Cases Of Shoulder Dystocia Research Articles

Perineal Travmayı Azaltmaya Yönelik Alternatif Yöntemler

Episiotomy, one of the causes of perineal trauma, is one of the world’s leading obstetric surgical practices that have increased significantly during the 20th century. The American Gynecology and Obstetric Union 2016 does not recommend the routine application of episiotomies during spontaneous vaginal deliveries and recommends it in cases where a rapid delivery of the fetus is required, in operative vaginal deliveries and in shoulder dystocia cases. In current studies, the episiotomy frequency in the world varies between 50% and 95% for nulliparas and 6-20% for multiparas. In our country, studies on the frequency of episiotomy are limited, but the application frequency of episiotomy is 90-99% for nulliparas and 50% -75% for multiparas in those studies. Today, much current evidence suggests that limited episiotomy is more protective than routine episiotomy in terms of perineal trauma. In this respect, there are various applications in the literature aimed at reducing the incidence of perineal trauma. These applications include perineal massage, warm application to the perineum, birth positions, hand maneuvers and push out. These methods are methods that reduce perineal trauma. The practitioners of these methods are midwives and obstetric and gynecological nurses who have a very important role and responsibility at/ during the vaginal birth. For this reason, this review study was carried out in order to increase the sensitivity to the subject and to guide health professionals by drawing attention to the alternative methods in order to reduce perineal traumas such as episiotomies and lacerations in accordance with the related current literature.

Fetal growth velocity in diabetics and the risk for shoulder dystocia: a case-control study

Introduction Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia. Methods We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on the year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (<0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise. Results Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, p = .01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR = 1.8, 95% confidence interval (CI) = 0.9–3.3; OR = 1.6, 95% CI = 0.8–3.2; OR = 1.7, 95% CI = 0.7–3.9; and OR = 1.8, 95% CI = 0.6–5.3; respectively); however, this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR = 3.3, 95% CI = 1.5–7.1, OR = 4.8, 95% CI = 1.3–17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls. Conclusion Future research is required to determine if fetal growth velocity proves to be a useful tool in identifying women at increased risk for shoulder dystocia. Larger studies are required for precise estimates of risk, and associated neonatal outcomes.

The epidemiological study of neonatal brachial plexus injury in Guangxi, China

Objective To analyze the epidemiological characteristics and risk factors of neonatal brachial plexus injury in Guangxi. Methods A retrospective study was conducted on 114 cases of neonatal brachial plexus injury recruited from twelve hospitals in Guangxi between January 2007 and December 2017. The basic situation of the mothers before pregnancy, during pregnancy and during childbirth was analyzed. Results The average birth weight of the children was (4 056.49±701.57) g, of which 61 cases had total brachial plexus injury. The average BMI before pregnancy of the mothers was (22.83±3.23) kg/m2 and the average weight gain during pregnancy was (13.68±3.41) kg. There were 80 cases of shoulder dystocia and 59.65% of the mothers delivered in county or township hospitals. Conclusion The birth weight, maternal weight before and during pregnancy, and delivery mode are all related to neonatal brachial plexus injury. It is necessary to strengthen health education, control the weight of pregnant women before and during pregnancy, reduce the incidence of macrosomia, strengthen the monitoring of high-risk pregnant women, and carefully use the devices for midwifery. Key words: Infant, newborn; Brachial plexus; Epidemiology; Guangxi

Are OB/GYN Residents Receiving Adequate Training for Shoulder Dystocia? [29J

INTRODUCTION: Data are lacking to determine whether residents are competent to manage shoulder dystocia, as the ACGME does not track this condition. We sought to ascertain whether OB/GYN residents felt that they had received adequate training to independently handle shoulder dystocia. METHODS: A 25-question web-based survey was electronically disseminated to program directors of all accredited US OB/GYN residency programs. The survey was sent four times on a weekly basis. A Likert scale was used to query the residents with regards to clinical and didactic training experience. Survey monkey and IBM SPSS Statistics were used to analyze the responses. RESULTS: Nearly all (97%) of the 116 residents who responded had received formal lecture training and underwent simulation drills (87%), and most (89%) felt that they had received appropriate didactic training. 64% of residents had participated in < 10 total cases of shoulder dystocia. Only 51.7% and 48.3% agreed that they could currently independently perform delivery of the posterior fetal arm and fetal rotational maneuvers, respectively. Approximately half of residents (47%) responded that they had never independently managed a shoulder dystocia from start to finish. Slightly more than one third of residents strongly agreed that after completion of residency training they would feel comfortable independently managing a shoulder dystocia. CONCLUSION: Residency programs have incorporated simulation and didactic lectures into shoulder dystocia teaching. This does not appear to have translated into clinical competence in handling this obstetrical emergency.

