Shoulder dystocia training effects

Abstract

We have some questions and comments on the interesting article by Inglis et al.1Inglis S.R. Feier N. Chetiyaar J.B. et al.Effects of shoulder dystocia training on the incidence of brachial plexus injury.Am J Obstet Gynecol. 2011; 204: 322.e1-322.e6Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Did their protocol permit initial gentle downward traction as required by the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists definition? The elephant in the room is the cesarean rate rising from pretraining 29.90% to an astonishingly high posttraining 40.14%, an increase of 34.2% over a 3-year time period. It is our opinion that this large increase in the authors' cesarean rate would be a substantial factor in causing the decrease in obstetric brachial plexus injury (OBPI) in the posttraining period and should receive further discussion from the authors. Another factor would be the inordinately high pretraining shoulder dystocia–associated OBPI of 30% while the general literature reports around 10%, the same as the authors' posttraining period. Rouse et al2Rouse D.J. Owen J. Goldenberg R.L. et al.The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnoses by ultrasound.JAMA. 1996; 276: 1480-1486Crossref PubMed Google Scholar reported a shoulder dystocia–associated rate of OBPI of only 18% and 26% for birth weights of 4000-4499 g and ≥4500 g, respectively, vs the author's overall pretraining rate of 30%. The pretraining and posttraining cesarean rates for fetuses weighing >4000 g would be more revealing than the overall decrease in the average newborn weight of 182 g. Rouse et al2Rouse D.J. Owen J. Goldenberg R.L. et al.The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnoses by ultrasound.JAMA. 1996; 276: 1480-1486Crossref PubMed Google Scholar also reviewed 9 studies reporting a mean permanent OBPI of 6.7% of those with newborn OBPI. A total of 6.7% of 25 and 8 OBPIs, resulting from the pretraining and posttraining time periods, respectively, provides the actual number of permanent OBPIs of 1.7 and 0.5, or roughly 1 permanent OBPI prevented at a cost of 952 extra cesareans. How do the authors explain “all OBPI cases were associated with shoulder dystocia,” which is contrary to the literature? There are 23 recent studies reporting approximately 50% of their cases of OBPI have no associated shoulder dystocia with their deliveries. The authors' remarkable posttraining reduction in OBPI is at variance with other authors (Mackenzie, Crofts and possibly Draycott – authors' reference 15).3Mackenzie I.Z. Shah M. Lean K. Dutton S. Newdick H. Tucker D.E. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity.Obstet Gynecol. 2007; 110: 1059-1068Crossref PubMed Scopus (103) Google Scholar, 4Crofts J.F. Fox R. Ellis D. Winter C. Hinshaw K. Draycott T.J. Observations from 450 shoulder dystocia simulations: lessons for skills training.Obstet Gynecol. 2008; 112: 906-912Crossref PubMed Scopus (63) Google Scholar, 5Draycott T.J. Crofts J.F. Ash J.P. et al.Improving neonatal outcome through practical shoulder dystocia training.Obstet Gynecol. 2008; 112: 14-20Crossref PubMed Scopus (379) Google Scholar Draycott et al5Draycott T.J. Crofts J.F. Ash J.P. et al.Improving neonatal outcome through practical shoulder dystocia training.Obstet Gynecol. 2008; 112: 14-20Crossref PubMed Scopus (379) Google Scholar did find fewer newborn OBPIs during the posttraining period but they were transient and did not persist during the ensuing 6 months of the newborn's life. Effects of shoulder dystocia training on the incidence of brachial plexus injuryAmerican Journal of Obstetrics & GynecologyVol. 204Issue 4PreviewWe sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI). Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 205Issue 6PreviewWe read with great interest the insightful comments of Sandmire et al. Our protocol called for the “hands off” procedure when the diagnosis of shoulder dystocia was made; no gentle downward traction was allowed.1 This was followed by an assessment of the position of the shoulders. Full-Text PDF