Recurrent Shoulder Dystocia Research Articles

Recurrent shoulder dystocia: is it predictable?

To examine the course and outcome of deliveries occurring in women who previously experienced shoulder dystocia. In addition, recurrent shoulder dystocia risk factors were assessed. A retrospective cohort analysis comparing all singleton deliveries with and without shoulder dystocia in their preceding delivery was conducted. Independent predictors of recurrent shoulder dystocia were investigated using a multiple logistic regression model. Of the 201,422 deliveries included in the analysis, 307 occurred in women with a previous shoulder dystocia (0.015%). Women with a history of shoulder dystocia were more likely to be older, experienced higher rates of gestational diabetes mellitus, polyhydramnios, prolonged second stage, operative delivery and macrosomia (>4000g) in the following delivery. Previous shoulder dystocia was found to be an independent risk factor for recurrent shoulder dystocia (OR=6.1, 95% CI 3.2-11.8, p value<0.001) in the multivariable regression analysis. Shoulder dystocia is an independent risk factor for recurrent shoulder dystocia. Deliveries in women with a history of shoulder dystocia are characterized by higher rates of operative delivery, prolonged second stage of labor and macrosomia.

Women With Prior Shoulder Dystocia

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

Recurrent Shoulder Dystocia: Analysis of Incidence and Risk Factors

To determine the rate and associated risk factors for recurrent shoulder dystocia (SD). A retrospective analysis was performed of patients delivered from January 1991 to June 2001. Patients with and without recurrent SD were identified and compared. Among the 267,228 vaginal births during the study period, there were 1904 cases of SD (0.7%) and 270 patients with one additional vaginal birth. The recurrent SD rate was higher than the general population (3.7% versus 0.7%, odds ratio 7.36, 95% confidence interval 3.68 to 14.23, p < 0.001). Patients with recurrent SD had a slightly higher mean birth weight with the second delivery, but this difference was not statistically significant (4173 ± 544 g versus 4017 ± 577 g, p = 0.39). Prior SD is a risk factor for recurrence in a subsequent delivery, but our results demonstrate that the rate appears to be lower than previously estimated. Most variables, including birth weight, do not appear to be useful parameters in predicting recurrence.

La dystocie des épaules : analyse descriptive sur dix années dans une maternité de niveau III

Objective Shoulder dystocia is one of the most dreadful complications of vaginal deliveries. The aim of this observational study was to evaluate risk factors of dystocia, maternal and neonatal complications and recurrent risk factors. Patients and methods Sixty-six cases of shoulder dystocia occurring between January 1998 and August 2008 in our university hospital were identified. Demographic data, labor management, management of the shoulder dystocia and neonatal outcome were recorded. Results The incidence of shoulder dystocia was 0.3%. Multiparity, weight gain greater than 12 kg, and post-term delivery were more present in our study group. McRoberts’ manoeuver and symphyseal pressure were first realised. Brachial plexus injuries affected 9% of neonates with skeletal fractures in 7.5% of cases. Maternal morbidity was evaluated at about 8%. Twenty per cent had a recurrent shoulder dystocia. Discussion and conclusion Shoulder dystocia is an obstetric emergency which requires a prompt management of trained personnel. Despite the difficulty of being able to prevent shoulder dystocia, training the obstetric staff could probably improve management of shoulder dystocia.

Shoulder Dystocia: What is the Risk of Recurrence?

Shoulder dystocia is a unpreventable obstetric emergency complicating 0.19-3.3% of deliveries. Although a large number of potential risk factors for shoulder dystocia have been investigated, only in about one quarter of cases has at least one significant risk factor has been found, and the positive predictive value of antepartum factors individually and combined is low: <2% and <3%, respectively. There are few data on the risk of recurrence of shoulder dystocia in subsequent pregnancies and on the identification of women at risk of recurrence. Because the predisposing factors for the initial dystocia might be present in all subsequent pregnancies, it is assumed that previous shoulder dystocia is a risk factor for recurrence. This retrospective study evaluated the risk of recurrence of shoulder dystocia and investigated potential risk factors for recurrence in a population of Lebanese women. The investigators used medical records and charts to identify 193 women with shoulder dystocia (0.9%) among a population of 22,207 who had vaginal deliveries between 1990 and 2005. Of the 193 women with a first episode of shoulder dystocia, subsequent vaginal delivery occurred in 44 cases (index pregnancy). Recurrent shoulder dystocia was found in 11 cases (11/44, 25%). The investigators compared pregnancy characteristics among index pregnancies who developed recurrent shoulder dystocia (group I, n = 11) and those with no recurrence (group II, n = 33). No significant difference was found between the two groups for gestational age at delivery, parity, maternal age, duration of labor, gender, history of macrosomia, and obesity. The only significant differences between these groups were a larger mean birth weight for group I compared to group II (4019 ± 430 versus 3599 ± 398 gm, P ≤ 0.005); a higher percentage of women in group 1 with larger birth weight than in their prior pregnancy (72.7% versus 33.3%, P ≤.035); and a higher rate with macrosomia (≥4000) gm in group I (63.6% versus 15.2%, P ≤.004). Among these variables in multiple logistic regression analysis, the only independent risk factor associated with recurrence was larger birth weight in subsequent pregnancy (P ≤.008). The data show that the risk of recurrence of shoulder dystocia is about 25% in this study population, a rate higher than in previous studies. The investigators conclude that a lower birth weight than the previous pregnancy and absence of macrosomia (<4000 gm) may lower the risk.

Shoulder dystocia: What is the risk of recurrence?

