Brachial plexus injuries and shoulder dystocia: Medico-legal commentary and implications

Brachial plexus injuries may occur in association with or without recognised shoulder dystocia. Until recently many medico-legal experts argued that these injuries resulted from the negligent use of excessive or misdirected traction. These experts did not accept that the natural forces of labour could cause the injury. In cases of recognised shoulder dystocia, modern obstetric practice has recognised the importance of correct maternal positioning and the need to avoid excessive or misdirected traction, also the importance of not applying a rotational force to the fetal head. Informed practice and the increased use of caesarean section has not reduced the number of brachial plexus injuries. Judges in two recent trials found that the natural forces of labour were the cause of the injury and that the birth assistants had not caused the damage. This has important implications for medical note writing, teachers and risk managers, medico-legal experts and lawyers.

The negative birth experience of prolonged labour: a case-referent study

AIMS

This study aimed to analyse and describe women's different perceptions and experiences of childbirth following prolonged or normal labour.

BACKGROUND

In clinical practice prolonged labour, or dystocia, is a common delivery complication often causing a negative birth experience.

METHOD

Women giving singleton live birth to their first child with spontaneous labour after more than 37 completed weeks' pregnancy at three hospitals in northern Sweden were recruited to a case-referent study. Cases (n = 84) were women following a prolonged labour with assisted vaginal or abdominal delivery, and referents (n = 171) delivered following a normal labour. Participants completed a questionnaire that investigated childbirth experiences, previous family relationships and childhood experiences.

RESULTS

Women with prolonged labour had a negative childbirth experience more often (34%) than did women who had a normal labour (4%) (P < 0.05). Cases agreed significantly more than the referents with the statement, 'Pain relief during the delivery saved me' (OR 4.5, 95% CI: 1.9-11.1) and 'My difficulties during the delivery will mark me for life' (OR 12.4, 95% CI: 4.4-35.9). There were no differences between the cases and referents regarding perceived experience of professional or social support.

RELEVANCE TO CLINICAL PRACTICE

To improve care, midwives and doctors can alleviate pain and relieve the negativity and difficulty associated with the experience of prolonged labour from the perspective of the woman giving birth.

[Analysis of risk factors for perinatal brachial plexus palsy]

OBJECTIVES AND DESIGN

Risk factors of obstetrical brachial plexus palsy include: (1) large birth weight, (2) shoulder dystocia and prolonged second stage of labour, (3) instrumental vaginal delivery (forceps delivery, vacuum extraction), (4) diabetes mellitus and mother's obesity, (5) breech presentation, (6) delivery and infant with obstetrical brachial plexus palsy in antecedent delivery. The purpose was analysis of the classical risk factors for brachial plexus palsy based on our own clinical material.

MATERIAL AND METHODS

Clinical material consists of 83 children with obstetrical brachial plexus palsy treated at the Department of Trauma and Hand Surgery (surgically--54, conservatively--29). Control group consists of 56 healthy newborns. Data recorded included: birth weight, body length, head and chest circumference, Apgar test at 1 min., type of brachial palsy and side affected, type of birth, presentation, duration of delivery (II stage), age of mother, mother's diseases, parity.

RESULTS

The infants treated surgically have had a significantly higher birth weight, body height, head and chest circumference, in compression with control group and group treated conservatively. The differences were statistically important. Shoulder dystocia occurred in 32.9% of all vaginal delivery. Instrumental vaginal delivery was observed in 11.3% and breech presentation in 4.9% cases. There were no incidences of obstetrical brachial plexus palsy recurrence. Diabetes mellitus and mother's obesity was found in 3 cases.

CONCLUSIONS

(1) Fetal macrosomia is the important risk factor of the obstetrical brachial plexus palsy. (2) Obstetrical brachial plexus palsy may occur also in the absence of the classical risk factors.

A Multicenter Randomized Controlled Trial Comparing Patient-Controlled Epidural with Intravenous Analgesia for Pain Relief in Labor

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 microg/mL (n = 124). There was no difference in the incidence of cesarean delivery-10.2% (12 of 118) versus 9.7% (12 of 124)-or instrumental vaginal delivery-21.2% (25 of 118) versus 29% (36 of 124)-between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

[Obstetrical brachial plexus palsy--etiopathogenesis, risk factors, prevention, prognosis]

Obstetrical brachial plexus palsy (OBP) complicates a small proportion of births. The incidence is believed to be 0.35 to 5 cases per 1000 live births. Risk factors of OBP included: 1/ large birth weight, 2/ shoulder dystocia and prolonged second stage of labour , 3/ instrumental vaginal delivery (forceps delivery, vacuum extraction), 4/ diabetes mellitus and mother's obesity, 5/ breech presentation, 6/ delivery an infant with OBP in an antecedent delivery. Historically, the cause of OBP was excessive lateral traction applied to the fetal head at delivery, in association with anterior shoulder dystocia. Not all cases of brachial plexus palsy are attributable to traction. Brachial plexus injury may be occurring in the absence of shoulder dystocia, in the posterior arm of infants with anterior shoulder dystocia and can be associated with cesarean delivery. Intrauterine factors may play some role in the etiology of the OBP. Many strategies have been proposed to prevent the occurrence of OBP--control of the birth weight, induction of labour, cesarean delivery, intensified management of gestational diabetes. About 10-20% of patients with injuries of the brachial plexus require surgical intervention for optimal results.

Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery

OBJECTIVE

In an effort to reduce shoulder dystocia incidence and morbidity, some obstetricians use prophylactic maternal hip hyperflexion (McRoberts maneuver), with the hope of facilitating delivery and decreasing the traction needed for delivery. The objective of this study was to evaluate whether the delivery force is reduced with the prophylactic McRoberts maneuver in a prospective, objective manner.

