Rate Of Shoulder Dystocia Research Articles

98: Utilization of evidence based practice bundle decreases the rate of shoulder dystocia and brachial plexus injury

98: Utilization of evidence based practice bundle decreases the rate of shoulder dystocia and brachial plexus injury

Does the Presence of a Condition-Specific Obstetric Protocol Lead to Detectable Improvements in Pregnancy Outcomes?

In attempt to improve patient safety and outcomes, protocols for treatment of a specific complication have been suggested in various studies and encouraged by government regulation and malpractice carriers. However, evidence that condition-specific protocols improve obstetric outcomes is lacking. Studies that have shown improved outcomes because of these protocols have been primarily limited to single centers. This study examined if risk-adjusted patient outcomes would be better in hospitals with condition-specific obstetric protocols in place compared with hospitals without protocols. This study was a secondary analysis of the data set from a cohort study at 25 hospitals that was performed between 2008 and 2011, the Assessment of Perinatal Excellence (APEX) study. Participating hospitals submitted all protocols for labor and delivery quarterly and included the dates that those protocol were in effect. Patients were categorized by whether they delivered in the presence of a protocol. Data were analyzed to find whether the outcomes, adjusted for risk, related to specific complications were associated with condition-specific protocols used during deliver. Data from 115,502 patients were collected. The rate of hemorrhage was significantly higher in hospitals with a hemorrhage protocol. Hospitals without preeclampsia protocols had significantly higher rates of intensive care unit admissions for preeclampsia (odds ratio, 0.28; 95% confidence interval, 0.18–0.44), and preeclampsia-specific protocols were also associated with fewer cases of severe hypertension (odds ratio, 0.86; 95% confidence interval, 0.77–0.96). Protocols for postpartum hemorrhage were associated with an increased rate of postpartum hemorrhage and not associated with a lower rate of cases with more than 1000-mL estimated blood loss. Protocols for shoulder dystocia were not associated with a change in the rate of shoulder dystocia or rate of shoulder dystocia maneuvers used. There was not a consistent relationship found between condition-specific protocols and the severity of those complications. The adjustment for risk in these data was important for determining results. The different results found between preeclampsia protocols and hemorrhage protocols may be explained by the fact that preeclampsia is a more frequently occurring complication, and providers may be more familiar with that protocol. In conclusion, the results suggest whether a protocol is in place does not matter. More research is necessary to better understand high-quality protocol.

Maternal complications associated with stillbirth delivery: A cross-sectional analysis

This study sought to identify delivery complications associated with stillbirth labour and delivery. We conducted a retrospective chart review evaluating stillbirth demographics, pregnancy and maternal risk factors, and complications of labour and delivery. We performed bivariable analysis and multivariable logistic regression to evaluate factors associated with medical complications and variations by race. Our cohort included 543 mothers with stillbirth, of which two-thirds were African-American. We noted high rates of shoulder dystocia, clinical chorioamnionitis, postpartum haemorrhage and retained placenta in women with stillbirths. Thirty-three women (6%) experienced at least one serious maternal complication. Complication rates did not vary by maternal race. Providers who perform obstetrical care should be alert to the high rate of maternal medical complications associated with labour and delivery of a stillbirth foetus.

Cesarean delivery among women with prolonged labor induction.

The objective of this study was to determine characteristics associated with cesarean delivery among women with labor induction lasting over 24 h. Women with live singleton pregnancies without prior cesarean delivery undergoing a labor induction lasting >24 h between September 2006 and March 2009 at Duke University Hospital were identified. Collected variables were compared between subjects by mode of delivery. A multivariate logistic regression model for the outcome cesarean delivery was constructed separately for nulliparous and parous women. There were 303 women who met inclusion criteria. The overall cesarean delivery rate was 57% (n=172) and remained constant with time (P=0.15, test-for-trend). Nulliparous women having a cesarean delivery were more likely to be obese [adjusted OR (aOR) 2.00; 95% CI 1.05, 3.80] and have a larger fetus [aOR 1.11 (aOR for every 100 g increase in birthweight), 95% CI 1.03, 1.20] compared to those having a vaginal delivery. Increasing BMI and birthweight were independent predictors of cesarean delivery among nulliparous women with prolonged labor induction. Despite this, after 24 h of labor induction, the overall mean cesarean delivery rate remained constant at 57%, and did not change with time. Among women having a vaginal delivery following a prolonged labor induction, we saw high rates of shoulder dystocia, operative vaginal delivery and severe perineal laceration.

