Shoulder dystocia: incidence, mechanisms, and management strategies

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.

Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial

This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.

Neonatal birth trauma and associated factors in low and middle-income countries: A systematic review and meta-analysis

Neonatal birth trauma, although it has steadily decreased in industrialized nations, constitutes a significant health burden in low-resource settings. Keeping with this, we sought to determine the pooled cumulative incidence (incidence proportion) of birth trauma and identify potential contributing factors in low and middle-income countries. Besides, we aimed to describe the temporal trend, clinical pattern, and immediate adverse neonatal outcomes of birth trauma. We searched articles published in the English language in the Excerpta Medica database, PubMed, Web of Science, Google, African Journals Online, Google Scholar, Scopus, and in the reference list of retrieved articles. Literature search strategies were developed using medical subject headings and text words related to the outcomes of the study. The Joana Briggs Institute quality assessment tool was employed and articles with appraisal scores of seven or more were deemed suitable to be included in the meta-analysis. Data were analyzed using the random-effect Dersimonian-Laird model. The full search identified a total of 827 articles about neonatal birth trauma. Of these, 37 articles involving 365,547 participants met the inclusion criteria. The weighted pooled cumulative incidence of birth trauma was estimated at 34 per 1,000 live births (95% confidence interval (CI) 30.5 to 38.5) with the highest incidence observed in Africa at 52.9 per 1,000 live births (95% CI 46.5 to 59.4). Being born to a mother from rural areas (odds ratio (OR), 1.61; 95% CI1.18 to 2.21); prolonged labor (OR, 5.45; 95% CI 2.30, 9.91); fetal malpresentation at delivery (OR, 4.70; 95% CI1.75 to 12.26); shoulder dystocia (OR, 6.11; 95% CI3.84 to 9.74); operative vaginal delivery (assisted vacuum or forceps extraction) (OR, 3.19; 95% CI 1.92 to 5.31); and macrosomia (OR, 5.06; 95% CI 2.76 to 9.29) were factors associated with neonatal birth trauma. In conclusion, we found a considerably high incidence proportion of neonatal birth trauma in low and middle-income countries. Therefore, early identification of risk factors and prompt decisions on the mode of delivery can potentially contribute to the decreased magnitude and impacts of neonatal birth trauma and promote the newborn's health.

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.

The proposal of the novel fetal shoulder dystocia graduation: a clinical-based opinion

BACKGROUND

Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to significantly poor perinatal outcome, especially permanent disability or perinatal death.

CONTENT

To better objectify the graduation and to include other important clinical parameters, we believe it is appropriate to present a proposal for a complete perinatal weighted graduation of shoulder dystocia, based on several years of numerous other and our own clinical and forensic studies and thematic biobibliography. Obstetric maneuvers, neonatal outcome, and maternal outcome are three components, which are evaluated according to the severity of 0-4 proposed components. Thus, the gradation is ultimately in four degrees according to the total score: I. degreee, score 0-3: slightly shoulder dystocia with simple obstetric interventions, but without birth injuries; II. degree, score 4-7: mild shoulder dystocia resolved by external, secondary interventions and minor injuries; III. degree, score 8-10: severe shoulder dystocia with severe peripartum injuries; IV. degree, score 11-12: extremely difficult, severe shoulder dystocia with ultima ratio interventions applied and resulting extremely severe injuries with chronic disability, including perinatal death.

SUMMARY

As a clinically evaluated graduation, it certainly has an applicable long-term anamnestic and prognostic component for subsequent pregnancies and access to subsequent births, as it includes all relevant components of clinical forensic objectification.

Newborn screening for Duchenne muscular dystrophy: A two-year pilot study

OBJECTIVE

Duchenne muscular dystrophy (DMD) is an X-linked disorder resulting in progressive muscle weakness and atrophy, cardiomyopathy, and in late stages, cardiorespiratory impairment, and death. As treatments for DMD have expanded, a DMD newborn screening (NBS) pilot study was conducted in New York State to evaluate the feasibility and benefit of NBS for DMD and to provide an early pre-symptomatic diagnosis.

METHODS

At participating hospitals, newborns were recruited to the pilot study, and consent was obtained to screen the newborn for DMD. The first-tier screen measured creatine kinase-MM (CK-MM) in dried blood spot specimens submitted for routine NBS. Newborns with elevated CK-MM were referred for genetic counseling and genetic testing. The latter included deletion/duplication analysis and next-generation sequencing (NGS) of the DMD gene followed by NGS for a panel of neuromuscular conditions if no pathogenic variants were detected in the DMD gene.

