Shoulder dystocia

Impact of Introducing PROMPT on Permanent Brachial Plexus Injury and Tears III°/IV° in Shoulder Dystocia: The Hanover Cohort Study

Objective

To test the hypothesis that PROMPT reduces permanent brachial plexus palsy and perineal tears.

Design

A prospective/retrospective cohort study. Setting. Hanover Medical School, Germany. Population/Sample. A self-selected population.

Methods

The training period is from November 9th, 2017, until December 31st, 2019; control: January 1st, 2004, until November 8th, 2017. Main Outcome Measures. Shoulder dystocia, nonpermanent and permanent brachial plexus injuries (BPIs), perineal tears III°/IV°, manual manoeuvres, and asphyxia.

Results

There was a total of 22,640 births, and shoulder dystocia increased from 48/18,031 (0.27%) to 23/4,609 (0.50%) ((p=0.017), OR: 1.88, 95% CI: (1.14; 3.09)), whereas BPIs decreased from 7/48 (14.6%) to 1/23 (4.3%) (p=0.261). There was 1/7 (14.2%) of permanent BPI before and 0/1 (0%) case after. Perinatal asphyxia increased from 3/48 (6.3%) to 4/23 (17.4%) (p=0.23). However, adverse outcomes after one year were zero. McRoberts' manoeuvre increased from 37/48 (77.1%) to 23/23 (100%) ((p=0.013), OR: 1.62, 95% CI: (1.33; 1.98)), and internal rotation manoeuvres and manual extraction of the posterior arm from 6/48 (12.5%) to 5/23 (21.7%) (p=0.319). Episiotomies decreased from 5,267/18,031 (29.2%) to 836/4,609 (18.1%) ((p < 0.001), OR: 0.54, 95% CI: (0.49, 0.58)), whereas perineal tears III°/IV° associated with shoulder dystocia increased from 1/48 (2.1%) to 1/23 (4.8%) (p=0.546). Vaginal operative deliveries remained constant (6.5% vs. 7%).

Conclusions

PROMPT significantly improves the management of shoulder dystocia and decreases permanent brachial plexus injuries but not perineal tears III°/IV°.

Precipitous and difficult deliveries

Any delivery in the emergency department is considered a precipitous birth and is an anxiety-producing event. Many deliveries proceed without incident. However, the emergency physician must be prepared for several dreaded scenarios, such as nuchal cord, shoulder dystocia, and breech birth. This article reviews the basics, complications, and management of such deliveries.

Care of the infant of the diabetic mother

Gestational diabetes mellitus (GDM) from all causes of diabetes is the most common medical complication of pregnancy and is increasing in incidence, particularly as type 2 diabetes continues to increase worldwide. Despite advances in perinatal care, infants of diabetic mothers (IDMs) remain at risk for a multitude of physiologic, metabolic, and congenital complications such as preterm birth, macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, hypertrophic cardiomyopathy, and congenital anomalies, particularly of the central nervous system. Overt type 1 diabetes around conception produces marked risk of embryopathy (neural tube defects, cardiac defects, caudal regression syndrome), whereas later in gestation, severe and unstable type 1 maternal diabetes carries a higher risk of intrauterine growth restriction, asphyxia, and fetal death. IDMs born to mothers with type 2 diabetes are more commonly obese (macrosomic) with milder conditions of the common problems found in IDMs. IDMs from all causes of GDM also are predisposed to later-life risk of obesity, diabetes, and cardiovascular disease. Care of the IDM neonate needs to focus on ensuring adequate cardiorespiratory adaptation at birth, possible birth injuries, maintenance of normal glucose metabolism, and close observation for polycythemia, hyperbilirubinemia, and feeding intolerance.

Complications of labor and delivery: shoulder dystocia

This article reviews one of the less common but most dreaded complications of labor and delivery, shoulder dystocia, an infrequent but potentially devastating event that results from impaction of the fetal shoulders in the maternal pelvis. Shoulder dystocia occurs most commonly in patients without identified risk factors, and can result in both maternal and fetal morbidity. Because the vast majority of cases of shoulder dystocia are unpredictable, obstetric care providers must be prepared to recognize dystocia and respond appropriately in every delivery. Detailed documentation is essential after any delivery complicated by shoulder dystocia.

