Management of shoulder dystocia - Trends in incidence and maternal and neonatal morbidity
Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom. Obstetrics and Gynecology
(Impact Factor: 5.18).
12/2007; 110(5):1059-68. DOI: 10.1097/01.AOG.0000287615.35425.5c
To investigate trends in the incidence of shoulder dystocia, methods used to overcome the obstruction, and rates of maternal and neonatal morbidity.
Cases of shoulder dystocia and of neonatal brachial plexus injury occurring from 1991 to 2005 in our unit were identified. The obstetric notes of cases were examined, and the management of the shoulder dystocia was recorded. Demographic data, labor management with outcome, and neonatal outcome were also recorded for all vaginal deliveries over the same period. Incidence rates of shoulder dystocia and associated morbidity related to the methods used for overcoming the obstruction to labor were determined.
There were 514 cases of shoulder dystocia among 79,781 (0.6%) vaginal deliveries with 44 cases of neonatal brachial plexus injury and 36 asphyxiated neonates; two neonates with cerebral palsy died. The McRoberts' maneuver was used increasingly to overcome the obstruction, from 3% during the first 5 years to 91% during the last 5 years. The incidence of shoulder dystocia, brachial plexus injury, and neonatal asphyxia all increased over the study period without change in maternal morbidity frequency.
The explanation for the increase in shoulder dystocia is unclear but the introduction of the McRoberts' maneuver has not improved outcomes compared with the earlier results.
Available from: medik.net
Available from: Michael Bruce Brimacombe
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ABSTRACT: The study explores the roles of routine prenatal diabetic screening and control in the occurrence of neurological birth injuries
associated with shoulder dystocia. The investigation involved retrospective review of 226 medical records that contained information
about the antenatal events in cases that resulted in permanent neonatal injuries following arrest of the shoulders at delivery.
Close attention was paid to diabetic screening and management of mothers with evidence of glucose intolerance. Analysis of
the records revealed that one-third of all women, including those with predisposing factors, received no diabetic screening
during pregnancy. The majority of confirmed diabetic patients were not treated adequately. Among babies of diabetic women,
birth weights exceeding 4500 g were about 30-fold more frequent than among those with normal glucose tolerance. The data suggest
that universal screening and rigid diabetic control, including mothers with borderline glucose tolerance, are effective measures
for the prevention of excessive fetal growth and intrapartum complications deriving from it. If ignored, impaired maternal
glucose tolerance may become a major predisposing factor for neurological birth injuries. It appears therefore that with routine
screening for diabetic predisposition and effective control of gestational diabetes the risk of fetal damage can be reduced
Available from: Andrew Whitelaw
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ABSTRACT: To compare the management of and neonatal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simulation training.
This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to December 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The management of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoulders was recorded during the two study periods.
There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After training was introduced, clinical management improved: McRoberts' position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P=.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11-0.57]).
The introduction of shoulder dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by shoulder dystocia.
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