Cases Of Shoulder Dystocia Research Articles

Predictors of maternal and neonatal outcomes in labors complicated by shoulder dystocia: a comparative analysis

IntroductionStudies investigating the risk factors associated with unfavorable maternal/neonatal outcomes in cases of shoulder dystocia are scarce. This study aims to uncover the predictive factors that give rise to unfavorable outcomes within the context of shoulder dystocia.Materials and methodsMedical records of pregnancies complicated by shoulder dystocia was obtained between 2008–2022 from a single tertiary center. This study involved the comparison of sociodemographic, sonographic, and delivery characteristics among pregnancies complicated by shoulder dystocia resulting in favorable vs. unfavorable maternal/neonatal outcomes.ResultsA total of 275 pregnancies were analyzed, with 111 (40.3%) classified as unfavorable outcomes and 164 (59.7%) as favorable outcomes. Employing a multivariable regression analysis, several independent associations were identified with unfavorable maternal/neonatal outcomes. Specifically, short maternal stature, pre-gestational diabetes, vacuum extraction, Wood’s screw maneuver, and macrosomia merged as significant predictors of unfavorable maternal/neonatal outcomes.ConclusionShort maternal stature, pre-gestational diabetes, vacuum extraction, Wood’s screw maneuver, and macrosomia may all contribute to poor maternal/neonatal outcomes in shoulder dystocia cases. This knowledge allows clinicians to improve their decision-making, patient care, and counseling.

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.

Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998–2015

BackgroundAustralian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP.MethodsStratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg.ResultsRates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg.ConclusionsAboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study.

Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries. The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery. During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery. The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.

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

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. 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. 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). 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.

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong.

Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019. This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods. The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045). More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019.

Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries

PurposeShoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb’s and Klumpke’s palsy and the use of ICD-10 code 066.0.MethodsA retrospective, register-based case–control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006–2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes.ResultsThe pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb’s palsy and increasing use of ICD-10 code O66.0.ConclusionThere are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb’s palsy and improved coding of shoulder dystocia.

Risk factors for brachial plexus injury and permanent sequelae due to shoulder dystocia.

The primary aim of this study was to determine the risk factors for the occurrence of brachial plexus injury in cases of shoulder dystocia. Secondly, it was aimed to determine the factors affecting the occurrence of permanent sequelae in cases with brachial plexus injury. ICD-10 codes were scanned from the records of patients who gave birth between 2012 and 2018, and the records of patients with brachial plexus injury and shoulder dystocia were reached. Shoulder dystocia cases with brachial plexus damage were accepted as the study group, and shoulder dystocia cases without brachial plexus damage were considered the control group. Shoulder dystocia patients with brachial plexus injury and without injury were compared for 2-year orthopedics clinic follow-up reports, surgical intervention, permanent sequelae status as well as birth data, maternal characteristics, and maneuvers applied to the management of shoulder dystocia. Five hundred sixty births with shoulder dystocia were detected. Brachial plexus injury was observed in 88 of them, and permanent sequelae were detected in 12 of these patients. Maneuvers other than McRobert's (advanced maneuvers) were used more and clavicle fracture was seen more in the group with plexus injury (P < 0.05, P < 0.05, respectively). Logistic regression analysis was performed to determine the risk factors of brachial plexus injury. Brachial plexus injury was observed 4.746 times more in infants who were delivered with advanced maneuvers and 3.58 times more in infants with clavicle fractures at birth. In patients with shoulder dystocia, the risk of brachial plexus injury increased in deliveries in which advanced maneuvers were used and clavicle fracture occurred.

Incidence of obstetric brachial plexus palsy after a training program in shoulder dystocia

IntroductionShoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis. Material and methodsRetrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008–2016). ResultsIn the 2017–2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation). ConclusionThese results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.

An Extractor for the Management of Shoulder Dystocia.

The Yaari Extractor is intended to wrap around and guide the fetal shoulder to facilitate vaginal delivery in cases of shoulder dystocia. The Yaari Extractor is a single-use device for fetal shoulder extraction. The device consists of two curved, rigid plastic-coated metal arms with handles and an elastic engagement element that includes two hollow sleeves that cover the portion of the device that enters the vagina and contacts the fetus. The device has been used in three cases of shoulder dystocia. In all three cases, the shoulder dystocia was resolved without the need for ancillary obstetric maneuvers, and there was no reported maternal or fetal injury. The Yaari Extractor is a novel technology that can be used to successfully resolve shoulder dystocia.

Incidencia de parálisis braquial obstétrica tras programa de entrenamiento en distocia de hombros

IntroductionShoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis. Material and methodsRetrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008–2016). ResultsIn 2017–2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation). ConclusionThese results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications.