RESULTS

In the two-year pilot study, 36,781 newborns were screened with CK-MM. Forty-two newborns (25 male and 17 female) were screen positive and referred for genetic testing. Deletions or duplications in the DMD gene were detected in four male infants consistent with DMD or Becker muscular dystrophy. One female DMD carrier was identified.

INTERPRETATION

This study demonstrated that the state NBS program infrastructure and screening technologies we used are feasible to perform NBS for DMD. With an increasing number of treatment options, the clinical utility of early identification for affected newborns and their families lends support for NBS for this severe disease.

Obstetrics injuries during shoulder dystocia in a tertiary perinatal center

OBJECTIVES

This study will present our results in management of fetal shoulder dystocia with special consideration of maternal and neonatal outcome.

STUDY DESIGN

A retrospective study was performed at a university tertiary perinatal center. The study included data of singleton vaginal term deliveries in the period of 15 years (2006-2020). Analized informations include: obstetrics maternal and neonatal data and outcomes.

RESULTS

This period included 45,687 deliveries with diagnosed shoulder dystocia in 254 (0.7 %) cases in vaginal deliveries. Most of the deliveries were spontaneous births 69.7 %, induced deliveries 30.3 %, 47.2 % primiparas and preexisting or gestational diabetes in 21.7 %. The delivery was managed by vacuum extraction in 13.8 %, mediolateral episiotomy in 48.0 % of births, most of the shoulder dystocia were unilateral anterior, while only two cases were diagnosed as more difficult bilateral and 5 cases were recurrent. 87.4 % cases were resolved by McRobert's maneuver, 7.8 % by Barnum's 3.9 % by Wood's maneuver and one case was managed by Menticoglou and by Bourgoise-Siegemundin maneuver. 4.3 % injuries were classified as OASIS of III/IV degree, early postpartum hemorrhage due in 1.6 %. 54.3 % of newborns were male sex, 61.0 % of newborns had birth weight of above 4000 g (mean 4071 g). Maximal Apgar scores were atributed to 92.5 % in first and to 97.2 % in fifth minute, one case that requaired resuscitation. Clavicle fracture was found in 9.5 %, humerus fracture in 0.4 %, transient form of Duchenne Erb obstetrics brachial palsy was diagnosed in only in 7.5 % newborns, while we have not found any case of permanent brachial palsy.

CONCLUSIONS

Our results confirmed that strategy of prompt identification of shoulder dystocia accompanied by cessation of axial fetal head traction decrease the risk of brachial plexus strain, injury or tear, while performance of exact obstetrical maneuvers resulted in decanceration of fetal shoulders without permanent obstetrics brachial palsy or cerebral morbidity. We think that our good results corelate with our opinion that the performance of external obstetrical manoeuvres should be done without one minute postpone since efforts should be put in sooner shoulder liberation decreasing the time of fetal hypoxia.

Application of natural shoulder delivery combined with free position delivery in maternal delivery

OBJECTIVE

This research was designed to probe into the influences of natural shoulder delivery combined with free position delivery on pregnant outcome and genital tract of puerperants.

METHODS

Totally 128 puerperants who gave birth in our hospital from May 2018 to November 2019 were selected as the research objects. Among them, 66 in traditional position combined with traditional shoulder delivery were assigned to a conventional group (CG), and 62 in free position combined with natural shoulder delivery were assigned to a research group (RG). Their psychological mood, pain degree, pregnancy outcome, labor time, postpartum recovery and genital tract injury were compared.

RESULTS

Compared with the CG, the scores of visual analogue scale (VAS) pain, postpartum self-rating depression scale (SDS) and self-rating anxiety scale (SAS) in the RG during delivery were lower (P<0.05); the first, second, third and total labor stages in the RG were shorter (P<0.05). What's more, in the RG, the incidences of lateral episiotomy, urinary retention, stress urinary incontinence, transit cesarean section, shoulder dystocia and neonatal asphyxia were lower, while the perineum integrity and natural delivery rates were higher (P<0.05); the postpartum height of uterus, lochia discharge and blood loss were lower, while milk yield was higher (P<0.05).

CONCLUSION

Natural shoulder delivery combined with free position delivery can effectively improve the pregnancy outcome, benefit the postpartum recovery, shorten the labor process and reduce the degree of genital tract injury. Hence, it is worthy of clinical application.