Determining factors associated with shoulder dystocia: a population-based study

OBJECTIVE

The study was aimed to define obstetric factors associated with shoulder dystocia.

METHODS

A population-based study comparing all singleton, vertex, term deliveries with shoulder dystocia with deliveries without shoulder dystocia was performed. Statistical analysis was done using multiple logistic regression analysis.

RESULTS

Shoulder dystocia complicated 0.2% (n = 245) of all deliveries included in the study (n = 107965). Independent risk factors for shoulder dystocia in a multivariable analysis were birth-weight > or =4000 g (OR = 24.3; 95% CI 18.5-31.8), vacuum delivery (OR = 5.7, 95% CI 3.4-9.5), diabetes mellitus (OR = 1.7, 95% CI 1.2-2.5) and lack of prenatal care (OR = 1.5, 95% CI 1.1-2.3). A significant linear association was found between birth-weight and shoulder dystocia, using the Mantel-Haenszel procedure. Pregnancies complicated with shoulder dystocia had higher rates of third-degree perineal tears as compared to the comparison group (0.8% versus 0.1%; P < 0.001). Similarly, perinatal mortality was higher among newborns delivered after shoulder dystocia as compared to the comparison group (3.7% versus 0.5%; OR = 7.4, 95% CI 3.5-14.9, P < 0.001). In addition, these newborns had higher rates of Apgar scores lower than 7 at 1 and 5 min as compared to newborns delivered without shoulder dystocia (29.7% versus 3.0%; OR = 13.8, 95% CI 10.3-18.4, P < 0.001 and 2.1% versus 0.3%; OR = 7.2, 95% CI 2.8-18.1, P < 0.001, respectively). Combining risk factors such as large for gestational age, diabetes mellitus and vacuum delivery increased the risk for shoulder dystocia to 6.8% (OR = 32.6, 95% CI 10.1-105.8, P < 0.001).

CONCLUSIONS

Independent factors associated with shoulder dystocia were birth-weight > or =4000 g, vacuum delivery, diabetes mellitus and lack of prenatal care.

Shoulder dystocia: a comparison of patients with and without diabetes mellitus

BACKGROUND

The study was aimed to compare pregnancies complicated with shoulder dystocia, of patients with and without diabetes mellitus.

METHODS

A comparison of all singleton, vertex, term deliveries between the years 1988-1999, complicated with shoulder dystocia with and without diabetes mellitus was performed. Statistical analysis was done using receiver operating characteristic curve analysis.

RESULTS

Using a receiver operating characteristic curve analysis, the area under the curve for birth weight was 0.92 (95% CI 0.90-0.93). However, for birth weight of 4,000 g the sensitivity was only 56% with specificity of 95%. While comparing shoulder dystocia between patients with (n=38) and without diabetes mellitus (n=207), neonates of the diabetic patients were significantly heavier (mean birth weight 4,244.2+/-515.1 vs. 4,051.6+/-389.5; P=0.008) and had higher rate of Apgar scores lower than 7 at 1 min (50.0% vs. 25.9%; P=0.030), but not at 5 min (2.6% vs. 2.0%; P=0.083) when compared to the non-diabetic group. No significant differences were noted regarding perinatal mortality between the groups (0% vs. 4.3%; P=0.362).

CONCLUSIONS

The newborn of the diabetic mother complicated with shoulder dystocia does not appear to be at an increased risk for perinatal morbidity compared with the newborn of the non-diabetic mother.

Infants of diabetic mothers

Advances in the management of the mother with diabetes have reduced the rate of morbidity and mortality for her infant. Aggressive control of maternal glycemic status is warranted, because most morbidities are epidemiologically and pathophysiologically closely linked to fetal hyperglycemia and hyperinsulinemia. The burgeoning public health problem of overweight and obesity in children will likely result in an increased incidence of metabolic syndrome X, characterized by insulin resistance and type II diabetes in adulthood. An early manifestation of this may be glucose intolerance during pregnancy in overweight women without diabetes. Clinicians must continue to have a high degree of suspicion for the diagnosis of diabetes during gestation and screen offspring of women with gestational diabetes for neonatal sequelae.