Antenatal risk score for prediction of shoulder dystocia with focus on fetal ultrasound data

Shoulder dystocia is one of the most threatening complications during delivery, and although it is difficult to predict, individual risk should be considered when counseling for mode of delivery. This study aimed to develop and validate a risk score for shoulder dystocia based on fetal ultrasound and maternal data from 15,000 deliveries. Data were retrospectively obtained of deliveries in 3 tertiary centers between 2014 and 2017 for the derivation cohort and between 2018 and 2020 for the validation cohort. Inclusion criteria were singleton pregnancy, vaginal delivery in cephalic presentation at ≥37+0 weeks' gestation, and fetal biometry data available within 2 weeks of delivery. Independent predictors were determined by multivariate regression analysis in the derivation cohort, and a score was developed on the basis of the effect of the predictors. The derivation cohort consisted of 7396 deliveries with a 0.91% rate of shoulder dystocia, and the validation cohort of 7965 deliveries with a 1.0% rate of shoulder dystocia. Among all women, 13.8% had diabetes mellitus, and 12.1% were obese (body mass index ≥30 kg/m2). Independent risk factors in the derivation cohort were: estimated fetal weight ≥4250 g (odds ratio, 4.27; P=.002), abdominal-head-circumference ≥2.5 cm (odds ratio, 3.96; P<.001), and diabetes mellitus (odds ratio, 2.18; P=.009). On the basis of the strength of effect, a risk score was developed: estimated fetal weight ≥4250 g=2, abdominal-head-circumference ≥2.5 cm=2, and diabetes mellitus=1. The risk score predicted shoulder dystocia with moderate discriminatory ability (area under the receiver-operating characteristic curve, 0.69; P<.001; area under the receiver-operating characteristic curve, 0.71; P<.001) and good calibration (Hosmer-Lemeshow goodness-of-fit; P=.466; P=.167) for the derivation and validation cohorts, respectively. With 1 score point, 16 shoulder dystocia cases occurred in 1764 deliveries, with 0.6% shoulder dystocia incidence and a number needed to treat with cesarean delivery to avoid 1 case of shoulder dystocia of 172 (2 points: 38/1809, 2.1%, 48; 3 points: 18/336, 5.4%, 19; 4 points: 10/96, 10.5%, 10; and 5 points: 5/20, 25%, 4); 40.8% of the shoulder dystocia cases occurred without risk factors. The presented risk score for shoulder dystocia may act as a supplemental tool for the clinical decision-making regarding mode of delivery. According to our score model, in pregnancies with a score ≤2, meaning having solely estimated fetal weight ≥4250 g, or abdominal-head-circumference ≥2.5, or diabetes mellitus, cesarean delivery for prevention of shoulder dystocia should not be recommended because of the high number needed to treat to avoid 1 case of shoulder dystocia. Conversely, in patients with a score of ≥4 with or without diabetes mellitus, cesarean delivery may be considered. However, in 40% of the shoulder dystocia cases, no risk factors had been present.

Role of Decapitation in Management of A Case of Complete Shoulder Dystocia with Rupture Uterus - A Case Report

Complete Shoulder dystocia in the presence of scarred uterus is an acute obstetrical emergency and if not properly handled can lead to serious fetal and maternal complications. A G5P4AO previous II cesarean sections, presented in emergency after delivery of fetal head and impacted shoulders, at a small private clinic in a village, four hours back. On laparotomy, there was uterine rupture from the previous uterine scar along with posterior bladder wall rupture . The shoulder dystocia was relieved by decapitation and breech extraction abdominally. Subtotal hysterectomy and repair of the bladder wall was done. This case highlight the dilemma of lack of regular antenatal care and maternal education, malpractices by untrained health professionals and time lapse in referral system that is still a very serious and major issue in developing countries like Pakistan . Keywords: Shoulder dystocia, obstructed labor, and uterine rupture

Cohort study of use of the hands-and knees-position as the first approach to resolving shoulder dystocia and preventing neonatal birth trauma