Association of isolated polyhydramnios at or beyond 34 weeks of gestation and pregnancy outcome.

To evaluate pregnancy outcome among women with isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation. Retrospective cohort study at a tertiary medical center between 2007 and 2012. Isolated polyhydramnios was defined as amniotic fluid index (AFI) greater than 25 cm at admission in the absence of gestational or pregestational diabetes mellitus or fetal structural or chromosomal anomalies. Women with isolated polyhydramnios were compared with women with a normal AFI (5-25 cm). Overall, 31,376 women were eligible for analysis, of whom 215 (0.7%) had isolated polyhydramnios and 31,161 normal AFI. Women with isolated polyhydramnios had higher rates of labor induction (7.9% compared with 4.8%, P=.04) and cesarean delivery (12.1% compared with 5.1%, P<.001). They also had higher rates of placental abruption (0.9% compared with 0.2%, P=.02), abnormal or intermediate fetal heart rate (FHR) tracings (7.0% compared with 3.2%, P=.002), and prolonged first stage of delivery (6.0% compared with 1.4%, P<.001). Isolated polyhydramnios was also associated with higher rates of shoulder dystocia (1.9% compared with 0.3%, P<.001) and respiratory distress syndrome (0.5% compared with 0.03%, P=.001). On a multiple logistic regression model, isolated polyhydramnios was an independent risk factor for labor induction (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.01-2.8), cesarean delivery (adjusted OR 2.6, 95% CI 1.7-4.0), prolonged first stage of delivery (adjusted OR 3.6, 95% CI 1.97-6.7), abnormal or intermediate FHR tracings (adjusted OR 2.6, 95% CI 1.6-4.5), placental abruption (adjusted OR 8.4, 95% CI 2.00-35.4), shoulder dystocia (adjusted OR 3.4, 95% CI 1.2-9.7), and respiratory distress syndrome (adjusted OR 38.9, 95% CI 4.6-332.6). Mild isolated polyhydramnios (AFI 25.1-30.0) was independently associated with cesarean delivery, prolonged first stage of delivery, placental abruption, abnormal or intermediate FHR tracings, and shoulder dystocia. Isolated polyhydramnios at admission for labor at or beyond 34 weeks of gestation is associated with adverse obstetric and neonatal outcomes.

Kielland's forceps: demise before the 100th anniversary?

