Shoulder dystocia without versus with brachial plexus injury: A case–control study

Objective. To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI).

Study design. A case–control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

Results. From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88).

Conclusions. Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.     

A scoring system for detection of macrosomia and prediction of shoulder dystocia: A disappointment

Objective. To develop a scoring system for the detection of a macrosomic fetus (birth weight (BW) ≥ 4000 g) and predict shoulder dystocia among large for gestational age fetuses.

Study design. We retrospectively identified all singletons with accurate gestational age (GA) that were large for GA (abdominal circumference (AC) or estimated fetal weight (EFW) ≥ 90% for GA) at ≥37 weeks with delivery within three weeks. The scoring system was: 2 points for biparietal diameter, head circumference, AC, or femur length ≥90% for GA, or if the amniotic fluid index (AFI) was ≥24 cm; for biometric parameters <90% or with AFI <24 cm, 0 points. The predictive values for detection of shoulder dystocia were calculated.

Results. Of the 225 cohorts that met the inclusion criteria the rate of macrosomia was 39% and among vaginal deliveries (n = 120) shoulder dystocia occurred in 12% (15/120; 95% confidence interval (CI) 7–20%). The sensitivity of EFW ≥4500 g to identify a newborn with shoulder dystocia was 0% (95% CI 0–21%), positive predictive values 0% (95% CI 0–46%), and likelihood ratio of 0. For a macrosomia score >6, the corresponding values were 20% (4–48%), 25% (5–57%) and 2.3.

Conclusion. Though the scoring system can identify macrosomia, it offers no advantage over EFW. The scoring system and EFW are poor predictors of shoulder dystocia.     

Shoulder dystocia and the next delivery: Outcomes and management

Objective. To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia.

Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described.

Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048).

Conclusion. In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high—approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.     

The FL/AC ratio for prediction of shoulder dystocia in women with gestational diabetes

Purpose: To determine if sonographic variables, including fetal femur length to abdominal circumference (FL/AC) ratio, are associated with shoulder dystocia in women with gestational diabetes.

Methods: This was a retrospective cohort study of women with gestational diabetes who delivered singleton infants at Parkland Hospital from 1997 to 2015. Diagnosis and treatment of gestational diabetes were uniform including sonography at 32–36 weeks. Biometric calculations were evaluated for correlation with shoulder dystocia.

Results: During the study period, 6952 women with gestational diabetes underwent a sonogram at a mean gestation of 34.8?±?1.8 weeks. Of 4183 vaginal deliveries, 66 experienced shoulder dystocia (16/1000). The FL/AC was associated with shoulder dystocia (p?p?=?0.54) whereas age-adjusted AC and HC/AC were not (p?Conclusions: The FL/AC is associated with shoulder dystocia in women with gestational diabetes. Additionally, it is a simple ratio that is independent of the reference used and remains stable, unlike age-adjusted AC and HC/AC ratio.     

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.     

Glucose challenge test: Screening threshold for gestational diabetes mellitus and associated outcomes

Objective. To examine whether women with an 1-hour 50-g glucose challenge test (GCT) for gestational diabetes mellitus (GDM) between 120 and 140 mg/dL and ≥140 mg/dL are at risk of perinatal complications.

Study design. A retrospective cohort study of women with singleton pregnancies screened for GDM between 1988 and 2001 with a 1-hour 50-g GCT. Values of GCT were stratified into four subgroups: <120, 120–129, 130–139, and ≥140 mg/dL. Perinatal outcomes were compared using the Chi-square test and multivariable logistic regression analysis.

