Management of Shoulder Dystocia: Trends in Incidence and Maternal and Neonatal Morbidity

Abstract

not associated with longer second stage labor. Women who delivered within 0 to 1 hour had a spontaneous vaginal delivery (SVD) 90% of the time; those delivered in 2 to 3 hours had a 62.4% SVD rate, with 30.1% having operative vaginal delivery and 7.5%, CS; at Z3 hour, SVD rates dropped to 35.8%, with 37.4% having operative vaginal delivery, and 26.8%, CS.Epidural anesthesia was associated with an increased risk for operative vaginal deliveries, but not with higher CS rates in second stages exceeding 3 hours. Rates of thirddegree or fourth-degree perineal laceration, postpartum hemorrhage, chorioamnionitis, and endomyometritis increased with lengthening duration of second stage. Neonates delivered after a second stage of Z2 hours had higher undesirable neonatal outcomes, including 5-minute Apgar scores <7, umbilical artery pH <7, base excess < À 12, meconium-stained amniotic fluid, intensive care nursery admission, and prolonged hospital stays.A small subgroup of multiparous women do experience a second stage of labor >2 hours in duration. Whether to intervene depends on a thorough evaluation of the ongoing risks of the intervention versus further expectant management, along with patient preference. The authors believe their findings can help facilitate such a discussion and counseling of multiparous women in this situation. They recommended larger, randomized, controlled studies regarding intervention when the second stage of labor progresses beyond 2 hours in multiparous women.I n the late 1990s, the McRoberts maneuver was widely used in the United Kingdom to manage shoulder dystocia during vaginal delivery and protocols to overcome this complication had become established at most centers. This study investigated trends in shoulder dystocia prevalence, methods used to overcome the obstruction, and associated maternal, fetal, and neonatal morbidity at one medical center in the United Kingdom.Cases of shoulder dystocia from 1991 to 2005 were identified from maternal delivery records. Cases of brachial plexus injury and other neonatal diagnoses made during the same period were identified separately. The demographic and delivery statistics for all vaginal deliveries during each year were obtained. Information on shoulder dystocia management, once the condition was diagnosed, was also recorded. Neonate conditions at birth were assessed by recording APGAR scores, umbilical cord blood gases, evidence of orthopedic injury, and neurologic outcome. The level of obstetrician training was recorded. Maternal injury was documented as was management of subsequent deliveries, including recurrent shoulder dystocia and neonatal birth weight.Among 95,321 deliveries, 79,781 were vaginal and among these were 514 cases of shoulder dystocia, 44 cases of neonatal brachial plexus injury, and 36 asphyxiated neonates. The mean annual rate of vaginal deliveries was 82.4%, which decreased by 0.64% each year. Use of epidural analgesia averaged 28.3% annually. The overall rate of shoulder dystocia during the 15 year was 0.64% of vaginal deliv...

Prevention of brachial plexus injury—12 years of shoulder dystocia training: an interrupted time‐series study

“…There are a number of publications investigating the incidence of BPI pre-and post-training intervention, 8,[19][20][21] but they are difficult to compare because the incidence is expressed with different denominators. We suggest that this could usefully be standardised: the expression and publication of permanent brachial plexus injury rate as (i) the proportion of cases of shoulder dystocia, (ii) the proportion of vaginal births, and (iii) the proportion of total births.…”

“…[14][15][16][17] However, the effect of training on perinatal outcomes has been conflicting; there are reports of improvements after training, 8,18,19 whereas other training has been associated with no change in outcomes, 20 or even an increase in poor neonatal outcomes after training had been introduced. 21 Practice does not make perfect if it is the wrong practice.…”

Quality improvement demands quality measurement

“…In subsequent analyses of their outcome data, one unit found an associated decrease in the brachial plexus injury rate (70% reduction), 5 whereas the other unit had a 100% increase. 6 During the same period, both of these units satisfied CNST with their risk management processes, including having training in place, and were awarded the same CNST level.…”

Analysis of legal claims—informing litigation systems and quality improvement

“…[17][18][19] Not all training is effective however. 20 There is an evidence base developing for intrapartum skills training and the focus has to be on disseminating evidence-based programmes that incorporate the essential features of successful interprofessional learning, namely: multi-professional training of all staff locally in their units; teamwork training integrated with clinical teaching and use of accurate simulation models. 15 Aside from how teams work together, there is a need to know what is the best deployment of staff.…”