STUDY DESIGN

Between April 2002 and July 2003, we randomly assigned multiparous women with term, cephalic singleton gestations to delivery in the lithotomy or McRoberts position. A single physician used a force-measuring system that consisted of a custom glove with force sensors to record the amount of force that was exerted on the fetal head. The primary outcomes of the study were peak force (pounds; highest force needed to accomplish entire delivery), peak force for delivery of anterior shoulder (pounds), and peak force rate (pounds per second; the duration required to reach the peak force).

RESULTS

The peak force was not different between the patients in the lithotomy position (n=13) versus the McRoberts position (n=14; 7.2 +/- 0.8 lbs vs 8.0 +/- 0.7 lbs; P = .5). The peak force for delivery of the anterior shoulder (6.7 +/- 0.8 lbs vs 7.1 +/- 0.7 lbs; P = .7) and peak force rate (32.3 +/- 7.0 lbs/sec vs 29.1 +/- 3.5 lbs/sec; P = .7) were not different between the patients in the lithotomy position versus the McRoberts position, respectively. There was no difference between the groups for gestational age, birth weight, incidence of diabetes mellitus, or operative vaginal delivery. The subjective degree of difficulty of the delivery correlated with the peak force (R2 = 0.53; P = .001).

CONCLUSION

The use of the McRoberts maneuver before clinical diagnosis of shoulder dystocia provides no reduction in the force that is used in traction on the fetal head during vaginal delivery in multiparous patients. The acceptance of this maneuver to be used prophylactically requires re-evaluation.

Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes

OBJECTIVE

In severe shoulder dystocia, when initial maneuvers fail, either episiotomy or fetal manipulation (Rubin, Woods' screw, or posterior arm release) is recommended. We sought to compare maternal and neonatal outcomes between severe shoulder dystocia deliveries managed with episiotomy versus fetal manipulation.

STUDY DESIGN

We identified severe shoulder dystocia deliveries from three databases: all shoulder dystocia deliveries (1993-2003 and 1994-1997) from two teaching institutions and litigated cases of shoulder dystocia-associated permanent brachial plexus palsy from multiple U.S. institutions. Pair-wise comparisons were made among three groups of deliveries: those managed by fetal manipulation without episiotomy (fetal manipulation-only), those managed by episiotomy without fetal manipulation (episiotomy-only), and those managed with both (episiotomy + fetal manipulation). Rates of brachial plexus palsy, neonatal depression, and anal sphincter trauma were compared among groups using chi 2 , with significance at P < .05.

RESULTS

Among episiotomy-only, 13 of 22 (59.1%) sustained brachial plexus palsy, compared with 20 of 57 (35.1%) among fetal manipulation-only (P = .05). Twenty-eight of 48 (58.3%) in episiotomy + fetal manipulation had brachial plexus palsy, which did not differ from episiotomy-only (P = .95) but was higher than fetal manipulation-only (P = .02), suggesting that the addition of episiotomy conferred no benefit in averting neonatal injury. Anal sphincter trauma was significantly more common among episiotomy-only and episiotomy + fetal manipulation, compared with fetal manipulation-only.

CONCLUSION

In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.

Risk factors for umbilical hernia in Holstein heifers during the first two months after birth

OBJECTIVE

To determine risk factors associated with identification of an umbilical hernia during the first 2 months after birth in Holstein heifers.

DESIGN

Case-control study.

ANIMALS

322 Holstein heifers born in a single herd (45 with an umbilical hernia and 277 without).

PROCEDURE

Risk factors that were examined included sire, whether the dam had a history of umbilical hernia, milk yield, duration of gestation, whether the dam had a history of dystocia, whether the heifer had a twin, birth weight, total serum protein concentration, and whether the heifer had an umbilical infection. Logistic regression was used to analyze risk factors.

RESULTS

Heifers born to sires with > or = 3 progeny with an umbilical hernia were 2.31 times as likely to develop an umbilical hernia as were heifers born to sires with < or = 2 progeny with an umbilical hernia. Heifers with umbilical infection were 5.65 times as likely to develop an umbilical hernia as were heifers without umbilical infection.

CONCLUSIONS AND CLINICAL RELEVANCE

Sire and umbilical infection were associated with risk of an umbilical hernia during the first 2 months of life in Holstein heifers. Attributable proportion analysis indicated that the frequency of umbilical hernias in Holstein heifers with umbilical infection would have been reduced by 82% if umbilical infection had been prevented.

Splenic haemorrhage in a newborn as the first manifestation of wandering spleen syndrome

Wandering spleen is an unusual condition in children and is even more rarely diagnosed in the neonatal period. A case of splenic haemorrhage after dystocic birth in a newborn is reported. Before surgery, results of imaging studies were suggestive of a ruptured spleen. On laparotomy, a big haematoma surrounding a wandering spleen was found. Haemorrhage aroused from short splenic arteria. Haemostasia and splenopexy were performed. The spleen proved later to be viable. The authors speculate that the haemorrhage was the first manifestation of the wandering spleen.

[Uterine rupture of the unscarred uterus. About 28 cases]

OBJECTIVES

To determine the etiologic factors explaining the appearance of uterine rupture on unscarred gravid uterus and to value the maternal and foetal prognosis of this complication.

PATIENTS AND METHODS

The authors report a study of 28 cases of uterine rupture on unscarred gravid uterus, recorded between January 1989 and December 1997, at the department of obstetrics and gynecology, Farhat Hached University Hospital, Sousse, Tunisia.

RESULTS

Out of the 72283 deliveries during the study period, there were 28 ruptured uteri of unscarred uterus giving a hospital incidence of one in 2581 deliveries. Multiparity, neglected labour dystocia and obstetric procedure were the common etiologic factors accused in the occurring of this complication. To be added to these factors: the low socio-economic status of the patients and lack of antenatal care. The surgical management was conservative (repair) in 19 cases (67.9%); hysterectomy was indicated in nine cases (32.1%). Maternal and fetal morbidity and mortality were important: we deplore two maternal deaths (7.1%) and seven fetal deaths (24.1%).

