Abstract
OBJECTIVE: To determine whether trial of labor (TOL) or elective cesarean delivery is optimal in healthy women with a prior shoulder dystocia. STUDY DESIGN: A decision analytic model was created to compare attempted modes of delivery. For the TOL arm, both vaginal delivery and cesarean delivery were considered. We accounted for mode of delivery, shoulder dystocia, brachial plexus injury, asphyxia, fetal mortality, and maternal mortality. A literature review identified nine studies on the incidence of recurrent shoulder dystocia, which indicated a rate of 1–25%. Of these, one was a recent retrospective cohort study of greater than 8,000 American women. We used the rate of 13% recurrence found in this study. Large cohort data were used to estimate the risks of fetal morbidities and mortalities with elective cesarean delivery, cesarean delivery after TOL, vaginal delivery without shoulder dystocia, and vaginal delivery with shoulder dystocia. We assumed a population of 100,000 and considered maternal and neonatal quality-adjusted life-years equally. Univariate sensitivity analysis was performed to test for robustness. RESULTS: For women with a prior shoulder dystocia and a preference for vaginal delivery, TOL was the optimal approach at an incremental gain of 80,391 quality-adjusted life-years for the cohort as compared with elective cesarean delivery. Sensitivity analysis demonstrated that TOL was not optimal when the likelihood of repeat shoulder dystocia exceeded 26.4%. CONCLUSION: For women who have a preference for vaginal delivery, it is reasonable to offer TOL after a prior shoulder dystocia.
Published Version
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