Risk Of Shoulder Dystocia Research Articles

Maternal and Neonatal Outcomes with One Abnormal Value on 100g Three Hour Glucose Tolerance Test in Pregnancy

Purpose: The primary objective of this study was to compare pregnancy outcomes for patients with no elevated glucose values, one elevated glucose value, and 2 or more elevated glucose values on the 3-hour glucose tolerance test (GTT). Methods: This was a retrospective chart review of obstetric patients seen by residents and attending physicians at a single institution from 2015 to 2020 who were required to complete a 3-hour glucose tolerance test (GTT). Data extracted from the maternal chart included demographic information, BMI, route of delivery, presence of preeclampsia, chorioamnionitis, shoulder dystocia and preterm labor. Data extracted from the neonatal chart included blood glucose level after birth, birth weight, Apgar scores, and if NICU admission was required. Continuous data were analyzed using one-way ANOVA to compare the 3 groups, followed by post-hoc Tukey HSD to compare the 1 abnormal value group to the control group. Dichotomous data were analyzed using Chi square tests. Logistic regression was performed using shoulder dystocia as the outcome. Results: Patients with two or more elevated GTT values had higher age and BMI and were more likely to be prescribed diabetic medications compared to those with normal or one elevated value. They were also more likely to deliver at an earlier gestational age. Patients with one elevated GTT value experienced a statistically significant higher chance of shoulder dystocia compared to patients with all normal GTT results (OR 2.34; 95% CI 1.05, 5.20). Patients with two or more elevated values were more likely to have preeclampsia and a neonate requiring NICU admission. There were no differences in cesarean delivery rate, hemorrhage or chorioamnionitis between the groups. Conclusions: Patients with one elevated GTT value are a special subset of patients who do not meet criteria for gestational diabetes, yet do not have normal glucose testing results. We hypothesize that this group is at higher risk of shoulder dystocia because these patients may have hyperglycemia but often do not receive the same type of monitoring, dietary education, medication initiation and induction timing as patients who meet criteria for gestational diabetes.

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.

Demographic Disparities in Brachial Plexus Birth Injury [ID 2683383

INTRODUCTION: Black and Hispanic birthing individuals are at increased risk of delivering an infant with a brachial plexus birth injury (BPBI), but the reasons for these disparities are unclear. We evaluated the association of maternal race/ethnicity with established and suspected risk factors for BPBI to determine if these factors mediate these disparities. METHODS: Institutional review board approval was obtained for this retrospective cohort study of all live births occurring in California-licensed hospitals from 1996 to 2012. Multiple logistic regression was used to model adjusted associations of maternal race and ethnicity with an infant born with BPBI. Causal mediation analyses evaluated established and suspected risk factors for BPBI (obesity, diabetes, gestational diabetes, shoulder dystocia, macrosomia, prolonged second stage of labor, gestational age, post-term, vaginal delivery, insurance status, inadequate prenatal care) as potential mediators of the BPBI–maternal race/ethnicity relationship. RESULTS: The cohort included 6,278,562 births, with 7,762 BPBI. Although Black birthing individuals had an increased risk of obesity (adjusted odds ratio [aOR] 2.48) and diabetes (aOR 1.59) compared to non-Blacks, they had a lower risk of shoulder dystocia (aOR 0.76), macrosomia (aOR 0.60), prolonged second-stage labor (aOR 0.33), precipitous labor (aOR 0.88), and vaginal delivery (aOR 0.79). Blacks had an increased risk of inadequate prenatal care (aOR 1.26) and being underinsured (aOR 1.30). The combination of these factors explained only 16.3% of the increased risk for BPBI in Black people. Findings were similar in Hispanic individuals. CONCLUSION: The increased risk of BPBI in Black and Hispanic individuals is only modestly explained by known risk factors. Prenatal care utilization and socioeconomic factors may play a role.

Assessment of Women's Awareness of the Effects of Gestational Diabetes Mellitus on the Mother and Fetus in Saudi Arabia: A Cross-Sectional Study.