DISCUSSION AND CONCLUSION

Uterine rupture on unscarred uterus is a relatively rare complication of the pregnancy. However, its incidence remains high in developing countries. Its occurrence is significantly associated with grandmultiparity, lack of antenatal care and low socio-economic status of the patients.

Uterine rupture: risk factors and pregnancy outcome

OBJECTIVES

This study aimed at determining risk factors and pregnancy outcome in women with uterine rupture.

STUDY DESIGN

We conducted a population-based study, comparing all singleton deliveries with and without uterine rupture between 1988 and 1999.

RESULTS

Uterus rupture occurred in 0.035% (n=42) of all deliveries included in the study (n=117,685). Independent risk factors for uterine rupture in a multivariable analysis were as follows: previous cesarean section (odds ratio [OR]=6.0, 95% CI 3.2-11.4), malpresentation (OR=5.4, 95% CI 2.7-10.5), and dystocia during the second stage of labor (OR=13.7, 95% CI 6.4-29.3). Women with uterine rupture had more episodes of postpartum hemorrhage (50.0% vs 0.4%, P<.01), received more packed cell transfusions (54.8% vs 1.5%, P<.01), and required more hysterectomies (26.2% vs 0.04%, P<.01). Newborn infants delivered after uterine rupture were more frequently graded Apgar scores lower than 5 at 5 minutes and had higher rates of perinatal mortality when compared with those without rupture (10.3% vs 0.3%, P<.01; 19.0% vs 1.4%, P<.01, respectively).

CONCLUSION

Uterine rupture, associated with previous cesarean section, malpresentation, and second-stage dystocia, is a major risk factor for maternal morbidity and neonatal mortality. Thus, a repeated cesarean delivery should be considered among parturients with a previous uterine scar, whose labor failed to progress.

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies

OBJECTIVE

To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies.

METHODS

We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia-related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n=49) were matched 1:1 with cases of transient brachial plexus palsy.

RESULTS

Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519+/-94.3 g versus 4143.6+/-56.5 g, P<.001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures.

CONCLUSION

Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.

Intrapartum risk factors for permanent brachial plexus injury

OBJECTIVE

The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury.

STUDY DESIGN

Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant.

RESULTS

There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured).

CONCLUSION

No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.

Effect of operative vaginal delivery on the outcome of permanent brachial plexus injury

OBJECTIVE

To evaluate whether operative vaginal delivery worsens the extent and/or degree of permanent brachial plexus injury.

STUDY DESIGN

We utilized a dataset (n = 104) of vaginal deliveries resulting in permanent brachial plexus injury that ultimately underwent litigation. We excluded patients on whom neonatal injury information was incomplete (n = 5). Patients who had an operative vaginal delivery (n = 33) were compared with those who did not (n = 66) in regard to neonatal outcome and the location and extent of neurologic injury.

RESULTS

The 2 classes were similar in demographic and obstetric variables. There were no differences in rates of 5-minute Apgar scores < 7 (17.9%, or 5/28, vs. 5.2%, or 3/57, P = .1), complete neurologic injury to the brachial plexus (C5-T1) (39%, or 13/33, vs. 38%, or 25/66; P = 1.0) or avulsion of the nerve roots (44%, or 12/27, vs. 36%, or 18/50; P = .5) between those with operative or spontaneous vaginal delivery.

CONCLUSION

Operative vaginal delivery did not increase the severity of impairment in a dataset of deliveries resulting in permanent brachial plexus injury.

Dam-related effects on heart girth at birth, morbidity and growth rate from birth to 90 days of age in Swedish dairy calves

We investigated the effects of dam-related factors (such as calving performance, milk leakage, diseases, milk production, and somatic-cell count (SCC)) on heart girth at birth and the incidence risk of diarrhoea and respiratory disease during the first 90 days in Swedish dairy calves. The effects of these dam-related factors and environmental and management-related (but not dietary) factors on the calves' growth rate during the first 90 days of life also were analysed. The study used nearly 3,000 heifer calves born in 1998 on 122 farms in the south-west of Sweden. Individual health records were kept by the farmers and visiting project veterinarians. The calf's heart girth was measured at birth and weaning. We used generalised linear mixed models for the size of the calf at birth and growth rate. Variables associated with the heart girth at birth were breed, calving performance, mastitis in the dam in the last 49 days before calving, milk production and parity. Variables associated with the growth rate were breed, calving performance, disease in the calf during its first 90 days of life, heart girth at birth, and housing of calves. The effect of the dam on the relative risk of diarrhoea and/or respiratory disease in the calf was evaluated by a generalised linear mixed model with a logit link. Morbidity in the dam during late pregnancy, retained placenta and SCC were associated with the relative risk of respiratory disease in the calf. None of the explanatory variables (other then breed) was associated with the relative risk of diarrhoea.

Arrest of descent in second stage of labour secondary to macrosomia: a case report

BACKGROUND

Fetal macrosomia, defined as birth weight greater than 4000 g, complicates 10% of pregnancies and is a well-documented cause of prolonged second stage of labour, as well as of arrest of descent of the fetal presenting part.

CASE

A multigravida woman with gestational diabetes mellitus was admitted in labour at term, and progressed to full dilatation. The fetal vertex failed to descend beyond -3 station. An emergency Caesarean section was performed and a 6452 g male infant was delivered.

CONCLUSION

Physicians should be aware of the possibility of macrosomia as the cause of failure of descent in the second stage. A heightened state of suspicion should be maintained, particularly in a multigravida woman with a prior macrosomic baby and the presence of other predisposing factors such as gestational diabetes mellitus.

