Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres: a retrospective review

Maternal and neonatal complications of shoulder dystocia with a focus on obstetric maneuvers: A case-control study of 1103 deliveries

INTRODUCTION

Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates.

MATERIAL AND METHODS

The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized.

RESULTS

Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24).

CONCLUSIONS

The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.

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.

Shoulder Dystocia: A Comprehensive Literature Review on Diagnosis, Prevention, Complications, Prognosis, and Management

The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the "failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head". This means that obstetric interventions are necessary to deliver the fetus's body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality.

A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia

In the management of shoulder dystocia, it is often recommended to start with external maneuvers, such as the McRoberts maneuver and suprapubic pressure, followed by internal maneuvers including rotation and posterior arm delivery. However, this sequence is not based on scientific evidence of its success rates, the technical simplicity, or the related complication rates. Hence, this review critically evaluates the success rate, technique, and safety of different maneuvers. Retrospective reviews showed that posterior arm delivery has consistently higher success rates (86.1%) than rotational methods (62.4%) and external maneuvers (56.0%). McRoberts maneuver was thought to be a simple method, however, its mechanism is not clear. Furthermore, McRoberts position still requires subsequent traction on the fetal neck, which presents a risk for brachial plexus injury. The 2 internal maneuvers have anatomic rationales with the aim of rotating the shoulders to the wider oblique pelvic dimension or reducing the shoulder width. The techniques are not more sophisticated and requires the accoucher to insert the correct hand (according to fetal face direction) through the more spacious sacro-posterior region and deep enough to reach the fetal chest or posterior forearm. The performance of rotation and posterior arm delivery can also be integrated and performed using the same hand. Retrospective studies may give a biased view that the internal maneuvers are riskier. First, a less severely impacted shoulder dystocia is more likely to have been managed by external maneuvers, subjecting more difficult cases to internal maneuvers. Second, neonatal injuries were not necessarily caused by the internal maneuvers that led to delivery but could have been caused by the preceding unsuccessful external maneuvers. The procedural safety is not primarily related to the nature of the maneuvers, but to how properly these maneuvers are performed. When all these maneuvers have failed, it is important to consider the reasons for failure otherwise repetition of the maneuver cycle is just a random trial and error. If the posterior axilla is just above the pelvic outlet and reachable, posterior axilla traction using either the accoucher fingers or a sling is a feasible alternative. Its mechanism is not just outward traction but also rotation of the shoulders to the wider oblique pelvic dimension. If the posterior axilla is at a higher sacral level, a sling may be formed with the assistance of a long right-angle forceps, otherwise, more invasive methods such as Zavanelli maneuver, abdominal rescue, or symphysiotomy are the last resorts.

Studying the Effects of Shoulder Dystocia and Neonate-Focused Delivery Maneuvers on Brachial Plexus Strain: A Computational Study

The purpose of this computational study was to investigate the effects of neonate-focused clinical delivery maneuvers on brachial plexus (BP) during shoulder dystocia. During shoulder dystocia, the anterior shoulder of the neonate is obstructed behind the symphysis pubis of the maternal pelvis, postdelivery of the neonate's head. This is managed by a series of clinical delivery maneuvers. The goal of this study was to simulate these delivery maneuvers and study their effects on neonatal BP strain. Using madymo models of a maternal pelvis and a 90th-percentile neonate, various delivery maneuvers and positions were simulated including the lithotomy position alone of the maternal pelvis, delivery with the application of various suprapubic pressures (SPPs), neonate in an oblique position, and during posterior arm delivery maneuver. The resulting BP strain (%) along with the required maternal delivery force was reported in these independently simulated scenarios. The lithotomy position alone served as the baseline. Each of the successive maneuvers reported a decrease in the required delivery force and resulting neonatal BP strain. As the applied SPP force increased (three scenarios simulated), the required maternal delivery force and neonatal BP strain decreased. A further decrease in both delivery force and neonatal BP strain was observed in the oblique position, with the lowest delivery force and neonatal BP strain reported during the posterior arm delivery maneuver. Data obtained from the improved computational models in this study enhance our understanding of the effects of clinical maneuvers on neonatal BP strain during complicated birthing scenarios such as shoulder dystocia.