Introduction Gestational diabetes mellitus (GDM) is a form of glucose intolerance that arises during pregnancy, affecting a significant portion of women. It has immediate and long-term effects on both the mother and fetus, including complications like preeclampsia, premature delivery, and an increased risk of cesarean sections. A cross-sectional study among Saudi Arabia's general population, which included 979 women aged between 18 and 60, found varying levels of awareness of GDM, emphasizing the need for more research on awareness levels regarding GDM in Saudi Arabia and more educational campaigns to improve awareness. Objectives The study evaluates the knowledge of pregnant women about GDM and its implications for the mother and fetus. It investigates the relationship between knowledge levels and demographic factors like age, education, and socioeconomic status, aiming to identify knowledge gaps regarding this health issue and develop targeted educational initiatives. Methodology This was a cross-sectional study that included 979 women and was conducted using a Google Forms (Google Inc., Mountainview, CA) questionnaire. The questionnaire covered demographics and explored the knowledge level of women about the impact of GDM on the mother and fetus. Statistical analysis was implemented by IBM SPSS software version 27.0 (IBM Corp., Armonk, NY), with a 5% significance level. Ethical approval was sought, emphasizing anonymous data collection. We did not collect any identifying or private information from participants, and all responses were kept confidential. Results A study of 979 women revealed that their knowledge of GDM was significantly influenced by their age, gestational age, and the number of prior deliveries (p-value < 0.05). The total mean knowledge score for women's correct responses stood at 7.62 (±4.49). The study found that a majority of women, exceeding 60%, accurately answered certain questions about GDM, such as its association with heightened risks, neonatal intensive care unit (NICU) admissions, cesarean section likelihood, high birth weight, and preeclampsia. However, less than 30% could answer yes to questions that indicated that GDM could increase the risk of shoulder dystocia, hypoglycemia at birth, premature rupture of membranes, postpartum hemorrhage, and vacuum delivery. Conclusion There is a need for targeted educational initiatives, particularly focusing on knowledge gaps that women are lacking regarding GDM. Age and prior deliveries were identified as significant determinants of knowledge levels.

Shoulder dystocia by severity in families: A nationwide population study.

Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are scarce. It is unknown if shoulder dystocia tends to be passed on between generations. We aimed to assess the recurrence risk of shoulder dystocia by severity in the same woman and between generations on both the maternal and paternal side. We also assessed the likelihood of a second delivery and planned cesarean section after shoulder dystocia. This was a population-based cohort study, using data from the Medical Birth Registry of Norway. To study recurrence in the same mother, we identified 1 091 067 pairs of first and second, second and third, and third and fourth births in the same mother. To study intergenerational recurrence, we identified an individual both as a newborn and as a mother or father in 824 323 mother-offspring pairs and 614 663 father-offspring pairs. We used Bayesian log-binomial multilevel regression to calculate relative risks (RR) with 95% credible intervals. In subsequent deliveries in the same woman the unadjusted RR of recurrence was 7.05 (95% credible interval 6.39-7.79) and 2.99 (2.71-3.31) after adjusting for possible confounders, including current birthweight. The RRs were higher with severe shoulder dystocia as exposure or outcome. With severe shoulder dystocia as both exposure and outcome, unadjusted and adjusted RR was 20.42 (14.25-29.26) and 6.29 (4.41-8.99), respectively. Women with severe and mild shoulder dystocia and those without had subsequent delivery rates of 71.1, 68.9 and 69.0%, respectively. However, the rates of planned cesarean section in subsequent deliveries for those without shoulder dystocia, mild and severe were 1.3, 5.2 and 16.0%, respectively. On the maternal side the unadjusted inter-generational RR of recurrence was 2.82 (2.25-3.54) and 1.41 (1.05-1.90) on the paternal side. Corresponding adjusted RRs were 1.90 (1.51-2.40) and 1.19 (0.88-1.61), respectively. We found a strong recurrence risk of shoulder dystocia, especially severe, in subsequent deliveries in the same woman. The inter-generational recurrence risk was higher on the maternal than paternal side. Women with a history of shoulder dystocia had more often planned cesarean section.