To the Editor: As the time for the centennial of the Kielland’s forceps approaches, one ponders: will this elegant instrument have its demise before its 100th anniversary? Introduced in 1915 by Dr Christian Kielland, a Norwegian obstetrician, for the “deep transverse arrest,” it evolved into the instrument of choice for arrest of descent with occipito-transverse or occipito-posterior position of a cephalic presentation.1.Patterson W.R. The Kielland forceps.Can Med Assoc J. 1928; 18: 177-180PubMed Google Scholar The malpresenting baby would often not be large, as opposed to a non-malpresenting baby that would usually be large to have arrested in the first place. With a high likelihood of failure with attempts at manual rotation or a rotational vacuum, the Kielland’s forceps became an ideal instrument for facilitating a vaginal birth for fetal malposition in cephalic presentation. The relatively straight handle with a gentle backward pelvic curve and a sliding lock were ingenious additions to the obstetric forceps design, allowing easy application to a severely asynclitic head. Further, this design, when combined with the Scanzoni manoeuvre, allowed rotation of up to 180 degrees within the tight constraints of the maternal pelvis due to a relatively small circle of rotation. Given the usual normal-sized baby being delivered, once the head could be successfully rotated, most skilled users would agree that the risk of a significant perineal laceration was small. However, the last decade has witnessed a rapid decline in the use of Kielland’s forceps.2.Ramin S.M. Little B.B. Gilstrap 3rd., L.C. Survey of forceps delivery in North America in 1990.Obstet Gynecol. 1993; 81: 307-311PubMed Google Scholar, 3.Vacca A. Current obstetric training programs are unlikely to provide registrars with sufficient skill in the safe use of Kielland forceps.Aust N Z J Obstet Gynaecol. 2000; 40: 226-227Crossref PubMed Google Scholar This can be attributed to concerns regarding poor neonatal outcomes that were associated with the use of Kielland’s forceps.4.Patel R.R. Murphy D.J. Forceps delivery in modern obstetric practice.BMJ. 2004; 328: 1302-1305Crossref PubMed Scopus (95) Google Scholar In the litigious field of obstetrics, it was tempting to give up a controversial practice for the easier option, the Caesarean section. Given the medico-legal climate, although North American centres were slow in adopting the use of Kielland’s forceps, they were quicker to let it go. However, more recent evidence suggests that the concerns regarding neonatal outcomes may have been misplaced. A retrospective review of deliveries at a tertiary care centre over a four-year period compared the use of Kielland’s forceps, rotational ventouse and emergency Caesarean section.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar With a 25% Caesarean section rate and a 13% operative vaginal delivery rate, a cohort of approximately 1300 cases that reached full cervical dilatation with fetal malposition was identified. With an intention-to-treat analysis, 80% had an attempted Kielland’s rotation, 8% had an attempted rotational ventouse, and 11% had an emergency Caesarean section. The likelihood of needing a Caesarean section was eight-fold higher if a ventouse was used as opposed to the Kielland’s forceps. Failure of delivery with Kielland’s occurred in 4% of cases. Other than a trend towards an increased rate of shoulder dystocia, no increase in adverse outcomes was noted.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar However, obstetric practice changed before the evidence relating to the long-term outcomes of babies could become available,6.Kotaska A. Menticoglou S. Gagnon R; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline no. 226, June 2009.J Obstet Gynaecol Can. 2009; 31 (567–78): 557-566Abstract Full Text PDF PubMed Scopus (72) Google Scholar leaving a generation of obstetricians who are untrained in the science and art of a rotational forceps delivery. With increasing Caesarean section rates and associated maternal morbidity and mortality, we need ongoing efforts to find viable alternatives to Caesarean section. This leads to the question: is it time to revive the Kielland’s forceps delivery before it is too late? Or should we helplessly watch this endangered species disappear and become a part of the annals of the history of medicine?

Epidemiologic aspects of shoulder dystocia-related neurological birth injuries

The first part of the study involved data collection for the detection of geographic variations and chronologic fluctuations in the rates of shoulder dystocia. The second part of the research evaluated head-to-body delivery times in cases of arrest of the shoulders at birth that had resulted in fetal damage during the last four decades in the USA. The study of geographic and chronologic changes in the rates of shoulder dystocia rested on reported statistics coming from the USA and 11 other countries. These data were obtained by computer search. Evaluation of head-to-body delivery times rested on 104 well-documented cases that resulted in permanent neonatal damage. Literary reports of shoulder dystocia indicate that the incidence of shoulder dystocia has increased in the USA about fourfold since the middle of the twentieth century. No comparable trend has been reported from most other countries. Study of head-to-body delivery times revealed that more than two-thirds of all injured fetuses had been extracted from the birth canal within 2 minutes. Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere.