Maternal obesity as an independent risk factor for caesarean delivery

The present study was aimed to investigate pregnancy outcome among obese women and specifically the correlation between maternal obesity and incidence of caesarean section (CS) while controlling for the potential confounding effects of other variables associated with obesity. A population-based study was performed comparing all pregnancies of obese (maternal pre-pregnancy body mass index (BMI) of 30 kg/m2 or more) and non-obese patients, between the years 1988 and 2002. Patients with hypertensive disorders and diabetes mellitus as well as patients lacking prenatal care were excluded from the analysis. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. During the study period there were 126,080 deliveries meeting the inclusion criteria, of which 1769 (1.4%) occurred in obese patients. Using a multivariable analysis, the following conditions were significantly associated with maternal obesity: failure to progress during the first stage (odds ratio (OR) = 3.1; 95% confidence interval [CI] 2.5, 3.8; P < 0.001), fertility treatments (OR = 2.0; [95% CI 1.6, 2.5]; P < 0.001), previous CS (OR = 1.7; [95% CI 1.5, 1.9]; P < 0.001), malpresentations (OR = 1.4; [95% CI 1.2, 1.6]; P < 0.001), recurrent miscarriages (OR = 1.4; [95% CI 1.2, 1.7]; P < 0.001) and fetal macrosomia (OR = 1.4; [95% CI 1.2, 1.7]; P < 0.001). Higher rates of caesarean deliveries were found among obese parturients (27.8% vs. 10.8%; OR = 3.2; [95% CI 2.9, 3.5]; P < 0.001). When controlling for possible confounders, using the Mantel-Haenszel technique, the association between maternal obesity and CS remained significant. No significant differences were noted between the groups regarding perinatal complications such as perinatal mortality, congenital malformations, shoulder dystocia and low Apgar scores. In conclusion, a significant association was found between obesity and CS even after the exclusion of hypertensive disorders and diabetes mellitus. Importantly, obesity alone was not associated with adverse perinatal outcome. Obstetricians should be encouraged to allow obese patients not suffering from diabetes or hypertensive disorders an adequate trial of labour.

Intrapartum Emergencies

Intrapartum emergencies are challenging to all perinatal nurses because of the increased risk of adverse outcomes for the mother and fetus. Perinatal emergencies, such as seizures, amniotic fluid embolus, hemorrhage, and uterine rupture, create physiological challenges and trigger intrinsic survival techniques. The pregnant uterus becomes a vital source of blood volume during hypovolemic events because it is not considered a vital organ. The pregnancy itself may become burdensome, and birth may occur as an intrinsic maternal compensatory mechanism. The resultant fetal hypoxemia may also stress the fetus into initiating labor. During extensive oxygen desaturation and decompensation, the focus should be on maternal stabilization, which will subsequently enhance fetal stabilization. Clinical assessments, critical thinking, decision making, and resource allocation must be quick and appropriate to increase the likelihood of a positive outcome for the mother, fetus, and neonate.

Emergency delivery and perimortem C-section

The emergency department is a suboptimal location for delivery, and the greater prevalence of complicated presentations and emergency deliveries results in higher morbidity and mortality. Any woman greater than 20 weeks' gestation in labor is considered medically unstable and should be triaged quickly. Fetal viability occurs after 24 to 26 weeks' gestation. Placenta previa and abruption should be considered in a woman in labor with ongoing bleeding, and ultrasound evaluation should be performed emergently. Continuous fetal monitoring is the best method to assess for heart rate variations, accelerations, or decelerations. After the fetus crowns, a finger sweep can exclude the presence of a cord prolapse or nuchal cord. Set up a safety net by notifying appropriate specialists when a complicated delivery is suspected. In shoulder dystocia, generous episiotomy, drainage of the bladder, McRobert's maneuver, and suprapubic pressure may all help disengage the anterior shoulder. With a cord prolapse, the mother is instructed not to push, and the presenting part is elevated off of the cord. Perimortum cesarean delivery is performed with gestational age greater than 24 to 26 weeks. The supine position can lead to aortocaval compression. Perimortum cesarean delivery should be performed within 4 minutes of maternal cardiopulmonary arrest.