Correlation of Cross-sectional Area of the Umbilical Cord on Antenatal Ultrasound with Neonatal Birth Weight in Pregnant Women with and without Gestational Diabetes Mellitus: A Prospective Cohort Study

Introduction: Many foetal and maternal complications, such as polyhydramnios, macrosomia, birth injuries, and operative interference, are linked with Gestational Diabetes Mellitus (GDM). Among these, macrosomia is particularly significant, as it increases the risk of shoulder dystocia, brachial plexus injury, birth asphyxia, and maternal complications, including emergency Lower Segment Caesarean Section (LSCS), Postpartum Haemorrhage (PPH), and perineal trauma. Therefore, one of the most essential perinatal goals in GDM is to predict macrosomia by estimating birth weight, thereby preventing adverse maternal and foetal outcomes. Aim: To evaluate whether there is a correlation between the cross-sectional area of the Umbilical Cord (UCA) and the Neonatal Birth Weight (NBW) in pregnant women with GDM. Materials and Methods: A prospective cohort study was conducted in the Departments of Radiology and Obstetrics Bangalore Medical College, Bengaluru, Karnataka, India. A total of 100 pregnant women (50 with GDM and 50 without GDM) were recruited from July 2021 to July 2022. Ultrasound examination (USG) was performed on pregnant women after 36 weeks of gestation. The UCA was measured in a free-floating loop, and the NBW was measured using a digital scale. The correlation coefficient was calculated to determine the degree of correlation between UCA and NBW. Results: The mean age of the subjects was 26.5±3.9 years. The frequency of macrosomia was higher in the GDM group (8%) compared to the control group (4%). A strong positive correlation was observed between UCA and NBW in both diabetics (r=0.819) and control groups (r=0.736). Conclusion: A strong positive correlation exists between UCA and NBW in women with GDM. Therefore, it should be estimated during routine antenatal USG for the prediction of birth weight in such women.

Effects of pelvic floor myofascial manipulation intervention on primiparas and neonates during the second stage of vaginal delivery.

A prolonged second stage of vaginal delivery increases the risk of shoulder dystocia, unnecessary episiotomies and cesarean sections. However, no standardized method has been proposed to tackle this issue. The effects of pelvic floor myofascial manipulation intervention during the second stage of labor in primiparas and its prognostic value in neonatal postpartum outcomes remain unknown. In the present study, a total of 60 primiparas who were expecting a vaginal delivery in the Second Affiliated Hospital of Hainan Medical College (Haikou, China) between October 2021 and January 2022 were selected. These women were randomly assigned to a control group (standard intrapartum care) or an experimental group (pelvic floor myofascial manipulation for 15-20 min during the second stage of labor along with standard intrapartum care) using a random number table, with 28 patients in each group. There was no significant difference in age, gestational time or body mass index between the two groups before delivery, indicating that the baseline data were comparable. The second stage of labor duration, forced breath-holding time and postpartum hemorrhage volume in the experimental group were significantly lower than those in the control group. The pain visual analog scale scores, fatigue scores and neonatal Apgar scores in the experimental group were also significantly lower than those in the control group. The rate of episiotomy in the experimental group was lower than that in the control group, but the difference was not statistically significant. In conclusion, pelvic floor myofascial manipulation intervention during the second stage of labor for primiparas with vaginal delivery can reduce the duration of the second stage of labor, the amount of bleeding during labor and the pain during labor. Meanwhile, it has the potential to improve neonatal outcomes.

Review on pharmacological therapies for management of gestational diabetes

The prevalence of Gestational Diabetes Mellitus (GDM) is increasing and is closely linked to numerous negative pregnancy outcomes. To mitigate these risks, early identification and management of GDM is critical. Treatment for GDM aims to maintain normal blood sugar levels and typically includes glucose monitoring, adjustments to diet, lifestyle changes, moderate physical activity, and medication as necessary. Insulin administration is generally the preferred choice for pharmacotherapy, but oral drugs such as metformin or glyburide may also be appropriate. Compared to glyburide, which has been linked to higher birth weight, neonatal hypoglycemia, raising the risk of shoulder dystocia, and necessitating a caesarean delivery, metformin is seen to be a safe first-line therapy. It should be emphasized that some expecting mothers choose complementary and alternative therapies, such as traditional herbal supplements and treatments. This review article will address present pharmacological options and considerations associated with treating GDM.