Anal sphincter injury associated with shoulder dystocia

Objective: Shoulder dystocia is an obstetric emergency, occurring in 0.2–3% of vaginal deliveries. Research has mainly focused on the neonatal morbidity arising from shoulder dystocia, such as brachial plexus injury and hypoxic-ischemic encephalopathy. Maternal morbidity is thought to be increased with shoulder dystocia though is much less commonly reported. Obstetric anal sphincter injury remains the leading cause of fecal incontinence in women and shares several antenatal and intrapartum risk factors with shoulder dystocia. The aim of this study was to identify risk factors for sphincter injury associated with shoulder dystocia.Methods: This retrospective analysis included all cases of shoulder dystocia from 2008 to 2017 in a single unit in North-East Ireland. Maternal characteristics and delivery outcomes were analyzed. Two groups were compared, those with and without anal sphincter injury in our shoulder dystocia cohort and those with and without shoulder dystocia, regardless of sphincter injury. Univariate and multivariate logistic regression models were used to examine risk factors for sphincter injury.Results: There were 24,159 singleton cephalic vaginal deliveries over the study period, with 495 cases of shoulder dystocia, giving an incidence of 2.1% (495/24 159). The rate of anal sphincter injury in those with shoulder dystocia was 4.4% (22/495), with 7.6% (12/158) in nulliparas, and 3.0% (10/337) among multiparas. Women with sphincter damage were more likely to be nulliparous than those with an intact sphincter (54.5% [12/22] vs. 30.9% [146/473]; p = .036) and have an operative vaginal delivery (72.7% [16/22] vs. 39.1% [185/473]; p = .004). Episiotomy was more common in those with a sphincter injury (68.2% [15/22] vs. 37.0% [175/473]; p = .007). On univariate regression analysis, nulliparity (OR 2.69) and operative vaginal delivery (OR 4.15) were associated with sphincter injury. No risk factors were identified on multivariate regression analysis.Discussion: In our population, the risk of anal sphincter injury with shoulder dystocia is 4.4%. Risk factors include nulliparity and operative vaginal delivery. After controlling for other factors, these associations became nonsignificant. Further research into sphincter injury at shoulder dystocia is warranted.

What's Happening When the Pregnancies Are Not Terminated in Case of Anencephalic Fetuses?

BackgroundTo review the obstetric outcomes of pregnancies with anencephalic fetuses when these pregnancies are not terminated and ongoing.MethodsA retrospective chart review is made of the cases with a prenatal diagnosis of anencephaly and who were opted to continue the pregnancy in 1-year period. The evaluated data included gestational age at diagnosis, gestational age at birth, labor induction rates, cesarean delivery rates, stillbirth, shoulder dystocia rate, antepartum and postpartum hemorrhage.ResultsA total of 28 cases that were selected from 87 cases with the diagnosis of anencephaly are included in the study. The average gestational age at diagnosis was 18 weeks. The average gestational age at birth was 31 weeks (range 23 - 37 weeks). Stillbirths were reported in 32% (9/28). Polyhydramnios developed at six patients and two of them required amniodrainage due to severe polyhydramnios. Vaginal birth was achieved in 67% (19/28) of the patients. Labor induction was applied at total 17 patients and one of them had gone to cesarean section due to failed induction. There were two cases of shoulder dystocia. Nine patients had gone to cesarean delivery. Any other complication was not encountered.ConclusionsParents should be counseled in detail about continuation of an anencephalic pregnancy before making their decision. The information about “what an anencephalic pregnancy can lead”' should be given. The redundant cesarean deliveries, polyhydramnios and associated complications, obstetrical hemorrhage risk should be discussed with patients. It should also be emphasized that these maternal risks are for the sake of a non-life expectant baby.

