Shoulder Dystocia Delivery Research Articles

Using Simulation to Improve Management of a Shoulder Dystocia Delivery by Experienced Nurse Midwives

Objective: To assess the impact of a standardized shoulder dystocia simulation experience on the management of a complicated delivery by experienced midwives at an academic institution.Method: Experienced midwives from a single institution underwent a standardized simulated shoulder dystocia delivery. The simulation was conducted four times for each midwife. The first simulation occurred prior to any educational intervention, and the subsequent three deliveries were performed after a standardized didactic. Performance was scored based on standardized criteria to assess for accuracy and comprehensiveness of the delivery.Results: Seven midwives were included. The lowest and highest scores for the first drill were 11 and 15 respectively, and for the fourth drill, 19 and 21 respectively. Conclusion: Simulation training of experienced midwives with a standardized shoulder dystocia scenario results in improved communication and leadership skills.

Pregnancy Outcomes among Women with Class III Obesity with Pre-diabetic Early Hemoglobin A1C.

We aimed to assess the risk of developing gestational diabetes mellitus (GDM) in women with a normal A1C (<5.7) compared with those with an A1C in the pre-diabetic range (5.7-6.4). This study comprises of a retrospective cohort of non-anomalous singleton pregnancies with maternal body mass index (BMI) ≥40 at a single institution from 2013 to 2017. Pregnancies with multiple gestation, late entry to care, type 1 or 2 diabetes, and missing diabetes-screening information were excluded. The primary outcome was development of GDM. Secondary outcomes included fetal growth restriction, macrosomia, gestational age at delivery, large for gestational age, delivery BMI at delivery, total weight gain in pregnancy, induction of labor, shoulder dystocia, and cesarean delivery. Bivariate statistics were used to compare demographics, pregnancy complications, and delivery characteristics of women who had an early A1C < 5.7 and A1C 5.7 to 6.4. Multivariable analyses were used to estimate the odds of the primary outcome. Eighty women (68%) had an early A1C <5.7 and 38 (32%) had a A1C 5.7 to 6.4. Women in the lower A1C group were less likely to be Black (45 vs. 74%, p = 0.01). No differences in other baseline demographics were observed. The median A1C was 5.3 for women with A1C < 5.7 and 5.8 for women with A1C 5.7 to 6.4 (p < 0.001). GDM was significantly more common in women with A1C 5.7 to 6.4 (3.8 vs. 24%, p = 0.002). Women with pre-diabetic range A1C had an odd ratio of 11.1 (95% CI 2.49-48.8) for GDM compared with women with a normal A1C. Women with class III obesity and a pre-diabetic range A1C are at an increased risk for gestational diabetes when compared with those with a normal A1C in early pregnancy. · One in 3 women with class III obesity had a pre-diabetic range early A1C.. · Class III obese women who have a pre-diabetic A1C have a higher risk of gestational diabetes.. · In this high-risk population, early A1C results in the pre-diabetic range are associated with higher rates of gestational diabetes..

Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis?

Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.

Shoulder Dystocia Delivery by Emergency Medicine Residents: A High-fidelity versus a Novel Low-fidelity Simulation Model-A Pilot Study.

Shoulder dystocia (SD) requires emergent intervention to prevent maternal and fetal harm, and simulation models for training can be expensive. We developed a novel, cheap and easily transportable low-fidelity simulation (LFS) model to compare to a commercially available high-fidelity simulation (HFS) model. Emergency medicine residents were randomized to training on the HFS or novel LFS model. Subjects completed a pretest and a 1-week and 6-month posttest including a self-assessment and a simulated SD delivery. Twenty-seven of the 43 residents completed the study (63%). The number of individuals performing dangerous maneuvers at baseline was similar, 1week after training was five in HFS and 11 in LFS (p=0.08) groups and at 6 months was again similar between groups. Mean checklist scores for appropriate actions increased 1 week after training but returned to baseline by 6 months and were similar between groups. The rate of successful delivery, median time to successful delivery, and maximum force applied improved at 1 week and was sustained at 6 months in both groups. Within our limited study population, we did not find a large difference in the occurrence of dangerous actions during simulated SD delivery following HFS and LFS training. Our novel and easily transportable LFS trainer, assembled for less than US$10 each, may be a useful tool to train inexperienced providers on the steps of this procedure. However, this requires further study, as does whether HFS models with force monitoring capabilities may be helpful to train providers to minimize dangerous maneuvers such as the application of excessive force.

