A critical evaluation of the external and internal maneuvers for resolution of shoulder dystocia

Neonatal and Maternal Outcomes following Shoulder Dystocia Resolution Utilizing ≥ versus < 3 Maneuvers

Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with ≥3 maneuvers, compared with fewer, is associated with a higher likelihood of adverse outcomes. The secondary objective was to examine if postpartum hemorrhage is associated with SD managed with ≥3 maneuvers versus fewer.This was a secondary analysis of the assessment of perinatal excellence (APEX) study, an observational cohort of over 115,000 deliveries in 25 U.S. hospitals from 2008 to 2011. We included individuals with singleton, vertex, and nonanomalous fetuses at ≥34 weeks who had SD requiring at least one maneuver. We stratified participants according to if ≥3 maneuvers, versus fewer, were utilized to resolve the SD. The primary outcome was the incidence of a neonatal composite adverse outcome including APGAR <5 at 5 minutes, fetal fractures, intracranial hemorrhage, brachial plexus palsy, facial nerve palsy, hypotension treated, hypoxic-ischemic encephalopathy, or neonatal death. Using modified-Poisson-regression, we calculated adjusted incidence relative risk (aIRR) with 95% confidence intervals (CI).The rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 cases of SD, 96% met the inclusion criteria. ≥3 maneuvers were utilized in 18.9% (391/2,062) of SD cases. The composite neonatal adverse outcome occurred in 8.1% (168/2,062) of cases, and in adjusted models, the risk for the composite outcome was significantly higher with SD requiring ≥3 maneuvers (15.1%) versus <3 maneuvers (6.5%; aIRR: 2.08; 95% CI: 1.50-2.89). Additionally, APGAR <5 at 5 minutes (aIRR: 4.10; 95% CI: 1.18-14.25), neonatal brachial plexus palsy (aIRR: 2.58; 95% CI: 1.45-4.60), and hypoxic-ischemic encephalopathy (aIRR: 2.83; 95% CI: 1.36 and 5.89) were significantly more likely when ≥3 were used. No significant difference was noted for postpartum hemorrhage (PPH) by number of maneuvers (aIRR: 0.74; 95% CI: 0.44 and 1.21).SD relieved by ≥3 maneuvers, compared with <3, was associated with a 2-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for PPH. · ≥3 Maneuvers increase neonatal adverse outcomes.. · With ≥3 maneuvers, higher risk of low APGAR and HIE.. · PPH rates similar for ≥3 versus <3 maneuvers..

Stratification of outcome of shoulder dystocia according to maneuver used for delivery, retrospective cohort and meta-analysis

BACKGROUND

Shoulder dystocia is an unpredictable obstetric condition with potential long-term neonatal complications. The risk of neonatal injury might be related to the condition itself as well as to the obstetrics maneuvers used for its release.

OBJECTIVES

To examine the available evidence to assess current management and possible improvement of outcomes.

SEARCH STRATEGY

A comprehensive search of MEDLINE, EMBASE, EMCARE, and The Cochrane Library database was performed, all studies reporting on neonatal outcomes in cases of shoulder dystocia stratified by obstetric maneuvers used for delivery were included. Data abstraction was performed and checked by two independent reviewers.

RESULTS

McRoberts maneuver was the least associated with risk of neonatal injury (odds ratio 0.6, 95% confidence interval 0.4-0.9), followed by delivery of posterior arm.

CONCLUSION

Delivery of posterior arm might be prioritized in cases of shoulder dystocia after failed McRoberts. Neonatal hypoxic injury correlates with the duration of dystocia rather than the maneuver used.

Maternal body mass index, maneuvers, and neonatal morbidity associated with shoulder dystocia

BACKGROUND

Shoulder dystocia is associated with neonatal morbidity. Higher maternal prepregnancy body mass index is an established risk factor for shoulder dystocia, yet the relationship between maternal prepregnancy body mass index and resulting neonatal morbidity after shoulder dystocia is not well-studied.

OBJECTIVE

We assessed the association between body mass index and neonatal adverse outcomes following shoulder dystocia. The frequency and type of maneuvers used to resolve shoulder dystocia by maternal body mass index was compared.