657: Improving the prediction of shoulder dystocia using artificial intelligence – a novel approach

The American College of Obstetricians and Gynecologists (ACOG) recommends consideration of elective cesarean section (CS) to prevent shoulder dystocia (ShD) for women without diabetes carrying fetuses with an estimated fetal weight (EFW) of at least 5,000g and for women with diabetes carrying fetuses with an EFW of at least 4,500g. However, most ShD cases occur in nondiabetic women with normal-sized infants. Our aim was to analyze the potential of artificial intelligence (AI) to predict ShD. A cohort of 53,754 singleton deliveries between 2011 to 2018 from a large tertiary university-affiliated hospital was analyzed. All ShD cases during the study period were identified, and comprehensive prenatal, obstetric and neonatal data from ShD cases were compared with 4:1 controls of singleton vaginal deliveries from the same institution. The AI model incorporated maternal factors (age, height, weight at delivery, smoking, diabetes, insulin treatment), obstetric history (parity, prior CS and prior ShD), fetal sonographic parameters within 2 wks of delivery (BPD, AC, HC, FL, and EFW) and neonatal factors (birth weight and sex). To develop a ShD prediction model, we split the data to training and test sets (80%-20%), and fit a generalized linear model with Lasso regularization on the training set. We repeated the learning with 100 random splits of the data. 239 (0.44%) cases of ShD occurred during the study period. The mean newborn weight among ShD cases was significantly higher than controls (3857g vs 3230g respectively, P < 0.01); however, there was a wide overlap between groups (Fig 1). The AI model identified 12 variables to include in the prediction of ShD with different predictive strengths, some of them protective (Fig 2). Incorporating all factors, the model was able to prevent 41.7% of ShD cases using a 10% elective CS rate cutoff. This CS rate is equivalent to a universal 4000g elective CS recommendation, although doing so would result in prevention of significantly less (35.9%, P<0.01) ShD cases compared with the AI model. We present the first robust study analyzing the potential of AI for prediction of ShD. The model was superior to traditional clinical parameters and therefore we plan to validate the clinical performance of the model using additional datasets with different population characteristics.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

396: Medication adherence in women with gestational diabetes and its effect on pregnancy outcomes

Treatment of gestational diabetes (GDM) is associated with improved pregnancy outcomes. Obstacles to taking prescribed medications can lead to non-compliance. The objective was to determine the challenges that lead to low medication adherence and whether this increases the rate of adverse pregnancy outcomes in women with GDM. A prospective, observational study was performed of women with GDM treated with metformin, glyburide or insulin at a tertiary care center. Women greater than 16 weeks gestation and treated for a minimum of 2 weeks were included. Women with pre-DM were excluded. Women completed a validated survey, MMAS-8 (low: score <6 and high: score 7-8), to identify women with low and high medication adherence. Information resulting in medication compliance was collected. The primary outcome was neonatal birth weight >4,000g. Secondary outcomes included factors with medication adherence, adherence rates for each medication and neonatal outcomes. Of 79 women who met study criteria, 42 reported high and 37 reported low adherence. Birth weight >4,000g were similar in each group, (low: 16.2% vs. high: 7.1%, p = 0.292). Women prescribed metformin had the highest rate of high adherence (38.1%) and women on glyburide had the highest rate of low adherence (46%). The rate of neonatal hypoglycemia was significantly higher in women with low adherence compared to high adherence, (low: 70.3% vs high 42.9%, p = 0.023). There were similar rates of induction of labor, cesarean section, NICU admissions, and neonatal respiratory complications. There were no cases of shoulder dystocia, Erb’s palsy, or major neonatal morbidities. Obstacles to medication adherence were documented in 14% of women including prescription error, insurance difficulties and delay in dispensing the medications. Adverse effects to medication were reported in 10-20% of women. Although there were no differences in neonatal birthweight between groups, low medication adherence was associated with neonatal hypoglycemia. Challenges to compliance with prescribed medications occurred in 14% of GDM women and up to 1 in 5 women reported a medication side effects. Further studies are needed to investigate patient-specific and system-level strategies to improve medication adherence in women with GDM.