Spiral fracture of the radius: an unusual case of shoulder dystocia-associated morbidity

BACKGROUND

The most common neonatal complications associated with shoulder dystocia include transient brachial plexus palsy, clavicular fracture, and humeral fracture. Fracture of the fetal radius has not been previously reported.

CASE

We encountered a shoulder dystocia with the fetal head in the right occiput anterior position that necessitated the McRoberts maneuver, suprapubic pressure, the Wood and Rubin maneuvers, and extraction of the posterior fetal arm to effect delivery. The 4610-g infant experienced a spiral fracture of the right (anterior) radius and a fracture of the left (posterior) midhumeral shaft.

CONCLUSION

Neonatal radial fracture can result from shoulder dystocia or the maneuvers employed for the alleviation of the shoulder dystocia.

Local anesthetic requirements are greater in dystocia than in normal labor

BACKGROUND

Dystocia is characterized by abnormal progress of labor and is a common contemporary indication for cesarean delivery in the United States. There has been considerable controversy as to whether epidural analgesia causes dysfunctional labor leading to cesarean delivery for dystocia. The minimum local analgesic concentration (MLAC) is a clinical model used to determine the relative potencies of local anesthetics in the first stage of labor. In this article, the authors report a prospective study determining the MLAC of bupivacaine in early labor of parturients who eventually delivered either vaginally or via cesarean section.

METHODS

An up-down sequential allocation technique was used to determine the MLAC of bupivacaine in 57 nulliparous parturients assigned to either vaginal delivery or cesarean section arms. In addition, patients were assigned to groups receiving or not receiving intravenous oxytocin at the time of epidural placement. Only patients who delivered by the assigned delivery mode were included in the MLAC analyses.

RESULTS

Parturients who later delivered vaginally had 25% and 31% lower MLAC values (0.078% and 0.085% wt/vol bupivacaine, receiving or not receiving intravenous oxytocin, respectively) than those who later delivered by cesarean section (0.102% and 0.106% wt/vol bupivacaine, receiving or not receiving intravenous oxytocin, respectively).

CONCLUSIONS

These data suggest that an increased local anesthetic requirement for epidural labor analgesia is associated with more intense pain related to dystocia. Women in early, clinically normal labor but who later develop dystocia require more local anesthetic and, by inference, are experiencing more severe pain than women who deliver vaginally. This association should be considered when studying the relation between the method of labor analgesia and the course of labor.

Fetal shoulder dystocia

Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years, probably just because it has now been regularly registered at maternity wards as an obstetric complication. The risk factors for shoulder dystocia include fetal macrosomia, fetal malformations and tumors, maternal adiposity, excessive weight gain during pregnancy, diabetes mellitus, pathologic pelvis, multiparity, short maternal stature, advanced maternal age, postterm pregnancy, so-called midforceps delivery or vacuum extraction, prolonged delivery stage II, oxytocin labor induction, premature fetal expression according to Kristeller, and previous shoulder dystocia in macrosomatic children. The sequels of shoulder dystocia and obstetric maneuvers for incarcerated shoulder release include clavicular fracture, brachial plexus lesions, sternocleidomastoid muscle distension with or without hematoma, diaphragmatic paralysis, Horner's syndrome, peripartal asphyxia and consequential cerebral lesions (cerebral palsy), and peripartal death. Maternal complications due to shoulder dystocia are postpartal hemorrhage, cervical and vaginal lacerations, frequent infections during the puerperium, symphysiolysis and rupture of the uterus, and secondary cesarean section with related complications due to unsuccessful obstetric procedures or as continuation of Zavanelli's maneuver. McRoberts' maneuver (or Gaskin maneuver) is recommended as the initial procedure for shoulder release in case of shoulder dystocia. If it fails, other obstetric procedures such as Resnik's suprapubic pressure and Woods' grip with posteriorly placed arm release should be used, always with gross lateral episiotomy. The performance of all these obstetric procedures requires skilfull and highly experienced obstetrician and obstetric team as a whole.

Diabetes, hypertension and birth injuries: a complex interrelationship

Seemingly coincidental occurrence of various pathological conditions may derive from common etiologic denominators. While reviewing 240 malpractice claims involving shoulder dystocia related fetal injuries, we found two antenatal complications in the background conspicuously often. Chronic or pregnancy induced hypertension was identifiable in 80 instances (33%). Pregnancy induced or preexisting diabetes was diagnosed 48 times (20%). Many of these patients were poorly controlled. The blood pressure was usually checked during the antenatal visits. However, about one-half of all patients received no diabetic screening. Therefore, this study may underestimate the actual incidence of diabetes. It has been calculated that the frequency of diabetes in pregnancy and that of hypertension, is about 5% in the United States. Thus, the rates of these complications in this selected group of gravidas was severalfold higher than in the general population. Since hypertension causes retarded fetal growth, it cannot be a direct cause of arrest of the shoulders at delivery. The likely common denominator is maternal diabetes a known predisposing factor both for preeclampsia and shoulder dystocia at birth. In the course of litigations for fetal injuries, demonstration of the predisposing role of seemingly unrelated shortcomings of the medical management may profoundly influence the outcome. This principle is demonstrated by the presentation of an actual malpractice action which resulted in a substantial settlement.

Reappraisal of neonatal clavicular fracture. Relationship between infant size and risk factors

OBJECTIVE

To examine the role of fetal size in neonatal clavicular fracture.

STUDY DESIGN

A retrospective, case-control study was performed on infants diagnosed with neonatal clavicular fractures and born vaginally between July 1997 and June 2000. For each index case, a control matched for gestational age (within one week) and birth weight (within 250 g) and delivered within the same 24-hour period was selected at random from the delivery suite registry. The maternal and intrapartum factors were compared and the results analyzed according to whether the infants were large for gestational age (LGA) or not.