Results. There were 13 901 women meeting the study criteria. Compared to women with a GCT of <120 mg/dL, women with a GCT of 130–139 mg/dL and ≥140 mg/dL were more likely to have preeclampsia and operative vaginal or cesarean deliveries. Neonates born to women with a GCT of 130–139 mg/dL also had higher odds of having a 5-minute Apgar score <7 (odds ratio (OR) = 1.51, 95% confidence interval (CI) 1.01–2.29), shoulder dystocia (OR = 2.02, 95% CI 1.16–2.55), birth trauma (OR = 1.47, 95% CI 1.06–2.02), and composite morbidity (OR = 1.25, 95% CI 1.03–1.51). Women with a GCT of ≥140 mg/dL had higher odds of macrosomia (OR = 1.32, 95% CI 1.13–1.54) and shoulder dystocia (OR = 1.68, 95% CI 1.11–2.55).

Conclusion. Women with GCT results of 130–139 mg/dL appear to be at increased risk for perinatal morbidity. Thus, utilizing a diagnostic test in women with a GCT above 130 mg/dL should be considered.     

Fetal macrosomia as a risk factor for shoulder dystocia during vacuum extraction

Objective: Vacuum extraction of a macrosomic fetus is considered a risk factor for shoulder dystocia (SD). We evaluated maternal and fetal outcomes following vacuum extraction of macrosomic infants.

Methods: A retrospective cohort study conducted in two large teaching hospitals. All deliveries of macrosomic infants by vacuum extraction and vaginal delivery were compared. The primary outcome measure was SD. Secondary outcome measures were severe perineal lacerations and postpartum hemorrhage. For statistical analysis, we used McNemar’s test and χ² or Fisher’s exact tests. Odds ratios were analyzed via a logistic regression model.

Results: From 2003 to 2013, there were 6019 (5.45%) deliveries of macrosomic fetuses, and 230 (0.21%) were delivered by vacuum extraction. There were 23 (10%) and seven (3.04%) cases of SD in the study and control groups, respectively. The risk of SD was significantly higher in the study group (p?>?0.05). We found a significant association between SD and vacuum delivery [p?=?0.003; OR?=?3.54 (95% CI: 1.49–8.42)]. The composite adverse neonatal outcome rate was 6.5% (15/230) and 1.7% (4/230) in the study and control groups, respectively (p?=?0.009).

Conclusion: Vacuum extraction of a macrosomic infant is a risk factor for shoulder dystocia but not for postpartum hemorrhage or severe vaginal tears.     

The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation

Objective.?To estimate the effects of computerized charting and shoulder dystocia (SD) simulation drills on the documentation of SD.

Methods.?180 cases of SD were evaluated in three consecutive time periods: T1: 45 written delivery notes; T2: 48 delivery notes after the implementation of a standardized SD note in the computerized medical record; T3: 87 computerized delivery notes after SD simulation drills.

Results.?A standardized SD computerized note resulted in a significant improvement in documentation of EFW, diabetic status, time of the body delivery, fetal head position, which shoulder was impacted, anesthesia, the length of each stage of labor, NICU admission, the birth weight, and that a discussion took place with the patient. The implementation of a SD simulation drill was associated with a further increase in the documentation of the instruments used for delivery, whether a cord pH was performed, and that a discussion took place with the patient. Additionally, the implementation of a SD simulation drill increased the rate of documented SD (1.61% vs. 2.37% of vaginal deliveries, p?=?0.0275) and the number of obstetricians who documented a SD (32.35% vs. 60.29% of delivering obstetricians, p?=?0.0020).

Conclusions.?Standardized SD notes as well as simulation drills improve documentation of SD events.     

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.     