Shoulder Dystocia Documentation

To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention. Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.

Comprehensiveness of Delivery Notes for Shoulder Dystocia

INTRODUCTION: Shoulder dystocia is an unpredictable obstetric emergency with the potential for significant morbidity. Accurate and comprehensive documentation is critical for clinical decision-making and risk management. This study evaluates physicians' shoulder dystocia delivery notes to assess for comprehensiveness and identify potential areas for improvement. METHODS: Physician narrative delivery notes for vaginal deliveries complicated by a shoulder dystocia at a single academic institution from 2006 to 2011 were evaluated. Delivery notes were analyzed for comprehensiveness based on their inclusion of intrapartum elements (20 elements) from the American College of Obstetricians and Gynecologists Patient Safety Checklist for documenting a shoulder dystocia. RESULTS: Sixty-six narrative delivery notes were analyzed. On average, delivery notes documented 11 (58%) elements. None of the notes included all 20 elements, and one delivery had no delivery note documented. Head-to-body interval was recorded in only 58% of notes. Commonly recorded elements (75% of notes or greater) were the date and time of delivery (96%), obstetric maneuvers used to relieve the affected shoulder (91%), maternal gravidity and parity (86%), Apgar scores (80%), and neonatal birth weight (77%). Infrequently recorded elements (25% of notes or less) included documentation of the anterior fetal shoulder (21%), estimated fetal weight (7%), patient counseling about the shoulder dystocia after delivery (4%), adequacy of the maternal pelvis (2%), and whether fundal pressure was or was not applied (1%). CONCLUSION: Physician narrative delivery notes lack many critical elements for documentation of a shoulder dystocia delivery. The use of standardized forms to improve comprehensiveness of delivery should be evaluated.

Does Teaching of Documentation of Shoulder Dystocia Delivery Through Simulation Result in Improved Documentation in Real Life?

ObjectiveDocumentation of deliveries complicated by shoulder dystocia is a valuable communication skill necessary for residents to attain during residency training. Our objective was to determine whether the teaching of documentation of shoulder dystocia in a simulation environment would translate to improved documentation of the event in an actual clinical situation. MethodsWe conducted a cohort study involving obstetrics and gynaecology residents in years 2 to 5 between November 2010 and December 2012. Each resident participated in a shoulder dystocia simulation teaching session and was asked to write a delivery note immediately afterwards. They were given feedback regarding their performance of the delivery and their documentation of the events. Following this, dictated records of shoulder dystocia deliveries immediately before and after the simulation session were identified through the Meditech system. An itemized checklist was used to assess the quality of residents' dictated documentation before and after the simulation session. ResultsAll eligible residents (18) enrolled in the study, and 17 met the inclusion criteria. For 10 residents (59%) documentation of a delivery with shoulder dystocia was present before and after the simulation session, for five residents (29%) it was only present before the session, and for two residents (18%) it was only present after the session. When residents were assessed as a group, there were no differences in the proportion of residents recording items on the checklist before and after the simulation session (P > 0.05 for all). Similarly, analysis of the performance of the10 residents who had dictated documentation both before and after the session showed no differences in the number of elements recorded on dictations done before and after the simulation session (P > 0.05 for all). ConclusionThe teaching of shoulder dystocia documentation through simulation did not result in a measurable improvement in the quality of documentation of shoulder dystocia in actual clinical situations.

Innovation, Collaboration, and Systemness: Three Sisters Playing Nice in the Sandbox