RESULTS

Among 9,540 neonates delivered vaginally during this period, 151 (1.6%) had a fractured clavicle. Multivariate analysis indicated that the independent risk factors were shoulder dystocia and vacuum extraction. When analyzed according to fetal size, shoulder dystocia was significant only for LGA infants, while vacuum extraction was significant only for non-LGA infants.

CONCLUSION

Independent risk factors for neonatal clavicular fracture are related to fetal size.

[Study of urogenital fistulas in the Ivory Coast at the end of the 20th century. Results of 70 cases]

The urogenital fistulas (UGF), mostly in Africa and particularly in Ivory Coast, still represent a great flail nowadays. However, the authors notice, through a study of 70 cases done in Ivory Coast over (ten) 10 years, that a relative decrease of the impact of the urogenital fistulas troubles still remains a serious affection of young women who can give birth. They are about 30 years old and more; that is to say primipares (44.28%) but over all multipares (54.28%) and poor ones (100%). Most cases are obstetrical causes which expose those women to genital mutilations (25.71%) linked to birth giving difficulties which also bring about many dead born (14.11%) and divorces (20%).

Erb's palsy without shoulder dystocia

OBJECTIVES

The purpose of this commentary is to review certain articles which have provided evidence that Erb's palsy can occur without associated shoulder dystocia. The mechanism of the specific cause of the injury will be described.

METHODS

Prior to the last 10-12 years it was assumed that Erb's palsy occurred exclusively with and was the result of shoulder dystocia. Gonik et al. [Am J Perinat 1991;8:31-34], reported on a research study based on the premise that when Erb's palsies occurred there must have been shoulder dystocia present but it went undetected by the delivering physician. Subsequently Gherman [Am J Obstet Gynecol 1998;178:423-427], published a detailed study which carefully looked at multiple aspects of shoulder dystocia including those similar injuries occurring with and without associated shoulder dystocia.

RESULTS

Both Gonik's and Gherman's research revealed distinct maternal and newborn differences when comparing Erb's palsy occurring with and without associated shoulder dystocia. These differences, which have nothing to do with the ability to recognize shoulder dystocia, provide conclusive evidence that Erb's palsy does occur without associated shoulder dystocia.

CONCLUSIONS

Therefore, Gonik's original premise, that shoulder dystocia must have been present if Erb's palsy occurred, is not supported. This brings into question the cause of Erb's palsy in those cases without shoulder dystocia. The maternal forces are the most likely cause both with and without shoulder dystocia.

[Mechanisms of the stagnation of dilatation in the active phase of labor]

OBJECTIVE

Our study was designed to explain determinants of nonprogressive labor in nulliparous patients.

STUDY DESIGN

One hundred consecutive nulliparous patients have got a cesarean section for active-phase arrest of labor after two hours of active management. Intrauterine pressure was monitored for all of them and a X-ray pelvimetry was done after surgery.

RESULTS

Eighty-three percent of patients showed X-ray data considered as normal; hypotonic labor was found in 50% of cases and occiput posterior position in 60%.

CONCLUSIONS

Our results suggest that occiput position and functional dystocia are more common in case of nonprogressive labor than abnormal measurements of the obstetrical pelvis.

Erb's palsy causation: a historical perspective

A better understanding of the forces involved when brachial plexus injury occurs has evolved over the past 10 to 15 years. A particular challenge was that all of the useful information had to be derived indirectly by identifying associations-a challenge that was met by individual researchers who made significant observations that, in turn, stimulated others to search for additional findings. Gradually the pieces of the puzzle began to form the picture. The significant steps in this journey were first, the recognition of the substantial number of injuries occurring without concurrent shoulder dystocia; second, the finding that a much greater frequency of injury is associated with an ultrashort second stage of labor; third, the observations that the injury rate is independent of the experience of the birth attendant; fourth, the recognition of the substantial numbers of injuries occurring in the posterior arm; and fifth, the anecdotal experience of countless delivery attendants, who relate that the forces applied in the injured cases were perceived to be no stronger than those applied when no injury occurred. We present a historical review for each step in this journey. We reviewed all articles published on this subject in Obstetrics and Gynecology and the American Journal of Obstetrics and Gynecology and some European journals. The period for review primarily covered articles published since 1980. Several textbooks on obstetrics and child neurology were also reviewed.

[The incidence of septal deviation in newborns]

OBJECTIVES

To determine the incidence of septum deviation and dislocation in newborns and to investigate relationships between these pathologies and maternal causes and the mode of delivery.

PATIENTS AND METHODS

The study included 195 mothers and 200 newborns, of which 10 were twins. Vaginal and cesarean deliveries were performed in 147 (73.5%) and 53 (26.5%) newborns, respectively. All newborns were examined with the use of anterior rhinoscopy. The nasal pyramid, columella, and septum were assessed to detect septal deviation or dislocation.

RESULTS

Twenty-three cases (15.6%) of vaginal delivery had septal deviation, while five (3.4%) had septal dislocation. In the newborns delivered by cesarean section, eight (15.1%) had septal deviation, but none had dislocation. Significant correlations were noted between pregnancy, delivery period, the way of delivery and the incidence of septal deviation and columella dislocation (p < 0.05). There was a significant correlation between head circumference and columella dislocation (p < 0.05).

CONCLUSION

Since early reconstruction of the potential pathologies may be problem-solving, a careful rhinologic examination should be carried out in the newborns who have prolonged delivery, increased head circumference, and vaginal delivery.