Birthweight thresholds for increased risk for maternal and neonatal morbidity following vaginal delivery: a retrospective study.

To determine neonatal birthweight (BW) thresholds for adverse maternal and neonatal outcome following vaginal delivery. A retrospective cohort study of all women with singleton pregnancies who underwent vaginal delivery in a university-affiliated tertiary hospital (1996-2015). The association between BW and adverse outcome in neonates with BW ≥ 3500g (> 90th centile BW at 37weeks' gestation) with 100g-increment groups was explored. Pregnancies complicated by diabetes mellitus, fetal anomalies or cesarean deliveries were excluded. The composite neonatal outcome was defined as shoulder dystocia or brachial plexus injury. The composite maternal outcome was defined as postpartum hemorrhage or third- or fourth-degree perineal tears. Of the 121,728 deliveries during the study period, 26,920 (22.1%) met inclusion criteria. Of these, 1024 (3.8%) had a composite adverse maternal outcome and 947 (3.5%) had a composite adverse neonatal outcome. The rates of composite maternal outcomes increased significantly only at a BW of 4800g and above. The composite neonatal outcomes increased significantly only at a BW of 4400g and above. In multivariate analysis, after subcategorizing our cohort into 3 BW groups [3500-3999g (control, n = 23,030); 4000-4399g (n = 3494); ≥ 4400g (n = 396)], BW was associated with adverse neonatal outcomes in a dose-dependent manner. In the BW ≥ 4400g group, to prevent one case of shoulder dystocia or Erb's palsy, 12 cesarean deliveries needed to be performed. For non-diabetic mothers who deliver vaginally, neonatal BW ≥ 4400g was associated with a significant increase in adverse neonatal outcomes, whereas neonatal BW ≥ 4800g was associated with a significant increase in adverse maternal outcomes.

Clinical features of a fatal shoulder dystocia: The hypovolemic shock hypothesis

Shoulder dystocia is a rare but severe obstetric complication associated with an increased risk of brachial plexus palsies, fractures of the clavicle and humerus, hypoxic-ischemic encephalopathy and, rarely, neonatal death.Here we describe a fatal case of shoulder dystocia in a term newborn, although labor was uneventful, fetal heart rate tracing was normal until the delivery of the head and the head-to-body delivery interval (HBDI) occurred within 5 min. Full resuscitation was performed for 35 min without success. Hemoglobin concentration evaluated on the umbilical cord still attached to the placenta was within normal range, while neonatal venous hemoglobin concentration blood gases at 9 min of life showed severe metabolic acidosis and anemia.As previously described by others, our case supports the hypothesis of a hypovolemic shock as the cause of neonatal death, probably due to acute placental retention of fetal blood.The death of the newborn following shoulder dystocia is an event that still presents numerous gaps in knowledge. Further research should focus on:•Performing neonatal resuscitation with an intact umbilical cord.•Milking the umbilical cord before clamping.•Clamp the umbilical cord leaving a long portion attached to the newborn and squeeze its content simultaneously with the first resuscitation maneuvers.•Consider postdelivery volume replacement therapy sooner than expected from resuscitation algorithm.

Anencephaly and obstetric outcome beyond the age of viability.

Objective To review the obstetric impact and natural history of anencephalic pregnancies beyond the age of viability. Study design A retrospective chart review of all cases with a prenatal diagnosis of anencephaly who delivered after 24 weeks' gestation during the period 1990 until 2016. Obstetric outcomes including mode of delivery, live births, shoulder dystocia, antepartum haemorrhage (APH), postpartum haemorrhage (PPH) and uterine rupture were studied. Results A total of 42 cases were studied. The average gestational age at diagnosis was 22 weeks (range 10-41). The average gestational age at birth was 36 weeks (range 25-44 weeks). Induction of labour was performed in 55% (23/42) of the cases. Livebirths were documented in 40% (17/42) of the cases. The average birth weight was 1597±746 g. The rate of vaginal birth was 69% (29/42), the overall rate of caesarean section was 31% (13/42), with a primary caesarean section in 31% (4/13) and a repeat caesarean section in 69% (9/13) of the patients. There were two cases of shoulder dystocia. No other complications were encountered. Conclusion Overall, anencephaly is not associated with an increased risk of obstetric complications; however, there is a tendency towards delivery via repeated caesarean section in women with a previous uterine scar and anencephaly. The prenatal counselling of potential obstetric outcomes could be of robust value for parents who opt to continue with anencephalic pregnancies.