Intrauterine fetal death followed by shoulder dystocia and birth by modified posterior axillary sling method: a case report

Background

Various manoeuvres such as McRoberts position, suprapubic pressure, rotational methods, posterior arm extraction and all-four position (HELPERR) have been proposed for relieving shoulder dystocia with variable success. Posterior axillary sling method using a rubber catheter was proposed in 2009 but has not been widely used. We modified this method using ribbon gauzes and a long right-angle forceps and report a successful case.

Case presentation

A 44 years old parity one Chinese woman with a history of a caesarean delivery and poorly controlled type 2 diabetes mellitus was admitted to the Accident and Emergency Department for advanced stage of labour at term. Upon arrival, intrauterine fetal demise was diagnosed with severe asynclitism causing obstruction at the perineum. Episiotomy resulted in birth of the fetal head. The fetal posterior right shoulder, however, remained very high up in the pelvis and HELPERR methods failed to extract the shoulders. We then tied two long ribbon gauzes together, and guided its knot to the anterior aspect of the posterior axilla. By using a long right-angle forceps (24 cm long) to grasp the knot on the posterior side of the axilla and pulling it through, a sling was formed. Traction was then applied through the sling to simultaneously pull and rotate the posterior shoulder. A stillbirth of 3488 g was finally extracted.

Conclusions

We modified the sling method by using two ribbon gauzes, tied together and a right-angle forceps with several advantages. Compared to a rubber catheter, ribbon gauze with a knot can be easily held between the fingers for easy guidance past the fetal axilla. It is also thin, non-elastic and stiff enough to ensure a good grip for traction. The long and slim design of the right-angle forceps makes it easy to pass through a narrow space and reach the axilla high up in the pelvis. We emphasize simultaneous traction and rotation, so that the shoulders are delivered through the wider oblique pelvic outlet dimension.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04126-4.

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia

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.

Shoulder dystocia: incidence, mechanisms, and management strategies

Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts’ position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier’s maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord.

Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study

BACKGROUND

McRoberts' and suprapubic pressure are often recommended as the initial choices of manoeuvres to manage shoulder dystocia, as they are believed to be less invasive compared to other manoeuvres. However, their success rates range from 23 to 40 %. This study aims to investigate the predictive factors for the success of McRoberts' manoeuvre with or without suprapubic pressure (M+/-S).

METHODS

All cases of shoulder dystocia in a tertiary hospital in South East Asia were recruited from 1995 to 2009. Subjects were analysed according to either 'success' or 'failure' of M+/-S. Maternal and fetal antenatal and intrapartum factors were compared by univariate and multivariate analysis.

RESULTS

Among 198 cases of shoulder dystocia, M+/-S as the primary manoeuvre was successful in 25.8 %. The other 74.2 % needed either rotational or posterior arm manoeuvres or combination of manoeuvres. Instrumental delivery was the single most significant factor associated with an increased risk of failed M+/-S on logistic regression (p < 0.001, OR 4.88, 95 % CI 2.05-11.60). The success rate of M+/-S was only 15.0 % if shoulder dystocia occurred after instrumental delivery but was 47.7 % after spontaneous vaginal delivery.

CONCLUSIONS

When shoulder dystocia occurs after instrumental vaginal delivery, the chance of failure of M+/-S is 85 %, which is 4.7 times higher than that after spontaneous vaginal delivery. Hence all operators performing instrumental delivery should be proficient in performing all manoeuvres to relieve shoulder dystocia when M+/-S cannot do so.

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.

[Management of shoulder dystocia]

OBJECTIVE

The objective of this review is to propose recommendations on the management of shoulder dystocia.

MATERIALS AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted.

RESULTS

In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus).

CONCLUSION

All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation.

Neonatal morbidity associated with shoulder dystocia maneuvers

OBJECTIVE

We sought to examine neonatal morbidity associated with different maneuvers used among term patients who experience a shoulder dystocia.