Overview of techniques to manage shoulder dystocia during vaginal birth

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

Evaluation of multidisciplinary shoulder dystocia simulation training on knowledge, performance, and documentation

BACKGROUND

Research has shown the utility of simulations involving individuals, yet little data exist on whether communication and documentation are impacted by the integration of all team members into a scenario. In 2018, the obstetrics department at this tertiary hospital began a multidisciplinary team-training simulation for shoulder dystocia. An educational portion was included, teaching a new practice where the provider announces delivery events (head, shoulder, body) to be marked on the delivery record, a standardized approach was introduced, and a pre- and post-simulation test was administered.

OBJECTIVE

In this study, we sought to evaluate the lasting impact of this team-based tool on the outcomes and documentation of shoulder dystocia cases, specifically the recording of the exact shoulder dystocia duration in seconds. Secondary outcomes included evaluation of the documentation of shoulder dystocia maneuvers and a pre- and post-simulation knowledge test. Included in this test were questions from the validated survey, the Safety Attitudes Questionnaire, a tool focused on evaluating team dynamics and communication. It was hypothesized that this simulation would improve communication as shown by sustained improvement in documentation, competence in shoulder dystocia care, and confidence among members of the team as shown by improved scores on the Safety Attitudes Questionnaire.

STUDY DESIGN

This was a retrospective cohort study of shoulder dystocia cases from 2017 and 2019 at a safety-net tertiary care hospital, 1 full year before and after the implementation of a multidisciplinary shoulder dystocia simulation in 2018. Delivery outcomes were compared, documentation of delivery event times was recorded and analyzed, and the delivery note was evaluated using the American College of Obstetricians and Gynecologists guidelines for shoulder dystocia. The surveys from participants were assessed for postsimulation improvement. Categorical variables were analyzed using chi-square tests and continuous variables were compared using Student t tests. Because shoulder dystocia duration is a nonparametric variable, this was compared using a Kruskal-Wallis test.

RESULTS

There were 28 cases in the 2017 cohort and 25 in the 2019 cohort. In the 2017 cohort, 25% of delivery documentation (7 of 25) included the exact shoulder dystocia duration, which increased to 96% (24 of 25) in the 2019 cohort (P<.001). There was no significant impact on the shoulder dystocia duration (P=.163). On average, 2.7 maneuvers were required in the 2017 cohort, which increased to 3.4 maneuvers used in the 2019 cohort, showing a significant increase in the use of shoulder dystocia maneuvers (P=.030). The posttests showed no impact on shoulder dystocia background knowledge (P=.142) or knowledge of risk factors (P=.171) but did show an increased understanding of the definition and performance of shoulder dystocia maneuvers (P=.008). The Safety Attitudes Questionnaire revealed that simulation participants would feel safe being treated by their colleagues with a score of 4.7/5. On the paired responses after the simulation, nurses reported feeling that their input was more highly valued (P=.045), and participants of all disciplines felt they received adequate feedback on their performances (P=.041).

CONCLUSION

A multidisciplinary simulation on shoulder dystocia led to sustained improvement in documentation and shoulder dystocia maneuvers used, suggesting increased comfort with advanced maneuvers. Future studies should evaluate whether multidisciplinary simulations, mimicking the normal delivery team, may lead to other sustained improvements in maternal care.

Childbirth Computational Models: Characteristics and Applications

The biomechanical process of childbirth is necessary to usher in new lives-but it can also result in trauma. This physically intense process can put both the mother and the child at risk of injuries and complications that have life-long impact. Computational models, as a powerful tool to simulate and explore complex phenomena, have been used to improve our understanding of childbirth processes and related injuries since the 1990s. The goal of this paper is to review and summarize the breadth and current state of the computational models of childbirth in the literature-focusing on those that investigate the mechanical process and effects. We first summarize the state of critical characteristics that have been included in computational models of childbirth (i.e., maternal anatomy, fetal anatomy, cardinal movements, and maternal soft tissue mechanical behavior). We then delve into the findings of the past studies of birth processes and mechanical injuries in an effort to bridge the gap between the theoretical, numerical assessment and the empirical, clinical observations and practices. These findings are from applications of childbirth computational models in four areas: (1) the process of childbirth itself, (2) maternal injuries, (3) fetal injuries, and (4) protective measures employed by clinicians during delivery. Finally, we identify some of the challenges that computational models still face and suggest future directions through which more biofidelic simulations of childbirth might be achieved, with the goal that advancing models may provide more efficient and accurate, patient-specific assessment to support future clinical decision-making.