An Initiative to Reduce the Episiotomy Rate: Association of Feedback and the Hawthorne Effect With Leapfrog Goals.

To assess the association of education, performance feedback, and the Hawthorne effect with a reduction in the episiotomy rate in a large academic institution. We describe a prospective observational study of a project conducted between March 2012 and February 2017 to assist clinicians in meeting the Leapfrog Group (www.leapfroggroup.org) target rates for episiotomy. Phases of this project included preintervention (phase 1, March 2012 to April 2014), education and provision of collective department episiotomy rates (phase 2, May 2014 to December 2014), ongoing education with emphasis on a revised Leapfrog target rate (phase 3, January 2015 to February 2016), and provision of individual episiotomy rates to practitioners on a monthly basis (phase 4, March 2016 to February 2017). We analyzed the department episiotomy rates before, during, and after these efforts. Cases of shoulder dystocia were excluded from this analysis. Statistical analysis was performed using a two-tailed Student t test and χ test with P<.05 considered significant. During the study period 1,176 episiotomies were performed in 16,441 vaginal deliveries (7.2%). In phase 2 (2,352 vaginal deliveries), there was a nonsignificant drop in the episiotomy rate with education alone (9.0-8.2%, P=.21). In phase 3 (4,379 vaginal deliveries), the episiotomy rate demonstrated an additional, significant drop to 5.9% (P<.001), but this reduction did not reach the new Leapfrog goal of 5%. In phase 4 (3,160 vaginal deliveries), the hospital episiotomy rate again dropped significantly from 5.9% to 4.37% (P=.007) and met the target rate of 5%. This reduction was sustained over a 12-month time period. During this same time period, the rate of operative vaginal delivery among vaginal births increased (4.5-5.4%, P=.003) and there was no significant change in the rates of third- and fourth-degree perineal laceration (3.8-3.3%, P=.19). Education, performance feedback, and the Hawthorne effect were associated with a reduction in the episiotomy rate in a large academic institution without a reduction in the rate of operative vaginal delivery or an increase in the rate of third- and fourth-degree lacerations.

Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p<0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p=0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p=0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

Immediate delivery or expectant management in gestational diabetes at term: the GINEXMAL randomised controlled trial.

To evaluate maternal and perinatal outcomes after induction of labour versus expectant management in pregnant women with gestational diabetes at term. Multicentre open-label randomised controlled trial. Eight teaching hospitals in Italy, Slovenia, and Israel. Singleton pregnancy, diagnosed with gestational diabetes by the International Association of Diabetes and Pregnancy Study Groups criteria (IADPSGC), between 38+0 and 39+0 weeks of gestation, without other maternal or fetal conditions. Patients were randomly assigned to induction of labour or expectant management and intensive follow-up. Data were analysed by 'intention to treat'. The primary outcome was incidence of caesarean section. Secondary outcomes were maternal and perinatal mortality and morbidity. A total of 425 women were randomised to the study groups. The incidence of caesarean section was 12.6% in the induction group versus 11.7% in the expectant group. No difference was found between the two groups (relative risk, RR 1.06; 95% confidence interval, 95% CI 0.64-1.77; P = 0.81). The incidence of non-spontaneous delivery, either by caesarean section or by operative vaginal delivery, was 21.0 and 22.3%, respectively (RR 0.94; 95% CI 0.66-1.36; P = 0.76). Neither maternal nor fetal deaths occurred. The few cases of shoulder dystocia were solved without any significant birth trauma. In women with gestational diabetes, without other maternal or fetal conditions, no difference was detected in birth outcomes regardless of the approach used (i.e. active versus expectant management). Although the study was underpowered, the magnitude of the between-group difference was very small and without clinical relevance. Immediate delivery or expectant management in gestational diabetes at term?