Retrospective Study on the Large for Gestational Age cases from SSBH, Brunei

Introduction: Large-for-gestational-age babies are at high risk for short-term outcomes such as shoulder dystocia, neonatal hypoglycaemia and birth trauma. Macrosomic babies are defined as those with birth weights of &gt;4,000 g, irrespective of gestational age, sex, or country/region-specific differences in mean birth weight and maternal body weight. In the recent past, the rate of large-for-gestational-age [LGA] babies, has increased all over the world. Purpose This study is aimed to investigate the prevalence of macrosomia/LGA in Suri Seri Begawan Hospital (SSBH) and to determine the maternal and fetal outcomes. Methodology: The selected universe for the study is at Suri Seri Begawan Hospital, for the time duration of 2 consecutive years (2018-19). The secondary data is used to calculate a prevalence. Result: The prevalence of 1.9% was found in this study (all &gt;4 kg) and 75% of male babies were born as macrosomia/LGA. 19% of the participants delivered big babies before, and 27% were diabetic in this current pregnancy. 63.6% were delivered by spontaneous vaginal delivery, and there was 1 shoulder dystocia with a 4.1 kg weighed baby. One LSCS wound infection and one vaginal haematoma occurred in this study, although only 21% of babies were admitted to the neonatal unit. Conclusion: The current study draws its conclusion based on the findings that macrosomia/LGAs in SSBH are not as high as like China. Expectant management was practiced in most of the cases and outcome wise is acceptable ensuring our management protocol was safe. Large-for-gestational-age babies are at high risk for shoulder dystocia with brachial plexus injury, which is of great concern for all obstetricians. The management of macrosomia/LGA pregnancy should be individualized by taking into account all maternal and foetal factors as well as all available diagnostic tools. Obstetricians should be vigilant and careful with proper clinical judgement and early recognition of possible complications.

Association between Diabetes in Pregnancy and Shoulder Dystocia by Infant Birth Weight in an Era of Cesarean Delivery for Suspected Macrosomia.

We estimated the association between diabetes and shoulder dystocia by infant birth weight subgroups (<4,000, 4,000-4,500, and >4,500 g) in an era of prophylactic cesarean delivery for suspected macrosomia. A secondary analysis from the National Institute of Child Health and Human Development U.S. Consortium for Safe Labor of deliveries at ≥24 weeks with a nonanomalous, singleton fetus with vertex presentation undergoing a trial of labor. The exposure was either pregestational or gestational diabetes compared with no diabetes. The primary outcome was shoulder dystocia and secondarily, birth trauma with a shoulder dystocia. We calculated adjusted risk ratios (aRRs) with modified Poison's regression between diabetes and shoulder dystocia and the number needed to treat (NNT) to prevent a shoulder dystocia with cesarean delivery. Among 167,589 assessed deliveries (6% with diabetes), pregnant individuals with diabetes had a higher risk of shoulder dystocia at birth weight <4,000 g (aRR: 1.95; 95% confidence interval [CI]: 1.66-2.31) and 4,000 to 4,500 g (aRR: 1.57; 95% CI: 1.24-1.99), albeit not significantly at birth weight >4,500 g (aRR: 1.26; 95% CI: 0.87-1.82) versus those without diabetes. The risk of birth trauma with shoulder dystocia was higher with diabetes (aRR: 2.29; 95% CI: 1.54-3.45). The NNT to prevent a shoulder dystocia with diabetes was 11 and 6 at ≥4,000 and >4,500 g, versus without diabetes, 17 and 8 at ≥4,000 and >4,500 g, respectively. Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered. Guidelines providing the option of cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights. · >Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered.. · Cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.. · These findings can inform delivery planning for providers and pregnant individuals with diabetes..