Shoulder dystocia: Definitions and incidence

Though subjective in nature, both the American College of Obstetricians and Gynecologists practice bulletin and the Royal College of Obstetricians and Gynaecologists green guideline are in agreement on the descriptor of shoulder dystocia: requirement of additional obstetric maneuvers when gentle downward traction has failed to affect the delivery of the shoulders. The rate of shoulder dystocia is about 1.4% of all deliveries and 0.7% for vaginal births. Compared to non-diabetics (0.6%), among diabetics, the rate of impacted shoulders is 201% higher (1.9%); newborns delivered by vacuum or forceps have 254% higher likelihood of shoulder dystocia than those born spontaneously (2.0% vs. 0.6%, respectively). When the birthweight is categorized as <4000, 4000–4449, and >4500g, the likelihood of shoulder dystocia in the US vs. other countries varies significantly. Future studies should focus on lowering the rate of shoulder dystocia and its associated morbidities, without concomitantly increasing the rate of cesarean delivery.

Counseling for fetal macrosomia: an estimated fetal weight of 4,000 g is excessively low.

Because of the known complications of fetal macrosomia, our hospital's policy has been to discuss the risks of shoulder dystocia and cesarean section (CS) in mothers with a sonographic estimated fetal weight (SEFW) ≥ 4,000 g at term. The present study was performed to determine the effect of this policy on CS rates and pregnancy outcome. We examined the pregnancy outcomes of the macrosomic (≥ 4,000 g) neonates in two cohorts of nondiabetic low risk women at term without preexisting indications for cesarean: (1) SEFW ≥ 4,000 g (correctly suspected macrosomia) and (2) SEFW < 4,000 g (unsuspected macrosomia). There were 238 neonates in the correctly suspected group and 205 neonates in the unsuspected macrosomia group, respectively. Vaginal delivery was accomplished in 52.1% of the suspected group and 90.7% of the unsuspected group, respectively, p < 0.001. There was no difference in the rates of shoulder dystocia. The odds ratio for CS was 9.0 (95% confidence interval, 5.3-15.4) when macrosomia was correctly suspected. The policy of discussing the risk of macrosomia with SEFW ≥ 4,000 g to women is not justified. A higher SEFW to trigger counseling for shoulder dystocia and CS, more consistent with American College of Obstetrics and Gynecology (ACOG) guidelines, should be considered.

Mechanism of Neonatal Brachial Plexus Injuries

This article is based on a literary review pertaining to the etiology and pathological mechanism of brachial plexus damage sustained by neonates at birth. The study attempts to identify characteristic environmental, chronologic, epidemiologic and clinical features of arrest of the shoulders at birth in order to establish their compatibilities with two competing concepts about the cause and mechanism of Erb’s and Klumpke’s palsies in newborn infants: A) Excessive traction exerted by the professional who assists the mother during the birthing process. B) Spontaneous injury ‘in utero’ caused by myometrial activity during gestation and/or labor. Of the pertinent literary data the following ones appear to be of importance within the context of this analysis: 1. Since fluid fills the amniotic cavity during pregnancy, according to Pascal’s law of fluids no part of the fetal body can be subjected to excessive pressure as long as the membranes are intact. 2. Uterine contractions spread from the fundus towards the cervix gradually, thus creating an expulsive force. The musculature generates no traction force; the mechanism responsible for evulsion and rupture injuries that manifest clinically as Erb’s and Klumpke’s palsies. 3. Because almost one-third of all births occur by cesarean section in contemporary practice, brachial plexus palsy should be frequent following abdominal deliveries if the spontaneous in utero damage hypothesis was correct. However, Erb’s and Klumpke’s palsies after cesarean section are extremely rare. 4. Forceps and ventouse deliveries increase the risk of brachial plexus damage up to 10-fold. This could not be the case if a high proportion of these injuries were unrelated to vaginal birth. 5. Shoulder dystocia and its associated injuries are 5 to 15-times more frequent in the USA than in England, Italy, Ireland, Israel or Hongkong (China). Because the reproductive process is largely identical among all races, a difference of such magnitude is unlikely to be caused by a factor which is intrinsic to human pregnancies. 6. During the last 50 years the rate of arrest of the shoulders and the typical injuries associated with it increased 5–10-fold in America. Such a sudden change is unlikely to be attributable to some inherited predisposition in a stable population. 7. Before 1975 non-interference with the birthing process was standard requirement in the USA. Then the policy changed and physicians were advised to extract the child promptly after the delivery of the head. Increase of rate of shoulder dystocia shortly after the introduction of the new policy suggests a cause-effect relationship between the two events. 8. Non-interference with the birthing process has been the recommended routine in Great Britain since the early 20th Century. The rates of shoulder dystocia in the USA and Great Britain were equally low before the 1970’s. Its occurrence has remained stable in the Britain but increased steeply in this country after obstetricians had changed the method of delivery from conservative to active. The above summarized observations have practical implications in obstetrics. These are discussed with emphasis upon the fact that some of the new developments in perinatology, perceived as part of the progress initially, have proved counterproductive in the long run.