STUDY DESIGN

We conducted a retrospective cohort study of pregnant individuals who experienced a shoulder dystocia at delivery from June 2012 to July 2021 at a tertiary care center. We included singleton nonanomalous live births ≥36 weeks of gestation at a single academic medical center in the Midwestern US. The primary exposure was prepregnancy body mass index categorized as: <30 kg/m2 [referent], 30 to 34.9 kg/m2, and ≥35 kg/m2. The primary outcome was a composite neonatal morbidity including birth injury (brachial plexus injury or fracture), seizures, hypoxic ischemic encephalopathy, and 5-minute Apgar <7. Secondary outcomes were neonatal intensive care unit admission and neonatal acidemia (cord arterial pH <7.10). Shoulder dystocia duration and the number and types of maneuvers were compared by body mass index group. Multivariable logistic regression was used and adjusted for nulliparity, diabetes, operative vaginal delivery, and gestational age.

RESULTS

Among 872 individuals who experienced a shoulder dystocia at delivery, 602 (69.0%) had a body mass index <30 kg/m2, 160 (18.3%) had a body mass index between 30 and 34.9 kg/m2, and 110 (12.6%) had a body mass index ≥35 kg/m2. The median duration of shoulder dystocia was 40 seconds (interquartile range 30, 60 seconds) and did not vary by maternal body mass index. Deliveries complicated by body mass index ≥35 kg/m2 required a greater number of maneuvers compared to those with lower maternal body mass index (P<.01). McRoberts (96.0%), suprapubic pressure (90.2%), and delivery of the posterior arm (41.1%) were the most frequent maneuvers in all body mass index groups. Rubin's maneuver was more frequently used with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (34.6% vs 22.4%, adjusted odds ratio 1.63, 95% confidence interval [CI] 1.04-2.57, P=.02). Composite neonatal morbidity did not differ by body mass index. Neonatal injury was more frequent with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (adjusted odds ratio 1.97, 95% CI 1.06-3.68). Interaction between body mass index and number of maneuvers was not statistically significant (P=.94).

CONCLUSION

Among pregnant individuals who experienced a shoulder dystocia, increased prepregnancy body mass index was associated with an increased number of maneuvers performed during a shoulder dystocia but not longer duration. Risk of neonatal injury following shoulder dystocia, but not the composite neonatal adverse outcome, was increased with body mass index ≥35 kg/m2.

Long-Term Outcomes of Obstetric Brachial Plexus Injury: A Single-Center Experience

Obstetric brachial plexus injury (OBPI) is an important preventable complication of the birth process. While most cases recover in the early period, a substantial number result in sequelae. Despite established risk factors, there are cases that occur without any apparent risk factors. Our study aims to identify prenatal risk factors by examining OBPI cases born in our hospital and to provide insights into the prognosis of the disease by comparing cases with panplexopathy to those without. We included 31 cases followed for OBPI in our hospital. Risk factors related to the infant and the mother were investigated. The range of motion (ROM) measurements of the affected upper extremity joints, muscle strength, atrophy, and scoliosis status were evaluated. Of the cases, 71% were girls, and 61.3% had left-sided involvement. Additionally, 84.1% had risk factors, with oxytocin administration being the most frequently identified risk factor. In our study, we compared cases with panplexopathy to those without. Shoulder abduction, shoulder adduction, wrist flexion, and wrist extension restrictions were significantly more common in cases with panplexopathy. Furthermore, muscle atrophy was significantly more frequent in the panplexopathy group. Since OBPI is a preventable injury, identifying risk factors is crucial. However, there are conflicting results regarding the most significant risk factor. Our study highlights that oxytocin administration is a very important risk factor for OBPI. We found that cases with panplexopathy had a worse prognosis, with more frequent ROM limitations and muscle atrophy.

Video analysis of real-life shoulder dystocia to assess technical and non-technical performance

INTRODUCTION

Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life shoulder dystocia is limited, and the impact of non-technical skills has not been adequately evaluated. We aimed to analyze videos of teams managing real-life shoulder dystocia to identify clinical challenges associated with correct management and particular non-technical skills correlated with high technical performance.