To study the recurrence risk of shoulder dystocia in women who have previously experienced at least once shoulder dystocia. A retrospective study of vaginal deliveries complicated by shoulder dystocia. Setting. American University of Beirut Medical Center - Lebanon. Vaginal deliveries complicated by shoulder dystocia over a 15-year period who had subsequent vaginal delivery. Methods. Charts of index and subsequent deliveries beyond 24 weeks' gestation were reviewed for demographics and intrapartum events. Women were divided into those with recurrent shoulder dystocia (group I) and those with uncomplicated subsequent delivery (group II) and compared. Recurrent shoulder dystocia and characteristics of women with recurrence. The incidence of shoulder dystocia was 0.9% of all vaginal deliveries. Of 193 shoulder dystocia cases, 48 women had a subsequent delivery. After excluding cesarean deliveries (n=4), 44 women were analyzed. Eleven had recurrent shoulder dystocia (25.0%). Mean birthweight was larger (4,019+/-430 vs. 3,599+/-398 g, p=0.005) with a higher rate of macrosomia > or =4,000 g (63.6 vs. 15.2%, p=0.004) and the birthweight in the subsequent pregnancy was larger than the index pregnancy in a significantly larger proportion of women in group I compared with group II (72.7% vs. 33.3%, p=0.035). Otherwise, maternal age, gestational age at delivery, parity, duration of labor, gender, history of macrosomia, and interval between pregnancies were similar. The risk of recurrence of shoulder dystocia is around 25%. When counseling women about recurrence risk, the absence of macrosomia and a smaller birthweight than the previous pregnancy could be reassuring.

Risk factors for recurrent shoulder dystocia, Washington state, 1987-2004

The objective of the study was to identify recurrent shoulder dystocia risk factors. This was a population-based case-control study in Washington state (1987-2004). Primary and recurrent shoulder dystocia incidences were calculated. Logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for subsequent shoulder dystocia risk factors. Primary and recurrent shoulder dystocia annual incidences were 2.3 of 100 and 13.5 of 100. Of 26,208 women with shoulder dystocia deliveries, 8991 had subsequent vaginal births, and of those, 1060 (11.8%) had a recurrent shoulder dystocia. Index pregnancy birthweight was associated with an increased risk of subsequent shoulder dystocia: 3500-3999 g, aOR 1.8 (95% CI 1.5 to 2.3); 4000-4499 g, aOR 3.3 (95% CI 2.6 to 4.1); 4500-4999 g, aOR 3.1 (95% CI 2.3 to 4.3); and 5000 g or greater, aOR 3.8 (95% CI 2.0 to 7.3). Vacuum delivery, aOR 1.4 (95% CI 1.2 to 1.7), and severe shoulder dystocia, aOR 2.1 (95% CI 1.6 to 2.7) in the index delivery, were also significant. Birthweight of 3500 g or greater, vacuum delivery, or severe shoulder dystocia in the index delivery were independent risk factors for shoulder dystocia recurrence.

Shoulder dystocia and the next delivery: Outcomes and management

Objective. To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia.Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described.Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048).Conclusion. In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high—approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.

96 Recurrent shoulder dystocia: How high is the risk?

96 Recurrent shoulder dystocia: How high is the risk?

How to predict recurrent shoulder dystocia

Objective: Our aim was to determine the rate and risk factors for recurrent shoulder dystocia. Study Design: A retrospective analysis of patients diagnosed with shoulder dystocia was performed by searching a computerized database from January 1, 1993, to June 30, 1999 for the following information: (1) vaginal deliveries, either spontaneous or operative, (2) shoulder dystocia, (3) birth weight, (4) duration of second stage of labor, (5) parity, and (6) gestational diabetes. Statistical analyses included χ 2 and t test. Results: There were 39,681 vaginal deliveries with 602 (1.5%) complicated by shoulder dystocia. Sixty-six patients underwent a subsequent vaginal delivery, and 11 (16.7%) experienced another shoulder dystocia. The odds ratio for a recurrent shoulder dystocia was 10.98 ( P < .000001). Nine of the 11 patients with recurrent shoulder dystocia compared with 28 of 55 without a recurence were nulliparous women in their index pregnancy ( P < .001). The mean fetal weights were 3885 g in the recurrent dystocia group and 3702 g in the group without recurrence ( P < .03). Gestational age, operative delivery, and gestational diabetes were similar in the two groups. Conclusion: Factors that appear to increase the recurrence risk of shoulder dystocia include fetal weight and maternal parity. Prior shoulder dystocia is the single greatest predictive factor. (Am J Obstet Gynecol 2001;184:1427-30.)

Perinatal implications of shoulder dystocia

To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. We conducted a 10-year (1980-1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forcepts delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.

Recurrence rate of shoulder dystocia

OBJECTIVE: Shoulder dystocia continues to be a major complication of obstetrics, and several factors have been identified to help predict its occurrence. A previous shoulder dystocia is one of the risk factors. However, the recurrence rate is unknown. The purpose of this study is to report the recurrence rate of shoulder dystocia. STUDY DESIGN: Our obstetric database was used to identify all vaginal deliveries between January 1983 through December 1992. A subset of vaginal deliveries complicated by shoulder dystocia was selected from this database. These records were reviewed to identify subsequent pregnancies, outcomes, risk factors, and demographic data. RESULTS: During the study period there were 37,465 total vaginal deliveries, with shoulder dystocia complicating 747 (overall rate 2%). Of these 747 cases, 101 patients had 123 subsequent vaginal deliveries, with shoulder dystocia complicating 17 of these pregnancies (13.8% recurrence rate, p < 0.0001). Comparisons were made between those patients with recurrent shoulder dystocia. CONCLUSION: Shoulder dystocia recurred at a rate approximately seven times higher than our primary rate. Whether patients with a history of shoulder dystocia should be offered an elective abdominal delivery requires further investigation.