BackgroundMcRoberts' maneuver, turning the woman's thighs up in the supine position, has become the dominant method for resolving shoulder dystocia (defined as failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery). Another method that is less commonly used is the Gaskin maneuver, which was first described by the midwife Ina May Gaskin, who learned of it from traditional midwives in Central America, and involves turning women to the hands-and-knees position. One retrospective observational study reported an 84% higher resolution of shoulder dystocia and less injury to the baby with the use of the hands-and-knees position as the first approach to resolving shoulder dystocia. The hands-and-knees position was reported to result in a wider pelvic diameter than the supine position and hence facilitate rotation of the baby and delivery, so it is possibly to resolving shoulder dystocia. The purpose of this study is to explore whether applying the Gaskin maneuver as the first approach for resolving cases of shoulder dystocia is a safer and better method than applying the McRoberts' maneuver first. MethodsA time series cohort study was conducted in Laiwu Maternal and Child Health Hospital in Shandong, China over a seven -year period. Between January 2011 and July 2013 all women receiving traditional support at delivery were enrolled as a control group. During this time period, when shoulder dystocia was suspected, McRoberts’ maneuver (MR) was the most commonly employed first maneuver as described in the HELPERR mnemonics. Between October 2013 and December 2017, a change of practice was implemented for all vaginal births at the site, whereby midwives were instructed to use the Gaskin maneuver (i.e., moving the mother onto hands-and-knees position) as the first protocol if shoulder dystocia was suspected. Patients in this group were assigned to the experimental group. The neonatal outcomes including birth asphyxia and baby injury in both groups were recorded and analyzed. ResultsThe injuries in the control group included 14 clavicular fractures, and one permanent brachial plexus injury, three temporary arm movement disorders that resolved within 7 days and those cases were not calculated as baby injury cases (the same in experimental group). In the experimental group, 58 cases of shoulder dystocia were reported, with one case of clavicular fracture, three temporary arm movement disorders that resolved within 3 days, and no permanent brachial plexus injuries. The rate of baby injury in the control group [14.6% (15/103)] was higher than that in the experimental group [1.7% (1/58)], and this difference was statistically significant [ χ2 ​= ​6.834, P ​= ​0.009; OR ​= ​1.150 (1.055–1.254)]. Multiple logistic regression analysis showed that using the McRoberts' maneuver as the first approach in cases of shoulder dystocia [OR ​= ​19.609 (1.620–273.430)], the mother's employment status [OR ​= ​1.909 (1.118–3.262)], and intravenous dripping of oxytocin [OR ​= ​5.969 (1.391–25.605)] are risk factors for baby injury. There was no difference in neonate Apgar score between the two groups, and no baby died in either group. ConclusionsResolving shoulder dystocia by turning to the Gaskin maneuver as the first approach reduces the incidence of baby injury. This method should be recommended in clinical practice for better neonate outcomes.

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

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. 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. 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. 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). 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.

Considering Criteria for Active Phase Labor Management of Nulliparous Women: A Cost-Effectiveness Analysis.

The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective. A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis. In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions. In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes. · Cervical dilation of 6 cm should be considered the threshold for the active phase of labor. This is a change from the prior definition of 4 cm.. · We built a theoretical model to compare outcomes and costs associated with the new active phase definition of 6 cm.. · Using a 6-cm threshold is a cost-effective strategy for decreasing primary cesarean deliveries..

754 Brachial plexus injury rate before & after a multi-disciplinary shoulder dystocia simulation program

Simulation of obstetric emergencies is implemented with the goal of improving clinical outcomes. We sought to assess whether mandatory, multi-disciplinary, department-wide shoulder dystocia simulation training was associated with a change in the rate of brachial plexus injury following shoulder dystocia. This is a retrospective pre-post study comparing brachial plexus injuries before and after implementation of a mandatory, multi-disciplinary simulation curriculum in 2015. All shoulder dystocia cases were identified from a contemporaneous obstetric database and confirmed via chart review. Cases between January 1, 2010 and December 31, 2015 (PRE) were compared with those between January 1, 2016 and December 31, 2019 (POST). The primary outcome was rate of brachial plexus injury. Additional outcomes included any birth injury, NICU admission, and 5 min Apgar ≤ 4. A total of 639 cases of shoulder dystocia were identified. 359 occurred prior to simulation implementation and 280 occurred afterwards. Birth weight, maternal BMI, and number of maneuvers required were similar between the two eras. The composition of delivery providers (between residents, midwives, and attending physicians) was significantly different after the simulation. The rate of brachial plexus injury decreased from 9.8% to 7.1% after simulation implementation, however not statistically significantly so (p = 0.24). 5 minute Apgar ≤ 4 was similar (PRE 1.7% vs. POST 1.8%, p = 0.91). The rate of any birth injury decreased significantly from 22.3% (PRE) to 12.5% (POST, p = 0.001); however, the rate of admission to the NICU increased significantly: 7.0% (PRE) vs. 12.9% (POST, p = 0.012). We found no change in the rate of brachial plexus injury following implementation of shoulder dystocia simulation. There was a decrease in birth injury overall and an increase in NICU admission rate, indicating some association between outcomes and simulation. Further research is needed to understand how to reduce injuries from shoulder dystocia; simulation in and of itself is not a panacea for all adverse obstetric outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