Professional Issues Poster Presentation Purpose for the Program Patient safety is in the forefront of education in the healthcare profession. The promotion of open communication and teamwork using obstetric simulation is the purpose of an innovative program introduced to our healthcare system. A new simulation lab was constructed at the College of Nursing within the system. The sister facilities are located within a 30‐mile radius and attempt to attract the same patient population. Proposed Change An obstetric simulation planning committee was formed to include educators from the three facilities within the healthcare system. The planning committee corresponded via e‐mails and had monthly meetings to share patient safety goals and develop a comprehensive plan for incorporating simulation as an educational component for nurses working in obstetric units. Implementation, Outcomes, and Evaluation Through scheduled monthly meetings the committee shared numerous ideas to support a fiscally responsible implementation plan. The drills are designed to enhance the learning of the nurse by incorporating the use of psychomotor skills. The nurse also will role‐play and care for a woman through the stages of labor and delivery using the simulator. Responding appropriately to spontaneous obstetric emergencies, including shoulder dystocia and precipitous delivery, are the first areas covered during the implementation of simulation. Implications for Nursing Practice Meaningful implications for the simulation training include effective communication as an interdisciplinary team; safe collaborative care to the obstetric simulator in the antepartum, intrapartum, and postpartum periods; and incorporate the collaboration of facilities to increase competency in varying skill mixes. The labor and delivery staff nurses are required to participate in 4 hours of simulation training annually. The scheduling of nurses from three facilities will allow 16 nurses to participate in training per month. Learning modules on shoulder dystocia and precipitous delivery were constructed to optimize the learning experience for each nurse. The modules contain objectives for each simulation module, pertinent educational materials, and learning assessments. Confidence level scoring will be performed by the nurse to evaluate the effectiveness of the simulation.

Midwife documentation of a shoulder dystocia delivery

Introduction: The objective of this study is to describe and analyse certified nurse midwife delivery notes after a simulated shoulder dystocia using a standardised case presentation and simulation technique. Methods: Seven experienced midwives from a single academic institution in california, US, underwent a standardised simulated shoulder dystocia delivery. Delivery notes were collected and analysed according to pre-specified criteria to assess for accuracy and comprehensiveness. Results: Fifteen documentation elements were examined. The median score was 11 out of 15, with 71% of participants recording 10 or more of the key components. The time of delivery, the presence of the paediatrics team for delivery, and the correct order of the manoeuvres performed were recorded by all midwives. The least commonly recorded items were the identification of the anterior shoulder, presence/absence of an epidural, and the name of the on-call supervising obstetrician Conclusion: Narrative shoulder dystocia documentation by experienced midwives contains many components of standard birth documentation but lacks certain critical elements.

Improved overall delivery documentation following implementation of a standardized shoulder dystocia delivery form.

Our objective was to evaluate whether using a standardized shoulder dystocia delivery form improved documentation. A standardized delivery form was added to our institution's obstetrical record in August 2003. A retrospective cohort study was conducted comparing 100 vaginal deliveries complicated by shoulder dystocia before, and 81 after implementation of the standardized delivery form. The two groups were compared in terms of obstetric characteristics, neonatal outcomes and documentation components. Charts that included the standardized delivery form were more likely to contain documentation of estimated fetal weight (82.7% vs. 39.0% without the form, P<0.001) and head-to-shoulder delivery interval (76.5% vs. 15.0% without the form, P<0.001). Both groups were statistically similar in terms of documenting estimated blood loss and fetal weight, umbilical cord pH, type and order of maneuvers utilized to relieve the shoulder dystocia, and second stage duration. Inclusion of a standardized form in the delivery record improves the rate of documentation of both shoulder dystocia-specific and general delivery components.

Using Simulation Training to Improve Shoulder Dystocia Documentation

To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience. Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations. Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25-63 years (mean+/-standard deviation 37.0+/-9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5+/-8.1). Documentation scores were significantly improved after training. Attendings' baseline documentation scores were 8.5+/-2.2 and improved to 9.4+/-2.3, P=.03. Residents' documentation scores also improved (9.0+/-2.1 compared with 10.6+/-2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores). Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation. II.

Improving shoulder dystocia management among resident and attending physicians using simulations

The objective of the study was to determine whether a simulation-based educational program would improve residents' and attending physicians' performance in a simulated shoulder dystocia. Seventy-one obstetricians participated in an unanticipated simulated shoulder dystocia, an educational debriefing session, and a subsequent shoulder dystocia simulation. Each simulation was scored, based on standardized checklists for 4 technical maneuvers and 6 communication tasks, by 2 physician observers. Paired Student t tests were used for analysis. Forty-three attendings and 28 residents participated. Residents showed significant improvement in mean maneuver (3.3 +/- 0.9 vs 3.9 +/- 0.4, P = .001) and communication (3.5 +/- 1.2 vs 4.9 +/- 1.0, P < .0001) scores after simulation training. Attending physicians' communication (3.6 +/- 1.6 vs 4.9 +/- 1.1, P < .0001) scores were significantly improved after training. Our program improved physician performance in the management of simulated shoulder dystocia deliveries. Obstetric emergency simulation training can improve physicians' communication skills, at all levels of training, and should be incorporated into labor and delivery quality improvement measures.