Women with gestational diabetes mellitus in the ACHOIS trial: risk factors for shoulder dystocia

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with increased risk of fetal macrosomia and shoulder dystocia. However, not all women with GDM and fetal macrosomia have shoulder dystocia. Aims: To identify the risk factors for shoulder dystocia in women with gestational diabetes using data from women recruited into the routine care group of the ACHOIS trial. METHODS: A secondary analysis was performed on data collected from women enrolled in the ACHOIS trial. Bivariate analyses were performed using the Fisher exact test. Variables found to be significantly associated with shoulder dystocia and previously identified risk factors were used as explanatory variables in multivariate analyses. RESULTS: A positive relationship was found between the severity of maternal fasting hyperglycaemia and the risk of shoulder dystocia, with a 1 mmol increase in fasting oral glucose-tolerance test leading to a relative risk (RR) of 2.09 (95% CI 1.03-4.25). Shoulder dystocia occurred more often in births requiring operative vaginal delivery (RR 9.58, 95% CI 3.70-24.81, P < 0.001). Macrosomic and large-for-gestational-age infants were more likely to have births complicated by shoulder dystocia (RR 6.27, 95% CI 2.33-16.88, P < 0.001 and RR 4.57, 95% CI 1.74-12.01, P < 0.005, respectively). Fetal macrosomia was the only variable to maintain its significance in all multivariate analyses. CONCLUSIONS: Fetal macrosomia is the strongest independent risk factor for shoulder dystocia. Effective preventative strategies are needed.     

The problem of shoulder dystocia

Shoulder dystocia occurs in 1 in 300 deliveries. It carries a high incidence of poor outcomes, particularly brachial plexus injury in the fetus. As well as fetal and maternal morbidity, suboptimal management leaves the NHS at major risk of litigation. Single risk factors are of little value in predicting shoulder dystocia, but consideration of combinations of risk factors may help to avoid some cases. The manoeuvres used to cope with shoulder dystocia are well known and must be regularly rehearsed to familiarize staff. Careful attention to practice and documentation will reduce the litigation risk.     

Shoulder dystocia without versus with brachial plexus injury: a case-control study.

OBJECTIVE: To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI). STUDY DESIGN: A case-control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88). CONCLUSIONS: Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.     

Maternal and anthropomorphic risk factors for shoulder dystocia

OBJECTIVE: To study maternal and anthropomorphic parameters as potential risk factors for shoulder dystocia. MATERIAL AND METHOD: From a series of 9667 vaginal deliveries between January 1998 and December 2003, a total of 138 cases complicated by shoulder dystocia were retrospectively identified and compared with a control group of 138 uncomplicated vaginal deliveries. In addition to maternal age, parity, diabetes, body mass index (BMI), and ethnicity, anthropometric factors including maternal height-to-infant weight ratio, characteristics of labor, management techniques, and outcome were evaluated as possible risk factors for shoulder dystocia. RESULTS: The overall incidence of shoulder dystocia in this retrospective series of vaginal deliveries was 1.4%. In univariate analysis, maternal obesity (OR; 95% CI: 3.6; 2.1-6.3), diabetes (OR: 19.4; 2.5-145.7), parity greater than 2 (OR: 2.5; 1.4-4.4), maternal height-to-infant weight ratio (OR: 1.02; 1.01-1.04; P < 0.001), and infant weight-to-maternal BMI ratio (OR: 1.02; 1.01-1.03; P < 0.001) were predictive of shoulder dystocia. In multiple regression analysis, obesity and multiparity were the most significant maternal risk factors for shoulder dystocia. The only anthropometric factors associated with shoulder dystocia in multiple regression analysis were maternal height <1.55 m (OR: 6.6; 1.3-34.9) and maternal height-to-infant weight ratio (OR: 1.02; 1.01-1.05). CONCLUSION: Shoulder dystocia may be anticipated in cases involving short women and discrepancy between maternal height or weight and infant weight.     

Sexual activity during pregnancy and prognosis of labor in Cameroonian women: a cohort study

Abstract

Objective: Our aim was to assess the effects of sexual activity during pregnancy on the prognosis of labor.

Methods: It was a prospective cohort study of labor comparing 72 women declaring unprotected vaginal sexual intercourse after 37 weeks of pregnancy consecutively recruited to 72 women claiming no sexual contact after 37 weeks of pregnancy also consecutively recruited.