Shoulder dystocia and brachial plexus injury: a population-based study

The objective of this work was to identify and evaluate risk factors for shoulder dystocia and for brachial plexus injury in a population-based study. In all, 1,397 parturients with shoulder dystocia occurring in Sweden between 1987 and 1996 were identified among 1,076,545 deliveries using information stored in the Medical Birth Registry (MBR) of the National Board of Health and Welfare, Stockholm. Information is missing for about 1.0% of singleton deliveries in the MBR. Validation of the diagnosis 'shoulder dystocia' in the MBR was performed using data of 4 of 63 delivery units and was confirmed in 96.5% of the original medical records. A total of 368 infants had brachial plexus injury (26.3%). However, a considerable variation in the rate of recorded shoulder dystocia was evident when comparing the 63 delivery units throughout Sweden. Overall, the incidence was 1.3 per 1,000 deliveries. A close association was found between birth weight and shoulder dystocia, with an odds ratio (OR) over 30 for a birth weight > or = 5,000 g. In the presence of maternal diabetes mellitus or gestational diabetes, the OR for shoulder dystocia was significantly increased in newborns weighing > or = 4,000 g. The overall perinatal mortality because of shoulder dystocia was 1.2%. This was increased to 6.4% if the mother had diabetes mellitus. About 25% of all infants suffered a brachial plexus injury. This potentially serious injury even occurred in connection with birth by cesarean section, and an OR for plexus injury over unity was seen in 7 of 9 weight groups; a significantly increased OR was seen for birth weights > or = 4,500 g. The birth weight is a strong risk factor for shoulder dystocia, as is diabetes mellitus. A considerable variation in the rate of shoulder dystocia was observed among the different delivery units, probably reflecting difficulties in definition. Brachial plexus injury is observed even after cesarean section, especially if the birth weight is > or = 4,500 g.

[Can clinical risk factors for perinatal mortality in West Africa be detected during antenatal care or during labor?]

INTRODUCTION

Perinatal mortality (PNM) is a public health problem in West Africa. Aims. To evaluate the rate of PNM in 6 countries of West Africa, to identify clinical risk factors for PNM, to quantify the relative contribution of antenatal care and labor survey in the detection of these risk factors.

METHODS

The MOMA study was a prospective population-based study that collected data about 20326 pregnant women in various, primarily urban, areas of Burkina-Faso, Ivory-Coast, Mali, Mauritania, Niger and Senegal. The present report analyses 19.870 singleton births and 31 simple clinical variables.

RESULTS

The mean PNM ratio was 42 per 1000 total births. In the crude analysis, after adjustment or taking prevalence into account, the principal risk factors were: immediately antenatal and intrapartum vaginal bleeding, labor hypertension, dystocia and infection.

CONCLUSION

The PNM are very high in West Africa. The principal risk factors for PNM can be detected only during labor.

Ruptured uterus: a study of 100 consecutive cases in Ilorin, Nigeria

OBJECTIVES

To determine the incidence, aetiology, trend, management maternal and fetal outcome of uterine rupture at University of Ilorin Teaching Hospital, Ilorin, Nigeria. To compare the results with previous reports from this centre.

MATERIALS AND METHODS

A prospective study of patients with ruptured uterus at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between February, 1992 and December, 1999 was undertaken. The patients were initially assessed in the labour ward where the clinical presentation, relevant socio-demographic data, previous medical and surgical histories were noted. Necessary investigations and resuscitation were carried out before the operation. A structured questionnaire was also administered either before or after the operation. Two consecutive spontaneous vaginal deliveries following each case of uterine rupture served as control. Statistical analysis was done using the Genstat 32 package.

RESULTS

Of the 20,960 deliveries during the study period, there were 100 ruptured uteri giving a hospital incidence of 1 in 210 deliveries. Oxytocin use (39%), uterine scar (23%) and obstructed labour (16%) were the common associated factors. When compared with the controls, uterine rupture in the study group was significantly associated with low socio-economic status p < 0.001, lack of antenatal care p < 0.001, and high parity p < 0.012. A maternal age 40 years and above was also a risk factor. The anterior wall of the uterus was the commonest site affected and repair with tubal ligation was the surgical procedure in 36% of cases. Maternal mortality was 13%, while fetal mortality was 92%. When compared with the previous incidence of 1 in 298 deliveries, a slight increase is noted.

CONCLUSION

Ruptured uterus is still a common obstetric hazard in our environment and its incidence appears to be on the increase. The condition is significantly associated with advanced maternal age, grandmultiparity, lack of antenatal care and the low socio-economic status of the patients.

Clavicle fracture in labor: risk factors and associated morbidities

OBJECTIVE

Neonatal clavicle fracture has been previously reported to occur in association with shoulder dystocia, suggesting liability on behalf of the obstetrician. However, clavicle fracture is often inconsistently diagnosed, and shoulder dystocia commonly subjectively defined. Using a formal pediatric diagnosis protocol and an objective definition of shoulder dystocia, we sought to determine the incidence, antecedents, and associated morbidities of clavicle fracture and the potential association with shoulder dystocia.

STUDY DESIGN

All deliveries at Harbor-UCLA Medical Center complicated by clavicle fracture from January 1996 to March 1999 were studied. Deliveries with clavicle fracture were compared to all vaginal deliveries during this period.

RESULTS

Among 4297 deliveries, twenty-six were complicated by clavicle fracture (0.5%). Clavicle fracture was significantly associated with increased maternal age and birth weight greater than 4 kg, though not associated with shoulder dystocia or operative vaginal delivery. Clavicle fracture was associated with meconium passage and with neonatal orthopedic abnormalities.

CONCLUSION

Neonatal clavicle fracture is associated with infant birth weight greater than 4 kg, but not with the occurrence of objectively defined shoulder dystocia. However, infants with clavicle fracture may be at increased risk for additional complications.

Multilocation trial of ceftiofur for treatment of postpartum cows with fever

OBJECTIVE

To evaluate the effect of ceftiofur for treatment of postpartum cows with fever.

DESIGN

Multilocation randomized complete block design trial.