Predictors of shoulder dystocia at the time of operative vaginal delivery: a prospective cohort study

Our aim was to identify factors associated with shoulder dystocia following an attempted operative vaginal delivery (aOVD) in a prospective cohort study and to evaluate whether these factors can be used to accurately predict shoulder dystocia by building a score of shoulder dystocia risk. This was a planned secondary analysis of a prospective cohort study of deliveries with aOVD at term from 2008–2013. Cases were defined as women with shoulder dystocia following an aOVD defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Multivariate logistic regression analyses were performed to determine risk factors for shoulder dystocia. Shoulder dystocia occurred in 57 (2.7%) of the 2118 women included. In the whole cohort, women with shoulder dystocia more often had a history of shoulder dystocia (3.5% vs. 0.2%, p = 0.01), and there was a significant interaction between aOVD and gestational age and the duration of the second stage of labor: women with shoulder dystocia more often had a gestational age > 40 weeks and a second stage of labor longer than 3 h specifically for midpelvic aOVD. In multivariable analysis, a history of shoulder dystocia was the only factor independently associated with shoulder dystocia following aOVD (aOR 27.00, 95% CI 4.10–178.00). The AUC for the receiver operating characteristic curve generated using a multivariate model with term interaction with head station was 0.70 (95% CI 0.62–0.77). The model failed to accurately predict shoulder dystocia.

Understanding risk factors for shoulder dystocia using interpretable machine learning

To use interpretable machine learning to identify the most important risk factors for shoulder dystocia (SD). This retrospective study used clinical data from 82,889 singleton vaginal births (24-43 weeks’ gestation) from 20 U.S. hospitals (01/2016 - 12/2021) to train and externally validate a predictive model for SD using 57 features available at the time of delivery plus birthweight (which can be estimated prenatally but is not known until birth). Using bootstrap analysis, an Explainable Boosting Machine (EBM) was trained using data from 59,665 births at 13 hospitals and externally validated using 23,224 births at 7 different hospitals. A logistic regression (LR) model was also trained for comparison. SD occurred in 3.4% of births. An AUC of 0.74 (95% CI 0.73 – 0.75) was obtained for the EBM. Sensitivity for SD was 62%, for a false positive rate (FPR) of 25%. LR yielded an AUC of 0.74 (95% CI 0.73 – 0.75). The most important features for predicting SD were birthweight, maternal height, BMI, cervical dilation at initial exam, and time from admission to full dilation. SD risk increased dramatically and linearly with birthweight and decreased as maternal height increased (Figure 1). Surprisingly, length of 2nd stage was not a strong predictor. Using only the top 5 features gave a slightly higher AUC of 0.75 (95% CI 0.74 – 0.76) and a 65% sensitivity for a 25% FPR, suggesting that eliminating some features might yield a small model with clinically useful SD prediction. AI models trained on these data yielded modest accuracy for predicting shoulder dystocia risk and EBM intelligibility highlighted that consideration of factors in addition to fetal weight, may add to the assessment of risk. EBMs also reinforced the need to accurately estimate fetal weight, as evident through birthweight’s exceptionally large contribution to risk. Our results suggest that a novel, clinically useful model for predicting SD at the time of delivery might be achievable using only a small number of features.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Induction of labour for predicted macrosomia: study protocol for the ‘Big Baby’ randomised controlled trial

IntroductionLarge-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected...

A Trial of Labor after Cesarean Section with a Macrosomic Neonate. Is It Safe?