A Forensic Aspect of Fetal Shoulder Dystocia

Fetal shoulder dystocia (FSD) is an unpredictable and critical obstetric intrapartum emergency, where an objective problem is the relationship between the mother's pelvis and the child, i. e., an anthropometric disorder of delivery mechanics and dynamics. It is evident that the need to perform other maneuvers indicates the severity of FSD, which in turn correlates with the consequent iatrogenic injury of the fetus and/or mother. FSD is certainly the most controversial forensic obstetric problem, with the most disputes, compensation for damages due to peripartum injury to the child and/or mother, pain suffered, the need for someone else's care, and permanent disability. Suboptimal procedures and inadequate documentation are factors of forensic risk and subsequent litigations. Prevention of FSD is generally not possible, although good antenatal care can sometimes exclude risky cases of FSD, and some rare, chronic intrauterine disorders can result in orthopedic and neurological sequelae, which is especially important in forensic analysis. Because FSD is largely impossible to predict, it must be viewed as an intrapartum acceptable risk. During childbirth, FSD may compromise the safety of the mother and unborn child, therefore education and skills acquisition are necessary for obstetric work. Risk control, proper procedures, and proper documentation, along with good communication with the pregnant women and their families, significantly reduce litigation procedures.

The second stage of labor

The second stage of labor, from full cervical dilatation to complete birth of the baby or babies, constitutes the time of greatest risk for the baby. Birth attendants at all levels require training in the skills necessary to overcome difficulties that may arise unexpectedly during the second stage, particularly poor progress, shoulder dystocia, and breech birth. The mother should receive emotional support and encouragement to bear down instinctively when she feels the urge to do so, in the position she feels enables her to push most effectively, but not the supine position. The baby's heart rate should be monitored after every second contraction. Recent guidelines such as those of the World Health Organization(WHO) recommend allowing 2-3 h for the second stage of labor. Uterine fundal pressure has not been shown to be effective, and may be dangerous. Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience.

Shoulder Shrug Maneuver to Facilitate Delivery During Shoulder Dystocia

The shoulder shrug maneuver is a simple technique to learn that can aid the obstetrician in the management of shoulder dystocia.

BACKGROUND:

Shoulder dystocia is a potential complication of vaginal delivery that increases the chances of injury to the neonate and the mother. The incidence of dystocia can be up to 3%, and sudden presentation and the lack of reliable predictors make shoulder dystocia a challenge for obstetricians.

TECHNIQUE:

The shoulder shrug technique involves shrugging the posterior shoulder and rotating the head–shoulder unit 180 degrees to resolve the shoulder dystocia.

EXPERIENCE:

We describe successful delivery in three cases of persistent shoulder dystocia using the shoulder shrug technique after the dystocia could not be resolved with McRoberts maneuver.

CONCLUSION:

When successful, the shoulder shrug maneuver may decrease the likelihood of morbidity for the neonate. The technique has resolved dystocia in three cases in which the posterior shoulder could be shrugged. Because it does not take much time to perform the shoulder shrug maneuver, it is worth considering this technique during management of unresolved shoulder dystocia.

Association Analysis of 14 Candidate Gene Polymorphism with Depression and Stress among Gestational Diabetes Mellitus

The association of candidate genes and psychological symptoms of depression, anxiety, and stress among women with gestational diabetes mellitus (GDM) in Malaysia was determined in this study, followed by the determination of their odds of getting psychological symptoms, adjusted for socio-demographical background, maternal, and clinical characteristics. Single nucleotide polymorphisms (SNPs) recorded a significant association between SNP of EPHX2 (rs17466684) and depression symptoms (AOR = 7.854, 95% CI = 1.330–46.360) and stress symptoms (AOR = 7.664, 95% CI = 1.579–37.197). Associations were also observed between stress symptoms and SNP of OXTR (rs53576) and (AOR = 2.981, 95% CI = 1.058–8.402) and SNP of NRG1 (rs2919375) (AOR = 9.894, 95% CI = 1.159–84.427). The SNP of EPHX2 (rs17466684) gene polymorphism is associated with depression symptoms among Malaysian women with GDM. SNP of EPHX2 (rs17466684), OXTR (rs53576) and NRG1 (rs2919375) are also associated with stress symptoms.