Customized large-for-gestational-age birthweight at term and the association with adverse perinatal outcomes

Using a cohort of 110,447 singleton, term pregnancies, we aimed to validate the previously proposed customized standard of large-for-gestational-age (LGA) birthweight, derive an additional customized LGA model excluding maternal weight, and evaluate the association between differing definitions of customized LGA and perinatal morbidities. Three customized LGA classifications, in addition to a population-based 90th percentile, were made according to the principals described by Gardosi: (1) customized LGA using Gardosi's previously published coefficients (LGA-Gardosi), (2) customized LGA using coefficients derived by a similar method but from our larger cohort, and (3) derived without customization for maternal weight. Associations between the LGA classifications and various perinatal morbidity outcomes were evaluated. Coefficients derived here for physiologic and pathologic effects on birthweight were similar to those previously reported by Gardosi. Customized LGA (any method) generally identified more births to younger, nonwhite, nulliparous mothers with female neonates of lower birthweight compared with population-based LGA. Rates of maternal and neonatal morbidity were greatest in births classified by both population-based LGA and customized LGA (any method). However, the model that excluded customization for maternal weight, revealed a greater proportion of women previously unidentified by population-based LGA who were more frequently black (40% vs 25%) and obese (30% vs 5.1%), along with greater rates of shoulder dystocia, neonatal intensive care unit admission and neonatal respiratory complications, than with LGA-Gardosi. The use of customized methods of defining LGA was not decisively superior compared with population-based LGA, but custom LGA may be improved by modification of the parameters included in customization.

Outcomes associated with a structured prenatal counseling program for shoulder dystocia with brachial plexus injury

We examined outcomes that were associated with a novel program to identify patients who are at high risk for shoulder dystocia with brachial plexus injury. The program included a checklist of key risk factors and a multifactorial algorithm to estimate risk of shoulder dystocia with brachial plexus injury. We examined rates of cesarean delivery and shoulder dystocia in 8767 deliveries by clinicians who were enrolled in the program and in 11,958 patients of clinicians with no access to the program. Key risk factors were identified in 1071 of 8767 mothers (12.2%), of whom 40 of 8767 women (0.46%) had results in the high-risk category. The rate of primary cesarean delivery rate was stable (21.2-20.8%; P = .57). Shoulder dystocia rates fell by 56.8% (1.74-0.75%; P = .002). The rates of shoulder dystocia and cesarean birth showed no changes in the group with no access to the program. With the introduction of this program, overall shoulder dystocia rates fell by more than one-half with no increase in the primary cesarean delivery rate.

Can shoulder dystocia be reliably predicted?

To evaluate factors reported to increase the risk of shoulder dystocia, and to evaluate their predictive value at a population level. The South Australian Pregnancy Outcome Unit's population database from 2005 to 2010 was accessed to determine the occurrence of shoulder dystocia in addition to reported risk factors, including age, parity, self-reported ethnicity, presence of diabetes and infant birth weight. Odds ratios (and 95% confidence interval) of shoulder dystocia was calculated for each risk factor, which were then incorporated into a logistic regression model. Test characteristics for each variable in predicting shoulder dystocia were calculated. As a proportion of all births, the reported rate of shoulder dystocia increased significantly from 0.95% in 2005 to 1.38% in 2010 (P=0.0002). Using a logistic regression model, induction of labour and infant birth weight greater than both 4000 and 4500g were identified as significant independent predictors of shoulder dystocia. The value of risk factors alone and when incorporated into the logistic regression model was poorly predictive of the occurrence of shoulder dystocia. While there are a number of factors associated with an increased risk of shoulder dystocia, none are of sufficient sensitivity or positive predictive value to allow their use clinically to reliably and accurately identify the occurrence of shoulder dystocia.