ANIMALS

330 cows.

PROCEDURE

Cows with rectal temperature > or = 39.5 C (103.1 F) during the first 10 postpartum days were randomly assigned to a treatment (ceftiofur; 1 mg/kg [0.45 mg/lb] of body weight daily for 3 days) or untreated control group. Cure (no additional or alternative antimicrobial treatment used, rectal temperature < 39.5 C, and no other concurrent clinical signs of disease when evaluated at 9 or 10 days after enrollment), milk production, and rectal temperature were evaluated.

RESULTS

Ceftiofur-treated cows were significantly more likely to be cured than control cows (56.0 vs 28.9%, respectively), with an odds ratio of 3.14 when vaginal discharge (a factor with moderate interaction with treatment) was present at enrollment. Among cows that had an abnormal calving (a significant interaction factor), treated cows had first milking yield 2.27 kg (5 lb) greater than control cows. Treated cows had a significantly greater reduction in rectal temperature (1.19 C [2.14 Fl), compared with control cows (1.04 C [1.87 F]).

CONCLUSIONS AND CLINICAL RELEVANCE

Parenteral administration of ceftiofur significantly improved cure rate, milk yield, and rectal temperature in postpartum cows with fever and vaginal discharge or dystocia. These findings provide information to determine appropriate treatment for postpartum cows, which for years has been debated in the dairy industry.

[High vacuum extraction: justifiably obsolete in view of the risks to the infant]

The author was asked to provide an expert assessment of the case histories of 28 patients delivered by vacuum extraction. At the start of the extraction the foetal head level was at station 0 or above in 25 of the patients. In 12 cases the duration of extraction exceeded 14 min and in 7 of the cases it exceeded 19 minutes with a maximum of 45 minutes. Nine of the infants died, 11 suffered cerebral damage, 4 had brachial plexus injury and 1 had both cerebral damage and plexus injury. In 17 cases a causal relation between the unfavourable outcome and the vacuum extraction seemed plausible. During the past 40 years several studies of patients who have undergone high pelvic vacuum extractions have been published; cerebral damage of the infants often occurred. The risk of shoulder dystocia resulting in brachial plexus injury is considerably increased in case of a large infant and mid pelvic or high pelvic delivery. In the paediatric literature a number of authors describe cerebral lesions caused by high pelvic vacuum extraction. High pelvic vacuum extraction is still occasionally practiced in the Netherlands; it is a hazardous technique and should be replaced by caesarean section.

Features of shoulder dystocia in a busy obstetric unit

OBJECTIVE

To assess the incidence and complications of shoulder dystocia and whether those complications could be avoided.

STUDY DESIGN

Retrospective analysis of shoulder dystocia between 1996 and 1999 to determine whether macrosomia, diabetes, height of head at full dilatation, length of second stage or instrumental delivery could predict shoulder dystocia. Fetal asphyxia, brachial plexus injury, maneuvers used to free the shoulders and experience of the attendant were also assessed.

RESULTS

There were 56 cases of shoulder dystocia in 24,000 births, 59% after spontaneous delivery. McRoberts maneuver was used in 48 deliveries but sufficed as a solitary procedure in nine cases. The addition of suprapubic pressure was sufficient for 25 patients and 27 when bilateral episiotomy was also used. Corkscrew procedures were required in 12 patients. Midwives were involved in 35 cases and required assistance in 27. Macrosomia > 4,000 g was a feature in 20 infants and diabetes in 6. Neither the height of the head nor the length of the second stage was helpful. There were 13 cases of Erb's palsy, seven after vacuum delivery and six after spontaneous delivery. Eight of these cases were associated with McRoberts procedure and suprapubic pressure, two with no procedure and three with the corkscrew procedure.

CONCLUSION

If all infants > 4,000 g had been delivered by cesarean section, there still would have been 36 cases of shoulder dystocia. If the ultrasonically estimated weight were used to select patients for cesarean section, seven cases would have been diagnosed. To lessen the degree and incidence of fetal injury, labor ward staff are urged to become as familiar as possible with the techniques of freeing the shoulders.

Dystocia among women with symptomatic uterine rupture

OBJECTIVE

The purpose of this study was to analyze cervical dilatation patterns among women with uterine rupture by means of a mathematic model and to use the results to determine optimal intervention criteria.

STUDY DESIGN

This was a case-control review that compared a case patient group of 19 women with uterine rupture during labor with control groups with either no previous cesarean deliveries, vaginal birth after cesarean delivery, or failure of attempted vaginal birth after cesarean delivery. The mathematic model quantified dilatation and adjusted for conditions specific to each patient. Case patients were compared with matched control subjects by means of paired t tests, analysis of variance, odds ratios, and conditional logistic regression.

RESULTS

Dystocia was present in 31.6% to 47.4% of patients with uterine rupture, versus 2.6% to 13.2% of the control group with no previous cesarean deliveries (P< or =.001). The incidence of an arrest disorder among patients with uterine rupture was similar to that seen in the control group with failure of attempted vaginal birth after cesarean delivery. However, the interval from diagnosis to rupture or cesarean delivery was 5.5 +/- 3.3 hours among case patients with uterine rupture and 1.5 +/- 1.3 hours in the control group with failure of attempted vaginal birth after cesarean delivery.

CONCLUSION

When cervical dilatation was lower than the 10th percentile and was arrested for > or =2 hours, cesarean delivery would have prevented 42.1% of the cases of uterine rupture and resulted in excess 2.6% and 7.9% cesarean delivery rates among women with no previous cesarean deliveries and women with vaginal birth after cesarean delivery, respectively.