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.

Optimizing Shoulder Dystocia Management to Prevent Birth Injury

A practical clinical review of those aspects of shoulder dystocia management that are directly relevant to birth injury is presented. In contrast to more popular viewpoints, the tenets of this paper are that, with few exceptions, clinically relevant, permanent brachial plexus injury is nearly universally associated with shoulder dystocia, injury is causally related to mechanical stresses induced during shoulder dystocia delivery, and management algorithms can be optimized to reduce the incidence of mechanical birth injury from shoulder dystocia. Advantages of direct rotational manipulation of the fetus within the birth canal are emphasized, supported by critical analysis of maneuver-related outcomes research. The competing issue of potential asphyxial insult with prolonged shoulder dystocia is addressed in light of evidence for differential time-dependency between central and peripheral nerve injury as head-to-body interval increases. The importance of proper execution of shoulder dystocia maneuvers for maximizing favorable outcome of shoulder dystocia is iterated, as is coordination of teamed response by multiple healthcare providers. To avoid permanent neurologic sequelae from shoulder dystocia, clinicians are encouraged to be ever mindful of traction applied to the fetal head and neck, to become adept at performance of alternative maneuvers that instead concentrate on finesse rather than force, and to be more favorably disposed to the use of such maneuvers early and often in shoulder dystocia management algorithms.

Effect of Cardinal Movements on Fetal Mechanical Response During Simulated Shoulder Dystocia Deliveries.

OBJECTIVE: In simulated shoulder dystocia deliveries, we sought to compare neck extension (NE), head rotation (HR), lateral deviation (LD), and anterior and posterior brachial plexus strain (BPS) between descent and expulsion. STUDY DESIGN: Using a biofidelic instrumented fetal model, a maternal model, and a data acquisition system, we performed 20 ROA deliveries. We recorded data continuously for each trial and compared the maximum values for each parameter: NE, HR, LD, and anterior and posterior BPS. We compared values throughout two time periods preceding and following impaction of the anterior shoulder behind the pubic symphysis: descent (engagement, descent, flexion, and internal rotation) and expulsion (extension and external rotation). We used the Student’s t-test for data analysis, with two-tailed p<0.05 considered significant RESULTS: As shown in the table, NE and posterior BPS are significantly larger for expulsion. HR, LD, and anterior BPS are significantly greater during descent.Table: Fetal Mechanical ResponseCONCLUSION: The fetus undergoes quantifiable mechanical stress during descent and during expulsion.

Comparing fetal response during stage two, external rotation and head-to-body interval in simulated shoulder dystocia deliveries

In simulated shoulder dystocia deliveries, we sought to compare mechanical fetal response during Stage 2, external rotation (ER), and head-to-body interval (HTB). Using biofidelic instrumented fetal and maternal models and a data acquisition system, we simulated a telescoped second stage and performed 30 ROA deliveries, with bisacromial diameter = 11.8 cm. For each delivery, we continuously measured traction, head rotation (HR), lateral deviation (LD), and anterior and posterior brachial plexus strain (BPS) during Stage 2, ER, and HTB, selecting peak values for analysis with ANOVA and Student's t-test, with p<0.05 considered significant. Results are summarized in the tables. During Stage 2, HR, LD and anterior BPS were significantly larger than during ER or HTB. Posterior BPS was significantly larger during HTB. During HTB, traction and anterior BPS were significantly greater during delivery of the anterior shoulder; during delivery of the fetal body, posterior BPS was significantly greater than during Stage 2. Significant fetal response differences occur during Stage 2, ER and HTB. Aligning the head with the body before trunk delivery would minimize HR, LD and BPS.Tabled 1Fetal Response Peak ValuesStage 2External RotationHTBp-valueHead Rotation (°)63.3±13.09.4±11.921.5±11.6<0.001Lateral Deviation (°)62.1±12.922.0±14.837.7±15.1<0.001Anterior BP Strain (%)14.0±1.65.6±4.012.2±3.40.018Posterior BP Strain (%)4.0±3.10.3±1.18.9±4.8<0.001 Open table in a new tab Tabled 1Head-to-Body Interval in DetailDelivery of Anterior ShoulderDelivery of Fetal Bodyp-valueTraction (lbs)19.9±6.615.1±8.30.01Anterior BP Strain (%)12.5±3.47.8±5.6<0.001Posterior BP Strain (%)6.5±4.410.1±3.5<0.001 Open table in a new tab

The effect of clinician-applied maneuvers on delivery force and brachial plexus strain during shoulder dystocia deliveries — assessment through mathematical modeling

The effect of clinician-applied maneuvers on delivery force and brachial plexus strain during shoulder dystocia deliveries — assessment through mathematical modeling

Are there differences in mechanical fetal response between routine and shoulder dystocia deliveries?