Critical analysis of risk factors for shoulder dystocia

The study was aimed to define trends, risk factors and perinatal outcome associated with shoulder dystocia (SD). A population-based study comparing all singleton deliveries with and without SD was conducted. Statistical analysis was performed using multiple logistic regression analysis. Shoulder dystocia complicated 0.2% (n = 451) of all deliveries included in the study (n = 240,189). The rate of SD declined from 0.4% in 1988 to 0.13% in 2009. Independent risk factors for SD in a multivariable analysis were fetal macrosomia (birth-weight ≥ 4 kg; OR = 16.1; 95% CI 13.2-19.6, P < 0.001), failure of labor to progress during the second stage (OR = 2.4; 95% CI 1.5-3.7, P < 0.001), diabetes mellitus (OR = 1.8; 95% CI 1.4-2.3, P < 0.001) and advanced maternal age (years, OR = 1.02; 95% CI 1.001-1.03, P = 0.029). Perinatal mortality was significantly higher after SD as compared to the comparison group (6.2 vs. 1.4%, P <0.001). Another multivariable analysis, with perinatal mortality as the outcome variable, controlling for confounders such as maternal age, gestational age, diabetes mellitus, etc. was constructed; SD was noted as an independent risk factor for perinatal mortality (adjusted OR = 11.1; 95% CI 7.2-17.1, P < 0.001). Shoulder dystocia, associated with macrosomia, labor dystocia, diabetes mellitus, and advanced maternal age, is an independent risk factor for perinatal mortality. In an era of increased rate of cesarean deliveries, and perhaps increased accuracy of birth weight estimation, the rate of shoulder dystocia gradually declines.

Management of large-for-gestational-age pregnancy and outcomes in non-diabetic fetal macrosomia

IntroductionFetal macrosomia is increasing in prevalence and is associated with increased maternal and neonatal morbidity. Challenges include varying definitions, difficulties in accurate antenatal diagnosis and lack of consensus on ideal...

Ventouse Kiwi ® versus forceps et spatules : évaluation de la morbidité maternelle et fœtale. À propos de 169 cas

Aim To evaluate maternal and fetal complications resulting from the use of the Kiwi ® vacuum extractor and to compare them with those resulting from the use of forceps or spatula. Patients and methods Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi ® vacuum extractor and those of other instruments were compared. Results One hundred and sixty-nine patients where included, 79 had extraction with Kiwi ® vacuum extractor. The two populations (women having extraction with Kiwi ® and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI ® (73.1% versus 94.4%; P = 0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P = 0.04). No perineal tear of second or third degree occurred with Kiwi ®. Kiwi ® vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi ® (11.4% versus 4.4%; P = 0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%). Discussion and conclusion This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi ® vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi ® vacuum extractor.

Management of large‐for‐gestational‐age pregnancy in non‐diabetic women

Key content Over the last two to three decades there has been a 15–25% increase in many countries in the number of women giving birth to large infants. Rates of shoulder dystocia and caesarean birth rise substantially at 4000 g and again at 4500 g. There is an increase in maternal and neonatal morbidity associated with fetal macrosomia. Serial measurement of fundal height adjusted for maternal physiological variables substantially improves antenatal detection. Sonographic assessment of fetal weight is frequently inaccurate. Induction of labour for suspected macrosomia in non‐diabetic women has not been shown to reduce the risk of caesarean section, instrumental delivery or perinatal morbidity. Learning objectives To identify the risks associated with fetal macrosomia and to be aware of the long‐term implications. To understand the limitations of predictive tools. To be able to take an informed approach to managing the macrosomic fetus. Ethical issues To what extent should the fear of medico‐legal action influence obstetricians' management of suspected fetal macrosomia? What advice should clinicians give women regarding modes of delivery? Please cite this article as: Aye SS, Miller V, Saxena S, Farhan M. Management of large‐for‐gestational‐age pregnancy in non‐diabetic women. The Obstetrician &amp; Gynaecologist 2010;12:250–256.