Training of midwives in advanced obstetrics in Liberia.

ProblemThe shortage of doctors in Liberia limits the provision of comprehensive emergency obstetric and neonatal care.ApproachIn a pilot project, two midwives were trained in advanced obstetric procedures and in the team approach to the in-hospital provision of advanced maternity care. The training took two years and was led by a Liberian consultant obstetrician with support from international experts.Local settingThe training took place in CB Dunbar Maternity Hospital. This rural hospital deals with approximately 2000 deliveries annually, many of which present complications. In February 2015 there were just 117 doctors available in Liberia.Relevant changesIn the first 18 months of training, the trainees were involved with 236 caesarean sections, 35 manual evacuations of products of conception, 25 manual removals of placentas, 21 vaginal breech deliveries, 14 vacuum deliveries, four repairs of ruptured uteri, the management of four cases of shoulder dystocia, three hysterectomies, two laparotomies for ruptured ectopic pregnancies and numerous obstetric ultrasound examinations. The trainees also managed 41 cases of eclampsia or severe pre-eclampsia, 25 of major postpartum haemorrhage and 21 of shock. Although, initially they only assisted senior doctors, the trainees subsequently progressed from direct to indirect supervision and then to independent management.Lessons learntTo compensate for a shortage of doctors able to undertake comprehensive emergency obstetric and neonatal care, experienced midwives can be taught to undertake advanced obstetric care and procedures. Their team work with doctors can be particularly valuable in rural hospitals in resource-poor countries.

Dystocie des épaules : évaluation de la qualité de la retranscription dans les dossiers médicaux

ObjectiveShoulder dystocia is a rare obstetrical event and potentially serious. Apart from possible psychological implications, it may be responsible for maternal (haemorrhage and perineal tear) and neonatal complications (brachial plexus) leading to complaints and even lawsuits. The transcription of this event in medical files is essential as it is a reflection of the work in an emergency. It allows the obstetrician to defend him in case of trial. Our objective was to assess the quality of the transcription of shoulder dystocia situations in medical files. MethodRetrospective chart study conducted in a university hospital with maternity type III. The primary objective was the rate of comprehensive records (name maneuvers and order of maneuvers of the anterior shoulder hand, time between the expulsion of the head and body, Apgar score). ResultsBetween 2007 and 2015, 54 cases of shoulder dystocia requiring a second line maneuver after vaginal delivery (Wood and/or Jacquemier) were included. In all, 98.2% of the files were incomplete. The maneuvers and their order were noted in 100% of cases. However, the operation was not correctly described in 16.7% of cases. The anterior shoulder was noted in 16.7% of cases. The time between the expulsion of the head and the body was noted in one single files. Neither broken collarbone nor brachial plexus were observed. ConclusionTo improve the management of dystocia shoulder and transcription of data in files, simulation sessions and the creation of a standardized form would be needed.

Effectiveness of team training in managing shoulder dystocia: a retrospective study

Objectives: To evaluate the effectiveness of simulation team training for the management of shoulder dystocia. Primary outcome measures were the number of reported cases of shoulder dystocia, as well as fetal injury that occurred from it. Secondary outcome is documentation of manoeuvres used to alleviate shoulder dystocia.Methods: Retrospective cohort study in a teaching hospital in the Netherlands, in a 38 month period before and after implementation of team training.Results: We compared 3492 term vaginal cephalic deliveries with 3496 deliveries before and after team training. Incidence of shoulder dystocia increased from 51 to 90 cases (RR 1.8 (95% CI: 1.3–2.5)). Fetal injury occurred in 16 and eight cases, respectively (RR 0.50 (95% CI: 0.21–1.2)). Before team training started, the all-fours manoeuvre was never used, while after team training it was used in 41 of 90 cases (45%). Proper documentation of all manoeuvres used to alleviate shoulder dystocia significantly increased after team training (RR 1.6 (95% CI: 1.05–2.5)).Conclusions: Simulation team training increased the frequency of shoulder dystocia, facilitated implementation of the all-fours technique, improved documentation of delivery notes and may have a beneficial effect on the number of children injured due to shoulder dystocia.