MATERIAL AND METHODS

We included 17 videos depicting teams managing shoulder dystocia in two Danish delivery wards, where deliveries were initially handled by midwives, and consultants were available for complications. Delivery rooms contained two or three cameras activated by Bluetooth upon obstetrician entry. Videos were captured 5 min before and after activation. Two obstetricians assessed the videos; technical performances were scored as low (0-59), average (60-84), or high (85-100). Two other assessors evaluated non-technical skills using the Global Assessment of Team Performance checklist, scoring 6 (poor) to 30 (excellent). We used a spline regression model to explore associations between these two score sets. Inter-rater agreement was assessed using interclass correlation coefficients.

RESULTS

Interclass correlation coefficients were 0.71 (95% confidence interval 0.23-0.89) and 0.82 (95% confidence interval 0.52-0.94) for clinical and non-technical performances, respectively. Two teams had low technical performance scores; four teams achieved high scores. Teams adhered well to guidelines, demonstrating limited head traction, McRoberts maneuver, and internal rotation maneuvers. Several clinical skills posed challenges, notably recognizing shoulder impaction, applying suprapubic pressure, and discouraging women from pushing. Two non-technical skills were associated with high technical performance: effective patient communication, with teams calming the mother and guiding her collaboration during internal rotational maneuvers, and situation awareness, where teams promptly mobilized all essential personnel (senior midwife, consultant, pediatric team). Team communication, stress management, and task management skills were not associated with high technical performance.

CONCLUSIONS

Videos capturing teams managing real-life shoulder dystocia are an effective tool to reveal challenges with certain technical and non-technical skills. Teams with high technical performance are associated with effective patient communication and situational awareness. Future training should include technical skills and non-technical skills, patient communication, and situation awareness.

Shoulder Dystocia: A Comprehensive Literature Review on Diagnosis, Prevention, Complications, Prognosis, and Management

The term dystocia refers to labor characterized by a slow progression with delayed rates or even pauses in the dilation of the cervix or the descent of the fetus. Dystocia describes the deviation from the limits that define a normal birth and is often used as a synonym for the term pathological birth. Shoulder dystocia, also known as the manual exit of the shoulders during vaginal delivery on cephalic presentation, is defined as the "failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head". This means that obstetric interventions are necessary to deliver the fetus's body after the head has been delivered, as gentle traction has failed. Abnormal labor (dystocia) is expressed and represented in partograms or by the prolongation of the latent phase or by slowing and pausing in the phases of cervical dilatation and fetal descent. While partograms are helpful in visualizing the progress of labor, regular use of them has not been shown to enhance obstetric outcomes considerably, and no partogram has been shown to be superior to others in comparative trials. Dystocia can, therefore, appear in any phase of the evolution of childbirth, so it is necessary to simultaneously assess all the factors that may contribute to its abnormal evolution, that is, the forces exerted, the weight, the shape, the presentation and position of the fetus, the integrity and morphology of the pelvis, and its relation to the fetus. When this complication occurs, it can result in an increased incidence of maternal morbidity, as well as an increased incidence of neonatal morbidity and mortality. Although several risk factors are associated with shoulder dystocia, it has proven impossible to recognize individual cases of shoulder dystocia in practice before they occur during labor. Various guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality.

Shoulder dystocia in deliveries of neonates <3500 grams

OBJECTIVES

To study risk factors for shoulder dystocia (ShD) among women delivering <3500 g newborn.

METHODS

A retrospective case-control study of all term live-singleton deliveries during 2011-2019. Women with neonatal birthweight <3500 g were included. We compared cases of ShD to other deliveries by univariate and multivariable regression.

RESULTS

There were 79/41 092 (0.19%) cases of ShD among neonates <3500 g. In multivariable regression analysis, the following factors were independently associated with ShD; operative vaginal delivery (odds ratio [OR] 2.78; 95% confidence interval [CI]: 1.28-6.02, P = 0.009), vaginal birth after cesarean (VBAC, OR 2.74; 1.22-6.13, P = 0.010), sonographic abdominal circumference to biparietal diameter ratio (3.73 among ShD vs. 3.62, OR 1.35; 95% CI: 1.12-1.63, P = 0.001) and sonographic abdominal circumference to head circumference ratio (1.036 among ShD vs. 1.011, OR 3.04; 95% CI: 1.006-9.23, P = 0.049).

CONCLUSIONS

There is an association between operative vaginal delivery and ShD also in deliveries <3500 g. Importantly, the proportions between the fetal head and abdominal circumference are a better predictor of ShD than the newborn fetal weight and VBAC is associated with ShD.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.