented by hypothermia and elucidate the perinatal factors associated with CP after NE in those who do not meet currently used clinical criteria required to qualify for hypothermia ("cooling criteria").

STUDY DESIGN

Using the Canadian CP Registry, we categorized children born at ≥ 36 weeks with birth weight ≥ 1800 g with CP after moderate or severe NE according to the presence or absence of cooling criteria. Maternal, perinatal, postnatal, and placental factors were compared between the 2 groups. A number needed to treat of 8 (95% CI 6-17) to prevent one case of CP was used for calculations.

RESULTS

Among the 543 term-born children with CP, 155 (29%) had moderate or severe NE. Sixty-four of 155 (41%) met cooling criteria and 91 of 155 (59%) did not. Shoulder dystocia was more common in those who did not meet cooling criteria (OR 8.8; 95% CI 1.1-71.4). Low birth weights (20% of all singletons), small placentas (42%), and chorioamnionitis (13%) were common in both groups.

CONCLUSIONS

The majority of children with CP after NE did not meet cooling criteria. An estimated 5.1% (95% CI 2.4%-6.9%) of term CP after NE may be theoretically prevented with hypothermia. Considering shoulder dystocia as an additional criterion may help recognize more neonates who could potentially benefit from cooling. In all cases, a better understanding of the antenatal processes underlying NE is essential in reducing the burden of CP.

Intrapartum care and substandard care: juridical recommendations to reduce the risk of liability

PURPOSE

To develop juridical recommendations to reduce medical liability of the obstetrician, providing intrapartum care.

METHODS

107 legal proceedings of the past 40 years from Belgium, France and the Netherlands, involving medical negligence of the obstetrician during intrapartum care, were analyzed in depth. The legal databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (the Netherlands). A minority of the cases were retrieved through contacts with insurance companies (Belgium only) and courts.

RESULTS

The judicial assessment of negligence is focused on four domains of expertise of the obstetrician: 36 % (38/107) recognizing a specific pathology, 33 % (35/107) interpreting fetal monitoring, 19 % (21/107) performing a forceps/vacuum-assisted delivery and 12 % (13/107) managing shoulder dystocia. The highest liability rate of 86 % (30/35) was reflected in the category of interpreting fetal monitoring.

CONCLUSION

To reduce the liability rate of 66 %, several policy recommendations can be made. Respond to the first symptoms of obstetric complications (particularly placental abruption and uterine rupture). Secondly, respond to disturbing messages of the midwife concerning fetal distress and evaluate every deviation in fetal heart rate monitoring. Education concerning the interpretation of fetal monitoring is a must for every midwife and obstetrician. Use proper methods to monitor the heart rate to optimize the quality of the signal. The third recommendation is to be cautious about opting for a forceps/vacuum-assisted delivery, consider all circumstances. Consider the risk of failed instrumental delivery. And finally in relation to shoulder dystocia, recognize the risk factors by ordering further examinations to purchase a diagnosis.

Caregiver's satisfaction with a video tutorial for shoulder dystocia management algorithm

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.

Diabetes in pregnancy: timing and mode of delivery

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the "appropriate" clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman's consent and informed decisions.