Clinical analysis of 41 cases of the shoulder dystocia

Objective To explore the high risk factors, clinical prediction and treatment methods of the shoulder dystocia to reduce the incidence of complications in mother and child. Methods The clinical data of 41patients with shoulder dystocia were retrospectively analyzed, and they were divided into the huge baby group and normal weight baby group.The causes, incidence of complications in mother and child and the treatment were analyzed. Results In the 41 cases of shoulder dystocia, the incidence of complications in mother and child in the macrosomia group was higher than the normal weight baby group(the incidence of postpartum hemorrhage, the incidence of neonatal asphyxia in the huge baby group were higher than the normal weight baby group, χ2=4.439, 5.225, all P 0.05, and the difference between the two groups reach the significant level. Conclusion The shoulder dystocia is a serious maternity emergency, the huge baby is the high factor of the shoulder dystocia, the important treatment to reduce the incidence of complications in mother and child is the correct prevention, prediction, early identification and proper treatment. Key words: Dystocia; Risk factors; Prengnancy complications

Indications for episiotomy performance – a cross-sectional survey and review of the literature

Our objective was to assess the reported reasons for episiotomy performance in Israel and to review the relevant professional literature. Using anonymous questionnaires, a survey was conducted among obstetricians and midwives in four northern Israel hospitals, and the accoucheurs were asked to score their agreement with 13 proposed indications for episiotomy. Overall, 84 doctors and 32 midwives completed the questionnaires. 86.1% of the responders reported performing episiotomy in all or most cases of shoulder dystocia, and more than half reported performing it in most cases of vacuum deliveries, fetal macrosomia and advanced perineal tear in previous delivery. Subjective assessment of perineal characteristics constituted a justified reason for episiotomy for 15.8–43.9% of the accoucheurs. In conclusion, there is a wide variation in reported reasons for episiotomy between the obstetricians, and many of these indications are not congruent with international practice guidelines. Uniform protocols and educational programmes are needed to guide episiotomy practice.

Fetal sonographic characteristics associated with shoulder dystocia in pregnancies of women with type 1 diabetes.

Shoulder dystocia is a rare but severe complication of vaginal delivery and diabetic women are at high risk. The aim of this study was to identify fetal sonographic and maternal glycemic characteristics associated with shoulder dystocia in pregnant women with type 1 diabetes. Twelve cases (5%) of shoulder dystocia among 241 consecutive vaginal deliveries in women with type 1 diabetes followed at Rigshospitalet University Hospital in 2009-2013 were retrospectively identified in a local database. Fetal sonographic and clinical data were compared with 69 women with type 1 diabetes and uncomplicated vaginal deliveries. Women experiencing shoulder dystocia compared with women with uncomplicated deliveries had a higher glycated hemoglobin (HbA1c) in early pregnancy [median 7.0% (range 5.9-8.1) vs. 6.6% (range 5.4-10.0, P = 0.04)], whereas in late pregnancy, HbA1c in the two groups of women was comparable [6.1% (range 5.5-6.9) vs. 6.0% (range 4.7-8.4, P = 0.30)]. Fetal biometry at 36 weeks showed a higher estimated fetal weight of 3597 g (range 3051-4069) vs. 2989 g (range 2165-4025), P < 0.001, corresponding to 20% (4-41%) vs. 5% (-20 to 44%) above the mean estimated fetal weight for gestational age (P = 0.002) and a greater abdominal circumference SD score of 2.51 (range 1.56-4.20) vs. 1.33 (range -1.08 to 4.25), P = 0.001). Head circumference was comparable. Vacuum extraction was more frequent during deliveries with shoulder dystocia (58 vs. 17%, P = 0.005). Seven (58%) newborns with shoulder dystocia had brachial plexus injuries, fractures, intra-abdominal bleeding or needed resuscitation. Excessive estimated fetal weight and abdominal circumference at 36 weeks' sonographic examination may help in identifying diabetic women at high risk of later shoulder dystocia.