762 Factors associated with brachial plexus injury following shoulder dystocia

Brachial plexus injury is an adverse outcome of shoulder dystocia that is difficult to predict and prevent. This study sought to identify risk factors for brachial plexus injury in shoulder dystocia, particularly examining prioritization of delivery of the posterior arm. This was a retrospective, case-control study of deliveries with shoulder dystocia, comparing characteristics between those with and without associated neonatal brachial plexus injuries. All shoulder dystocia cases between January 1, 2010 and December 31, 2019 were identified from a contemporaneously maintained obstetrical database and confirmed via chart review. Maternal BMI, birth weight, delivery provider, number of shoulder dystocia maneuvers used, and prioritization of delivery of the posterior arm (defined as inclusion of posterior arm within the first three maneuvers), were examined. 639 cases of shoulder dystocia were identified. 55 (8.6%) were complicated by brachial plexus injury. Brachial plexus injury was significantly more common with use of more maneuvers and prioritization of the posterior arm. Maternal BMI (available for 602) and neonatal birth weight were higher in the group with brachial plexus injury than without (36.5 vs. 33.3, p = 0.0007 and 4058 vs. 3865, p = 0.001). There was no difference in brachial plexus injury rate based on delivery provider (resident, midwife, or attending p = 0.31, available for 378). After controlling for BMI and birth weight, prioritization of the posterior arm remained associated with increased odds of brachial plexus injury (OR 3.37, CI 1.06-10.75, p = 0.04). This study corroborated previously identified factors associated with brachial plexus injury. The increased odds of brachial plexus injury associated with prioritization of the posterior arm stands in contrast to earlier data, which has suggested this maneuver has similar rates of injury to others and has the highest rate of successful delivery. Further research is needed to elucidate the ideal balance between number and order of maneuvers, in order to optimize management of shoulder dystocia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Neonatal outcomes of two-step delivery in low-risk pregnancy: A prospective observational study.

Extraction of the fetal body is typically performed immediately after delivery of the head in Western obstetric care. Reports justifying immediate extraction are few. Two-step delivery entails waiting for the next uterine contraction after delivery of the head. The present study evaluates neonatal asphyxia and respiratory impairment in two-step delivery using the head-to-body delivery interval. This prospective observational study performed at a single birth clinic used the data of 262 low-risk pregnant women with two-step delivery. We measured the time interval of head-to-body delivery and correlation analysis and simple linear regression analysis between the head-to-body delivery interval and umbilical artery pH. The women were divided into two groups according to the head-to-body delivery interval: ≤60 or >60 s. The prevalence of neonatal asphyxia and neonatal respiratory impairment was compared between the groups. The mean head-to-body delivery interval was 88.9 ± 71.3 s. The umbilical artery pH tended to decrease with increasing head-to-body delivery interval; however, there was almost no correlation and the decline of pH was only 0.010 for every additional minute. Low Apgar score incidence at 5 min did not differ significantly between the groups. No cases of shoulder dystocia were reported, and tachypnea at 4 h after birth occurred in 3% of the births. A longer head-to-body delivery interval is not associated with negative outcomes in two-step delivery. We believe that two-step delivery could have some superior outcomes compared with one-step delivery outcomes, particularly as to improving fetal circulation and preventing shoulder dystocia.

The Carit Maneuver: A Novel Approach for the Relief of Shoulder Dystocia-A Case Series.

Objective The main purpose of this article is to describe the technique and mechanism of action of a novel intervention for the relief of shoulder dystocia we are labeling Carit maneuver. Methods We report a cohort study of eight cases of shoulder dystocia not relieved by the combination of McRobert's maneuver and suprapubic pressure treated with the Carit maneuver. This intervention involves the use of the fetal head and neck as the grasping point of the fetus to exert a ventral rotation of the fetal trunk, reduce the bi-acromial diameter, and deliver the posterior shoulder by passive displacement. In all these cases, the direction of the original head restitution, direction of exerted rotation, and side and location of delivery of the first shoulder were recorded. Maternal and neonatal outcomes were reviewed and reported. Results In all cases, the Carit rotational maneuver resulted in the delivery of the posterior shoulder in the transverse (4), oblique anterior (2), or direct anterior (2) diameters. No instances of neonatal depression or fetal acidemia were noted in this cohort. Conclusion The Carit maneuver is an original and successful intervention in the management of shoulder dystocia unresponsive to McRobert's maneuver and suprapubic pressure.