This study aimed to determine whether a trial of labor after cesarean section (TOLAC) with a macrosomic neonate is associated with adverse outcomes. A retrospective cohort study was conducted in a population motivated for TOLAC. Women attempting TOLAC with a neonatal birth weight >4,000 g were compared with women attempting TOLAC with neonatal birth weights between 3,500 and 4,000 g. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery, uterine rupture, postpartum hemorrhage (PPH), shoulder dystocia, obstetric anal sphincter injury (OASI), Apgar's score <7 at 5 minutes, and umbilical artery pH <7.1. Data were analyzed using Fisher's exact test and Chi-square test. Overall, 375 women who underwent TOLAC with a neonate weighing >4,000 g comprised the study group. One thousand seven hundred and eighty-three women attempting TOLAC with a neonate weighing 3,500 to 4,000 g comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, parity, and vaginal birth after cesarean (VBAC) rate. There were no significant differences in the rates of successful TOLAC (94 vs. 92.3%, p = 0.2, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.5, 1.2), operative vaginal delivery (7.4 vs. 5.3%, p = 0.18, OR = 0.7, 95% CI: 0.4, 1.1), uterine rupture (0.4 vs. 0%, p = 0.6), PPH (3.2 vs. 2.3%, p = 0.36, OR = 1.4, 95% CI: 0.7, 2.7), OASI (0.8 vs. 0.2%, p = 0.1, OR = 3.6, 95% CI: 0.8, 1.6), Apgar's score <7 at 5 minutes (0 vs. 0.4%, p = 0.37), and umbilical artery pH <7.1 (0.5 vs. 0.7%, p = 1.0, OR = 0.73, 95% CI: 0.2, 3.2). Women with a neonate weighing >4,000 g had a significantly increased risk of shoulder dystocia (4 vs. 0.4%, p < 0.05, OR = 9.2 95% CI: 3.9, 22) CONCLUSION: Women attempting TOLAC with a macrosomic neonate are not at increased risk for failed TOLAC, operative vaginal delivery, uterine rupture, PPH, or OASI but are at risk of shoulder dystocia. This information may aid in prenatal counseling for women considering TOLAC with a macrosomic fetus. · TOLAC with fetal macrosomia does not increase the risk of uterine rupture.. · TOLAC with fetal macrosomia is associated with high chances of VBAC.. · TOLAC with fetal macrosomia is not associated with adverse neonatal outcomes..

Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies

BackgroundTo assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes.MethodThis was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital.ResultsThe primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals.ConclusionSelective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China.

Effectiveness of Telemedicine in Managing Diabetes in Pregnancy: A Systematic Review and Meta-Analysis.

Strict monitoring of blood glucose during pregnancy is essential for ensuring optimal maternal and neonatal outcomes. Telemedicine could be a promising solution for supporting diabetes management; however, an updated meta-analysis is warranted. This study assesses the effects of telemedicine solutions for managing gestational and pregestational diabetes. PubMed, EMBASE, Cochrane Library Central Register of Controlled Trials, and CINAHL were searched up to October 14, 2020. All randomized trials assessing the effects of telemedicine in managing diabetes in pregnancy relative to any comparator without the use of telemedicine were included. The primary outcome was infant birth weight. A meta-analysis comparing the mean difference (MD) in birth weight across studies was applied, and subgroup and sensitivity analyses were performed. The revised Cochrane tool was applied to assess the risk of bias, and the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. From a total of 18 studies, ten (totaling 899 participants) were used to calculate the effect on infant birth weight. The results nonsignificantly favored the control (MD of 19.34 g; [95% confidence interval, CI -47.8; 86.47]), with moderate effect certainty. Heterogeneity was moderate (I2 = 37.39%). Statistically significant secondary outcomes included differences in two-hour glucose tolerance postpartum (gestational diabetes; two studies: standardized mean difference 9.62 mg/dL [95% CI: 1.95; 17.28]) that favored the control (GRADE level, very low) and risk of shoulder dystocia (four studies: log odds -1.34 [95% CI: -2.61; -0.08]) that favored telemedicine (GRADE, low). No evidence was found to support telemedicine as an alternative to usual care when considering maternal and fetal outcomes. However, further research is needed, including economic evaluations.

Accuracy of Fetal Biacromial Diameter and Derived Ultrasonographic Parameters to Predict Shoulder Dystocia: A Prospective Observational Study