STUDY DESIGN

We conducted a retrospective cohort study of all women who experienced a clinically diagnosed shoulder dystocia at term requiring obstetric maneuvers at a single tertiary care hospital from 2005 through 2008. We excluded women with major fetal anomaly, intrauterine death, multiple gestation, and preterm. Women exposed to Rubin maneuver, Wood's screw maneuver, or delivery of the posterior arm were compared to women delivered by McRoberts/suprapubic pressure only, which served as the reference group. The primary outcome was a composite morbidity of neonatal injury (defined as clavicular or humeral fracture or brachial plexus injury) and neonatal depression (defined as Apgar <7 at 5 minutes, arterial cord pH <7.1, continuous positive airway pressure use, intubation, or respiratory distress). Logistic regression was used to adjust for nulliparity and duration of shoulder dystocia, defined as time from delivery of fetal head to delivery of shoulders.

RESULTS

Among the 231 women who met inclusion criteria, 135 were delivered by McRoberts/suprapubic pressure alone (57.9%), 83 women were exposed to Rubin maneuver, 53 women were exposed to Wood's screw, and 36 women were exposed to delivery of posterior arm. Individual maneuvers were not associated with composite morbidity, neonatal injury, or neonatal depression after adjusting for nulliparity and duration of shoulder dystocia.

CONCLUSION

We found no association between shoulder dystocia maneuvers and neonatal morbidity after adjusting for duration, a surrogate for severity. Our results demonstrate that clinicians should utilize the maneuver most likely to result in successful delivery.

Neonatal injury at cephalic vaginal delivery: a retrospective analysis of extent of association with shoulder dystocia

Purpose

To describe the risk factors and labor characteristics of Clavicular fracture (CF) and brachial plexus injury (BPI); and compare antenatal and labor characteristics and prognosis of obstetrical BPI associated with shoulder dystocia with obstetrical BPI not associated with shoulder dystocia.

Methods

This retrospective study consisted of women who gave birth to an infant with a fractured clavicle or BPI between January 2009 and June 2013. Antenatal and neonatal data were compared between groups. The control group (1300) was composed of the four singleton vaginal deliveries that immediately followed each birth injury. A multivariable logistic regression model, with backward elimination, was constructed in order to find independent risk factors associated with BPI and CF. A subgroup analysis involved comparison of features of BPI cases with or without associated shoulder dystocia.

Results

During the study period, the total number of vaginal deliveries was 44092. The rates of CF, BPI and shoulder dystocia during the study period were 0,6%, 0,16% and 0,29%, respectively. In the logistic regression model, shoulder dystocia, GDM, multiparity, gestational age >42 weeks, protracted labor, short second stage of labor and fetal birth weight greater than 4250 grams increased the risk of CF independently. Shoulder dystocia and protracted labor were independently associated with BPI when controlled for other factors. Among neonates with BPI whose injury was not associated with shoulder dystocia, five (12.2%) sustained permanent injury, whereas one neonate (4.5%) with BPI following shoulder dystocia sustained permanent injury (p = 0.34).

Conclusion

BPI not associated with shoulder dystocia might have a higher rate of concomitant CF and permanent sequelae.

Shoulder dystocia: management and documentation

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing shoulder dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency.

Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends

Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela.

Objective structured assessment of technical skills evaluation of theoretical compared with hands-on training of shoulder dystocia management: a randomized controlled trial

OBJECTIVE

To compare the skills of performing a shoulder dystocia management algorithm after hands-on training compared with demonstration.

METHODS

We randomized medical students to a 30-minute hands-on (group 1) and a 30-minute demonstration (group 2) training session teaching a standardized shoulder dystocia management scheme on a pelvic training model. Participants were tested with a 22-item Objective Structured Assessment of Technical Skills scoring system after training and 72 hours thereafter. Objective Structured Assessment of Technical Skills scores were the primary outcome. Performance time, self-assessment, confidence, and global rating scale were the secondary outcomes. Statistics were performed using Mann-Whitney U test, χ test, and multiple linear regression analysis.