Relationship between intra-uterine bacterial contamination, endotoxin levels and the development of endometritis in postpartum cows with dystocia or retained placenta

A study was conducted to investigate the relationship between intra-uterine bacterial contamination, endotoxin levels and the development of endometritis in cows that experienced a dystocia or retained their placenta. Fifteen healthy cows, 31 cows with retained placenta (RP) and 13 cows that had dystocia were clinically examined 1 or 2 days after parturition when a uterine swab for bacteriological examination was taken. In addition, plasma and uterine lochia samples were collected to determine lipopolysaccharide (LPS) and the plasma IgG anti-LPS concentrations. Subsequently, 15 RP and 6 dystocia cows were initially left untreated and another uterine swab was collected at 2 and 4 wk postpartum. Immediately after calving, RP cows had significantly higher LPS levels in uterine lochia (average of 2.24 x 10(4) Endotoxin Units (EU)/mL) as compared to dystocia and healthy postpartum cows (average of 0.10 and 0.26 EU/mL, respectively). However, plasma LPS levels were below the detection limit (<0.036 EU/mL platelet-rich plasma) in all groups of cows. IgG anti-LPS levels in plasma were not significantly different between the 3 groups immediately postpartum (average of 26, 16 and 44 Median Units (MU)/mL) for healthy, dystocia and RP cows, respectively), but they were significantly lower when compared to plasma IgG anti-LPS levels of healthy cows at more than 2 months postpartum (mean 83 MU/mL). High LPS levels in lochia at 1 or 2 days postpartum were significantly related to abnormal cervical discharge, the presence of Escherichia coli, black pigmented gram-negative anaerobes and Clostridium spp. shortly after calving, and Arcanobacterium pyogenes and gram-negative anaerobes in the uterus at 14 days postpartum. These results suggest that the presence of E. coli and LPS (endotoxins) in lochia early postpartum favor the development of uterine infections by A. pyogenes and gram-negative anaerobes later postpartum. LPS were not observed in plasma, suggesting that either they are not absorbed into the blood, or they are efficiently detoxified by IgG anti-LPS or other detoxification mechanisms.

Factors associated with rectovaginal injuries in Holstein dairy cows in a herd in Tehran, Iran

Rectovaginal injuries can result in subsequent infertility in cows. In a retrospective study, records of 147 Holstein cows with evidence of rectovaginal injuries were reviewed to determine the odds ratio (OR) of these injuries and their related risk factors. The study was conducted in a large dairy (typical herd size 1420 cows) in Tehran between the years 1993 and 1996. Period prevalences were 0.4% fistula, 1.9% laceration (third degree), 5.7% pneumovagina, 1.5% urovagina and 0.8% mixed injuries. The highest risk occurred among first-calf heifers. Animals with dystocia, first-calf heifers and male calves were at higher risk for rectovaginal injuries. We concluded that (1) handling dystocia with care might have a substantial role in reducing rectovaginal injuries, (2) first-calf heifers are to be under close observation and care during calving, and (3) because rectovaginal injuries reoccur in the next calving, cows with the history of these injuries should be monitored at the next labor.

Erb's palsy: concepts of causation

In the past, obstetric textbooks have stated (without evidence) that Erb's palsy is caused by the birth attendant. The mechanism cited is stated to be the application of excessive lateral traction placed on the fetal head and neck. Recent research findings refute this unproven theory. Findings include (1) only 50% of cases are associated with shoulder dystocia; (2) the 4.7-fold increase in the condition was associated with a precipitate second stage compared with one of normal length; and (3) the same injury rate with direct manipulation techniques (for resolving shoulder dystocia) was comparable to that of McRobert's position and/or suprapubic pressure. The overwhelming evidence indicts the propulsive nature of the stretching of the involved nerves over which the birth attendant has no control.

A matched case-control study of factors associated with retention of fetal membranes in dairy ewes in Southern Greece

We defined retention of fetal membranes (RFM) in dairy ewes as failure to expel the placenta within 6h after lambing the last lamb and designed a matched case-control study to identify factors that affect the risk of retention. For each ewe with RFM, the next ewe in the flock that lambed and expelled the placenta in <6h after lambing the last lamb was selected as control. Data analyzed included 92 pairs of ewes from 25 flocks comprising a total of 7275 ewes (median flocksize 270 ewes). Factors investigated for associations with RFM were induction of lambing, obstetrical assistance because of dystocia, parity, the number of liveborn lambs, the occurrence of stillbirth(s), the mean weight of the litter on the third day post-lambing and the occurrence of neonatal death in the litter. Conditional logistic regression indicated (1) that the risk of RFM increased linearly with increasing number of liveborn lambs and (2) that the risk of retention was 4-fold higher in ewes that received assistance at lambing than those that lambed normally.

Mathematic modeling of forces associated with shoulder dystocia: a comparison of endogenous and exogenous sources

OBJECTIVE

A mathematic model was developed to estimate the compressive pressure on the fetal neck overlying the roots of the brachial plexus by the symphysis pubis during a shoulder dystocia event. The induced pressure was calculated for both exogenous (clinician applied) and endogenous (maternal and uterine) forces during the second stage of labor.

STUDY DESIGN

Intrauterine pressure and clinician-applied force data were taken from the existing literature. A free-body diagram was generated and equilibrium equations were used to calculate the contact pressure between the base of the fetal neck and the symphysis pubis during a shoulder dystocia event.

RESULTS

Clinician-applied traction to the fetal head (exogenous force) led to an estimated contact pressure of 22.9 kPa between the fetal neck and the symphysis pubis. In contrast, uterine and maternal expulsive efforts (endogenous forces) resulted in contact pressures that ranged from 91.1 to 202.5 kPa. The estimated pressures resulting from endogenous forces are 4 to 9 times greater than the value calculated for clinician-applied forces.

CONCLUSION

Neonatal brachial plexus injury is not a priori explained by iatrogenically induced excessive traction. Spontaneous endogenous forces may contribute substantially to this type of neonatal trauma.