Background and Objectives: Shoulder dystocia (ShD) is one of most dangerous obstetric complication. The objective of this study was to determine if the ultrasonographic fetal biacromial diameter (BA) and derived parameters could predict ShD in uncomplicated term pregnancies. Materials and Methods: We conducted a prospective observational study in a tertiary care university hospital from March 2021 to February 2022. We included all full-term pregnancies accepted for delivery that received an accurate ultrasonography (USG) scan before delivery. USG biometry and estimated fetal weight (EFW) were collected. Therefore, we evaluated the diameter of the mid-arm, the transverse thoracic diameter (TTD) and the biacromial diameter (BA). BA was estimated using Youssef’s formula: TTD + 2 mid-arm diameters. The primary outcome was the evaluation of BA and its related parameters (BA/biparietal diameter (BPD), BA/head circumference (HC) and BA–BPD in fetuses with ShD versus fetuses without ShD. Diagnostic accuracy for ShD of BA, BA/BPD, BA/HC and BA–BPD was evaluated using receiver operator curve (ROC) analysis. Results: 90 women were included in the analysis, four of these had ShD and required extra maneuvers after head delivery. BA was increased in fetuses with ShD (150.4 cm; 95% CI 133.2 cm to 167.6 cm) compared to no-ShD (133.5 cm; 95% CI 130.1 cm to 137.0 cm; p = 0.04). Significant differences were also found between ShD and no-ShD groups for BA/BPD (1.66 (95% CI 1.46 to 1.86) vs. 1.44 (95% CI 1.41 to 1.48); p = 0.04), BA/HC (0.45 (95% CI 0.40 to 0.49) vs. 0.39 (95% CI 0.38 to 0.40); p = 0.01), BA–BPD (60.0 mm (95% CI 42.4 to 77.6 cm) vs. 41.4 (95% CI 38.2 to 44.6); p = 0.03), respectively. ROC analysis showed an overall good accuracy for ShD, with an AUC of 0.821 (p = 0.001) for BA alone and 0.881 (p = 0.001), 0.857 (p = 0.016) and 0.867 (p = 0.013) for BA/BPD, BA–BPD and BA/HC, respectively. Conclusions: BA alone, as well as BA/BPD, BA/HC and BA–BPD might be useful predictors of ShD in uncomplicated term pregnancies. However, such evidence needs extensive confirmation by means of additional studies with large sample sizes, especially in case of pregnancies at high risk for ShD (i.e., gestational diabetes).

Association between diabetes in pregnancy and risk of shoulder dystocia by infant birth weight

Association between diabetes in pregnancy and risk of shoulder dystocia by infant birth weight

Antenatal risk prediction of shoulder dystocia: influence of diabetes and obesity: a multicenter study.

To estimate the risk of shoulder dystocia (SD) in pregnancies with/without maternal diabetes or obesity; to identify antenatal maternal and fetal ultrasound-derived risk factors and calculate their contributions. A multicenter retrospective analysis of 13,428 deliveries in three tertiary hospitals (2014-2017) with fetal ultrasound data ≤ 14days prior to delivery (n = 7396). singleton pregnancies in women ≥ 18years old; vertex presentation; vaginal delivery at ≥ 37weeks of gestation. Estimated fetal weight (EFW) and birth weight (BW) were categorized by steps of 250g. To evaluate risk factors, a model was performed using ultrasound data with SD as the dependent variable. Diabetes was present in 9.3%; BMI ≥ 30kg/m2 in 10.4% and excessive weight gain in 39.8%. The total SD rate was 0.9%, with diabetes 2.0% and with obesity 1.9%. These increased with BW 4250-4499g compared to 4000-4249g in women with diabetes (12.1% vs 1.9%, P = 0.010) and without (6.1% vs 1.6%, P < 0.001) and at the same BW threshold for women with obesity (9.6% vs 0.6%, P = 0.002) or without (6.4% vs 1.8%, P < 0.001). Rates increased similarly for EFW at 4250g and for AC-HC at 2.5cm. Independent risk factors for SD were EFW ≥ 4250g (OR 3.8, 95% CI 1.5-9.4), AC-HC ≥ 2.5cm (OR 3.1, 95% CI 1.3-7.5) and diabetes (OR 2.2, 95% CI 1.2-4.0). HC/AC ratio, obesity, excessive weight gain and labor induction were not significant. Independent of diabetes, which remains a risk factor for SD, a significant increase may be expected if the EFW is ≥ 4250g and AC-HC is ≥ 2.5cm.

Rising Trends in the Incidence of Shoulder Dystocia and Development of a Novel Shoulder Dystocia Risk Score Tool: A Nationwide Population-Based Study of 800,484 Finnish Deliveries

(Abstracted from Acta Obstet Gynecol Scand 2021;100:538–547) Shoulder dystocia is an unpredictable, obstetric emergency. Its incidence has been reported to range from 0.1% up to 3.0%.