Mütterliche antepartale Risiken einer Schulterdystokie

PATIENTS RESPECTIVELY AND METHODS: 224,744 vaginal and spontanous births >or= the 37 (th) week of gestation were analysed (2002-2008) to calculate the maternal risks for shoulder dystocia (obesity BMI >30, high maternal weight gain >15 kg during pregnancy, Diabetes mellitus, Diabetes of gestation, duration of pregnancy >or= 298 days, multiparity >1 partus). It could be demonstrated for the first time (Degree of evidence III B), that multiparity and the weight gain>15 kg elevate the rate of shoulder dystocia independant of the birth weight. At a birth weight below 4 000 g in addition to the multiparity and the weight gain the obesity BMI>30 elevate significant the rate of shoulder dystocia (Degree of Evidence III B). In the birth weight group >or=4,000 g Diabetes mellitus elevate the risk of shoulder dystocia in addition to multiparity and weight gain >15 kg (Degree of Evidence III B). Diabetes mellitus elevate the risk of shoulder dystocia only in combination with macrosomia >4 000 g. The pregnant woman should be informed about the statistically proved different maternal risk factors for a shoulder dystocia and a possible paresis of the Plexus brachialis in relation to the fetal birth weight. The sensitivity of 60% of the sonographic estimation of the fetal birth weight is to low and cannot be the only content of an information about this danger for the newborn.

Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

Draycott, T. J.; Crofts, J. F.; Ash, J. P.; Wilson, L. V.; Yard, E.; Sibanda, T.; Whitelaw, A. Author Information

A Randomized Controlled Trial of Routine Versus Restrictive Use of Episiotomy at Operative Vaginal Delivery: A Multicentre Pilot Study

The use of episiotomy as a routine component of operative vaginal delivery (OVD) is decreasing. Although a majority of physicians believe that routine use of episiotomy at OVD is protective against anal sphincter tears, the evidence on this issue is conflicting. A recent large retrospective Dutch study reported that episiotomy was highly protective against anal sphincter tears. This randomized controlled pilot study compared the maternal and neonatal outcomes of routine versus restrictive use of episiotomy at OVD in 200 nulliparous women expected to deliver at ≥37 weeks of gestation with live singleton cephalic pregnancies. The women were recruited in the antenatal period at 2 urban maternity units in Scotland and England between 2004 and 2006. Of the 200 study subjects, 99 were randomized to routine use of episiotomy (in all cases) and 101 to restrictive use of episiotomy (only if tearing becomes apparent). Anal sphincter tearing (third or fourth degree) was the primary outcome. Compared with restrictive use of episiotomy, routine use was associated with only a small and statistically insignificant difference in the rate of anal sphincter tears (8.1% routine vs. 10.9% restrictive); the odds ratio (OR) was 0.72, with a 95% confidence interval (CI) of 0.28 to 1.87. Routine use of episiotomy was associated with a slight but statistically insignificant increase in the incidence of both primary postpartum hemorrhage: 36.4% routine vs. 26.7% restrictive, with an OR of 1.57 and a 95% CI of 0.86 to 2.86, and neonatal trauma: 45.5% routine versus 43.6% restrictive, with an OR 1.08 and a 95% CI of 0.62 to 1.89. There were also no statistically meaningful differences between the 2 groups in prolonged postnatal stay, prolonged catheterization, urinary or fecal incontinence, perineal infection, rates of shoulder dystocia, or pain requiring moderate or strong analgesia. The findings of this small pilot study provide no evidence to support a policy of either routine or restrictive use of episiotomy at OVD and suggest the need for a large randomized controlled trial.