AND SHOULDER DYSTOCIA DELIVERIES? ROBERT ALLEN, STEPHANIE CHA, LINDSAY KRANKER, TARA JOHNSON, EDITH GUREWITSCH, Johns Hopkins University, Biomedical Engineering, Baltimore, Maryland, Johns Hopkins University, Gynecology and Obstetrics, Baltimore, Maryland OBJECTIVE: Previous simulations of shoulder dystocia (SD) explored the effect of SD itself on the mechanical response of the fetus. Our objective was to perform an experimental study to explore the variations in fetal response due to routine, unilateral SD (USD) and bilateral SD (BSD) deliveries. STUDY DESIGN: Using a biofidelic maternal model, an instrumented fetal model and a data-acquisition system, we performed 30 experiments. For routine deliveries, we engaged the fetal head and allowed it to progress through cardinal movements using typical uterine contraction forces of 20-35 lbs, stopping the delivery when the head restituted to LOA presentation. For USD deliveries, we obstructed the anterior shoulder on the symphysis pubis; for BSD, the posterior shoulder was also impacted on the sacral promontory. Fetal shoulder widths were varied from 11.5, 12.9 and 12.1 cm, respectively for routine, USD and BSD deliveries. For each delivery we continuously measured head rotation (HR), brachial plexus (BP) stretch and neck extension (NE), selecting peak values for analysis. Maximum BP stretch, NE and HR were compared among groups using ANOVA, with P!0.05 considered significant. RESULTS: The table lists mean peak BP stretch, HR and NE among routine, USD and BSD deliveries. There are no differences among the three types of delivery for anterior BP stretch, HR and NE. CONCLUSION: Quantifiable mechanical response occurs in routine and SD deliveries. Posterior BP stretch is significantly longer for routine deliveries than either USD or BSD deliveries.

Does knowledge of prior shoulder dystocia affect management and outcome of subsequent deliveries?

OUTCOME OF SUBSEQUENT DELIVERIES? EDITH GUREWITSCH, ELLEN LANDSBERGER, ANJALI JAIN, STEPHANIE CHA, TARA JOHNSON, ROBERT ALLEN, Johns Hopkins University, Gynecology and Obstetrics, Baltimore, Maryland, Albert Einstein College of Medicine, Obstetrics and Gynecolgy, Bronx, New York, Johns Hopkins University, Biomedical Engineering, Baltimore, Maryland, Johns Hopkins University, Baltimore, Maryland OBJECTIVE: We sought to determine whether clinicians’ awareness of a woman’s prior shoulder dystocia (SD) affects management and outcome of her subsequent delivery. STUDY DESIGN: With IRB approval, records of all women with SD delivery (SDD) at Johns Hopkins Hospital from 6/1993-5/2004 who had at least 1 subsequent live birth at the same institution were reviewed for clinician cognizance of prior SD (as determined by specific documentation in admission or progress notes of subsequent delivery), allowance of a trial of labor (TOL), induction or augmentation of labor, attempted operative vaginal delivery (OpVD), subsequent delivery mode, SD recurrence and brachial plexus injury (BPI) occurrence. Using c and Fisher’s exact test, we compared subsequent deliveries with knowledge of prior SD to those with no knowledge (P!0.05 significant). RESULTS: 78 women met study criteria; 28% were associated with BPI. Knowledge of prior SD was recorded in only 13 (17%) and correlated with payor status and injury at the original SDD. We saw no differences in gestational age, BMI, diabetes or birth weight between groups. Despite elective cesarean without TOL if prior SD was known, SD recurred 9 (12%) times with similar frequency in both groups (table). CONCLUSION: Knowledge of prior SD affects both management and outcome of subsequent delivery. Elective cesarean without TOL does not affect SD recurrence; however, injury may be more likely when prior SD is unknown. Women should be informed of SD, even without clinical sequelae.

Traction training for routine and shoulder dystocia deliveries: An experimental study

Traction training for routine and shoulder dystocia deliveries: An experimental study