Suspected big baby: a difficult clinical problem in obstetrics

BACKGROUND

Large for gestational age fetuses, also called macrosomic fetuses, represent a continuing challenge in obstetrics.

METHODS

We review various problems with large for gestational age fetuses. We have performed a literature search, mainly through the database PubMed (includes the Medline database). The clinical problem is discussed from the primary care provider's, the patient's and the obstetrician's point of view.

RESULTS

Macrosomia is arbitrarily defined as having a fetal weight of above the 90th percentile, a birth weight of above 4000 g or 4500 g, or a birth weight of over +2 standard deviation of the mean birth weight by gestational age. The diagnosis of macrosomia is difficult, both by palpation and symphysis fundus measurement; even with sophisticated sonographic measures. The combination of biparietal diameter, femur length and abdominal circumference appears to be no better than abdominal circumference alone.

INTERPRETATION

Based on the literature, labor should not be induced in nondiabetic pregnancies. The best policy is to await spontaneous birth or to induce labor after 42 weeks completion. A great number of cesarean sections have to be performed to avoid a single case of plexus brachialis paresis resulting from a difficult shoulder delivery. Cesarean section should not be considered in nondiabetic pregnancies unless the estimated fetal weight is above 5000 g. In pregnancies complicated by diabetes mellitus there are reasons for selective induction of labor if macrosomia is suspected and for cesarean section if the calculated birth weight is above 4000 g. Each department should have a strategy to handle such a situation because the problem with the difficult shoulder delivery cannot be completely avoided. Different procedures of managing difficult shoulder delivery are described.

Prepregnancy body mass index in non-diabetic women with and without shoulder dystocia

OBJECTIVE

To investigate the distribution of prepregnancy body mass index (BMI) in non-diabetic women with and without shoulder dystocia.

STUDY DESIGN

Cases were 142 non-diabetic women experiencing shoulder dystocia during the period from 1 January 1993 to 31 December 1999. Shoulder dystocia was defined as the impossibility of delivering the fetal shoulders by standard procedures. Controls were 142 women vaginally delivering during the same period without experiencing shoulder dystocia. Cases and controls were matched for parity (primi-/multipara) and birthweight (+/-250 g). Women with diabetes mellitus, gestational diabetes or a history of shoulder dystocia in a previous birth were excluded. The BMI and selected obstetric data were extracted from an internal database in the department.

RESULTS

Delivery was performed using McRoberts maneuvre (42%), Woods screw (50%) or by primary delivery of the posterior arm (8%). Women experiencing shoulder dystocia had significantly more labor augmentation and more instrumental deliveries. No differences were shown in the prevalence of low Apgarscores. The proportion of children with Erbs palsy and clavicular fracture was very close to be significantly different in cases or controls. However, these data does not allow any conclusion. The distribution of BMI was equal in cases and controls.

CONCLUSION

Non-diabetic women experiencing shoulder dystocia do not have a higher BMI than non-diabetic women delivering without this experience, given a fixed fetal weight.

Indications for caesarean section

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.

Pregnancy outcome of personnel in Swedish biomedical research laboratories

Possible hazardous effects of laboratory work on the reproduction outcomes of female laboratory personnel in Sweden from 1990 to 1994 were investigated in a questionnaire-based study (n = 1052) by comparison with personnel in non-laboratory departments. The individual woman constituted the primary sampling unit, with her pregnancies defined as the unit of analysis. Allowance for dependence between different pregnancies of the same woman was considered by applying random effect models. With regard to spontaneous abortions, no elevated odds ratio was found for laboratory work in general, but an odds ratio of 2.3 and a 95% confidence interval of 0.9 to 5.9 (n = 856) was connected to working with chloroform. The odds ratio for large for gestational age infants in association with the mother's laboratory work was 1.9 (confidence interval, 0.7 to 5.2). The result with regard to spontaneous abortion partly supports previously reported increased risks of miscarriage related to laboratory work with solvents.