RESULTS

Two hundred three participants were randomized. Objective Structured Assessment of Technical Skills scores were significantly higher in group 1 (n=103) compared with group 2 (n=100) (17.95±3.14 compared with 15.67±3.18, respectively; P<.001). The secondary outcomes global rating scale (GRS; 10.94±2.71 compared with 8.57±2.61, respectively; P<.001), self-assessment (3.15±0.94 compared with 2.72±1.01; P=.002), and confidence (3.72±0.98 compared with 3.34±0.90, respectively; P=.005), but not performance time (3:19±0:48 minutes compared with 3:31±1:05 minutes; P=.1), were also significantly different, favoring group 1. After 72 hours, Objective Structured Assessment of Technical Skills scores were still significantly higher in group 1 (n=67) compared with group 2 (n=60) (18.17±2.76 compared with 14.98±3.03, respectively; P<.001) as were GRS (10.80±2.62 compared with 8.15±2.59; P<.001) and self assessment (SA; 3.44±0.87 compared with 2.95±0.94; P=.003). In a multiple linear regression analysis, group assignment (group 1 compared with 2; P<.001) and sex (P=.002) independently influenced Objective Structured Assessment of Technical Skills scores.

CONCLUSION

Hands-on training helps to achieve a significant improvement of shoulder dystocia management on a pelvic training model.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, NCT01618565.

LEVEL OF EVIDENCE

I.

Use of birth weight threshold for macrosomia to identify fetuses at risk of shoulder dystocia among Chinese populations

OBJECTIVE

To assess the incidence of macrosomia and the influence of birth weight on shoulder dystocia risk among a cohort of Chinese women.

METHODS

A retrospective analysis was conducted of 80953 singleton deliveries recorded at the Prince of Wales Hospital, Hong Kong, between 1995 and 2009. The incidences of macrosomia (birth weight ≥ 4000 g) and shoulder dystocia were assessed by birth weight; risk factors for shoulder dystocia were examined by multiple logistic regression analysis.

RESULTS

The incidence of macrosomia was 3.4%. The overall incidence of shoulder dystocia was 0.3%; however, the incidence rose with increasing birth weight. The odds ratio (OR) for a birth weight of 4000-4199 g was 22.40, while the OR for a birth weight of 4200 g or above was 76.10. Other independent risk factors for shoulder dystocia included instrumental delivery (OR 12.11), short stature (OR 2.16), maternal diabetes mellitus (OR 1.78), and obesity (OR 1.58).

CONCLUSION

Although the overall incidences of macrosomia and shoulder dystocia were low, the risk of shoulder dystocia was strongly linked to increasing birth weight. International guidelines for elective cesarean delivery in suspected cases of macrosomia may not, therefore, apply to Chinese women.

Precipitous and difficult deliveries

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

Planned hospital birth versus planned home birth

BACKGROUND

Observational studies of increasingly better quality and in different settings suggest that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications. This is an update of a Cochrane review first published in 1998.

OBJECTIVES

To assess the effects of planned hospital birth compared with planned home birth in selected low-risk women, assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2012) and contacted editors and authors involved with possible trials.

SELECTION CRITERIA

Randomised controlled trials comparing planned hospital birth with planned home birth in low-risk women as described in the objectives.

DATA COLLECTION AND ANALYSIS

The two review authors as independently as possible assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Two trials met the inclusion criteria but only one trial involving 11 women provided some outcome data and was included. The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn.

AUTHORS' CONCLUSIONS

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. However, the trials show that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new randomised controlled trials.

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

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

Complications of labor and delivery: shoulder dystocia

This article reviews one of the less common but most dreaded complications of labor and delivery, shoulder dystocia, an infrequent but potentially devastating event that results from impaction of the fetal shoulders in the maternal pelvis. Shoulder dystocia occurs most commonly in patients without identified risk factors, and can result in both maternal and fetal morbidity. Because the vast majority of cases of shoulder dystocia are unpredictable, obstetric care providers must be prepared to recognize dystocia and respond appropriately in every delivery. Detailed documentation is essential after any delivery complicated by shoulder dystocia.