Results: The sexually active group at term were significantly involved in more frequent heterosexual intercourse after 28 weeks pregnancy and before term (RR?=?37.8; CI?=?19.8–515.4). Women sexually active were significantly admitted during the active phase of labor (RR?=?2.4; IC?=?1.6–5.3), with the fetal head at station 0 and more (RR?=?1.5; CI?=?1.3-5.2). They significantly had a shorter active phase (RR?=?1.7; CI?=?1.5–3.7) and a shorter second stage (RR?=?1.5; CI?=?1.2–3.3). They significantly had a normal pattern of labor (RR?=?2.1; CI?=?1.2–5.3), a higher rate of spontaneous deliveries (RR?=?2.1; CI?=?1.5–4.5), a lower rate of caesarean sections (RR?=?0.46; CI?=?0.1–0.8) and needed less oxytocin usage before expulsion (RR?=?0.5; CI?=?0.2–0.7).

Conclusion: Sexual activity during pregnancy improves the prognosis of labor in Cameroonian women. In the absence of contraindications, consented unprotected heterosexual intercourse should be promoted in pregnant women.     

Obstetric brachial plexus palsy: a population-based retrospective case-control study and medicolegal considerations

Aims: The aim of this study was to examine 24 cases of obstetric brachial plexus palsy (OBPP) in 41,002 deliveries occurred at San Camillo–Forlanini Hospital in Rome, during the period 2000–2012.

Materials and methods: A population-based retrospective case-control study was designed and the database of the hospital was searched; for each case, maternal and fetal records were examined and some risk factors were evaluated.

Results: A statistically significant association between the 24 cases OBPP and the following risk factors: primiparity (p?p?p?p?p?Conclusions: The absence of OBPP cases in cesarean deliveries highlighted in this study supports the option of proposing an elective cesarean in the presence of known risk factors after a full disclosure with the mother of risks and benefits in order to obtain a valid consent. Furthermore, when cases of OBPP occur, communication between the physician and the parents of newborns is crucial and it may represent a valid risk-management tool to reduce malpractice lawsuits.     

Persistent pulmonary hypertension of the newborn following elective cesarean delivery at term

Objective.?To evaluate the frequency of persistent pulmonary hypertension of the newborn (PPHN) following elective cesarean at greater than 34 weeks' gestation in an academically affiliated community hospital.

Methods.?Retrospective cohort study involving chart review of 300 newborns with PPHN between 1999 and 2006. Infants less than 34 weeks' or with congenital anomalies were excluded. Subjects were divided into two groups: (1) intended vaginal delivery and (2) elective cesarean.

Results.?A total of 125 neonates were included. In all, 46 were delivered vaginally, 53 by cesarean after a trial of labor, and 26 by elective cesarean. No statistically significant differences were noted between groups in birth weight, gestational age, or length of stay. The crude relative risk (RR) of PPHN in cesareans prior to labor (elective cesareans) when compared to intended vaginal deliveries was 2.0 (95% CI 1.3–3.1). The RR of PPHN in elective cesareans when compared to spontaneous labor resulting in vaginal deliveries was 3.4 (95% CI 2.1–5.5). The adjusted RRs for these outcomes comparing the same delivery groups when considering gestational age at birth (less vs. equal to or more than 37 weeks') were 2.2 (95% CI 1.4–3.4) and 3.7 (95% CI 2.3–6.1), and birth weight (less vs. equal to or more than 2500 g) were 1.9 (95% 1.3–3.0) and 3.4 (95% CI 2.1–5.5), respectively. The incidence of PPHN in the elective cesarean group was 6.9 per 1000 deliveries. The number of cesareans to be avoided to prevent one case of PPHN in this cohort was 387 (number needed to harm, 95% CI 206.8–3003.1).

Conclusions.?Our findings include a high rate of PPHN following elective cesarean delivery, and suggest that physicians should consider this added morbidity when performing elective cesareans.     

Neonatal hypoxic-ischemic encephalopathy in apparently low risk pregnancies: Retrospective analysis of the last five years at the University of Bologna

Objective.?To provide recent figures on the occurrence of neonatal hypoxic-ischemic encephalopathy (NHIE) from a Teaching Hospital.

Study Design.?A retrospective case–control study was conducted in a tertiary level university hospital with more than 3000 deliveries annually. Twenty-four cases of NHIE that occurred in apparently low-risk pregnancies were analysed and compared to a group of controls for the most common labor variables. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

Results.?Of 15,371 apparently low-risk deliveries, 24 cases of NHIE were observed (0.16%), with perinatal death or cerebral palsy occurring in nine of these cases (0.06%). The following intra-partum variables were significantly more common in cases than in controls: stained amniotic fluid (OR: 7.50; 95% CI:1.77–31.79), maternal fever (none in the control group), abnormal CTG (OR: 253.0; 95% CI: 26.70–2397), persistent occiput posterior (OR: 15.67; 95% CI: 2.25–104.53) and operative delivery (OR: 3.98; 95% CI: 1.39–11.33).

Conclusion.?The incidence of NHIE is considerably low in a Tertiary care Centre.     

Pregnancy outcomes in women aged 35 years or older with gestational diabetes – a registry-based study in Finland

Objective: To compare pregnancy outcomes of women ≥35 years to women <35 years with and without gestational diabetes.

Methods: The data include 230?003 women <35 years and 53?321 women ≥35 years and their newborns from 2004 to 2008. In multivariate modeling, the main outcome measures were preterm delivery (<28, 28–31 and 32–36 weeks' gestation), Apgar scores <7 at 5?min, small for gestational age (SGA), fetal death, asphyxia, preeclampsia, admission to neonatal intensive care unit (NICU), shoulder dystocia and large for gestational age (LGA).

Results: In comparison to women <35 with normal glucose tolerance, preeclampsia (OR 1.57, CI 1.30–1.88), admission to the NICU (OR 3.30, CI 2.94–3.69) and shoulder dystocia (OR 2.12, CI 1.05–4.30) were highest in insulin-treated women ≥35 years. In women ≥35, diet- and insulin-treated gestational diabetes mellitus (GDM) increased the rates of preeclampsia, shoulder dystocia and admission to NICU (OR 3.07 CI 2.73–3.45). The effect of advanced maternal age was observed in very preterm delivery (<28 weeks), fetal death, preeclampsia and NICU. The increase in preeclampsia was statistically significant.

Conclusions: GDM at advanced age is a high risk state and, more specifically, the risk caused by age and GDM appear to be increasing in preeclampsia.     

Shoulder dystocia and the next delivery: outcomes and management.

OBJECTIVE: To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia. STUDY DESIGN: We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described. RESULTS: Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048). CONCLUSION: In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high--approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.     

Immediate perinatal outcomes of postterm deliveries

Objective: To investigate whether postterm pregnancy (≥42 0/7 weeks’ gestation) increases the risk for adverse perinatal outcome.

Study design: In this population based cohort study, all singleton deliveries occurring between 1991 and 2014 in a tertiary medical center were included. Pregnancy and perinatal outcomes were compared between postterm and term deliveries (37 0/7 to 41 6/7 weeks’ gestation). Preterm deliveries, unknown gestational age, congenital malformations, and multiple gestations, were excluded. The association between postterm and adverse perinatal outcomes was evaluated using a general estimation equation (GEE) multivariable analyses.

Results: During the study period, 226,918 deliveries were included in the analysis. Of them, 95.9% (n?=?217,544) were term and 4.1% (n?=?9374) were postterm. Post-term pregnancies were more likely to be complicated with oligohydramnios, macrosomia, meconium stained amniotic fluid, shoulder dystocia, low Apgar scores, and hysterectomy (p?Conclusions: Post-term delivery involves higher rates of adverse perinatal outcomes and is independently associated with significant perinatal mortality.