Intrapartum risk factors for permanent brachial plexus injury

OBJECTIVE: The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury. STUDY DESIGN: Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant. RESULTS: There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured). CONCLUSION: No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.     

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.     

Shoulder dystocia related fetal neurological injuries: the predisposing roles of forceps and ventouse extractions

On the basis of 333 documented cases of permanent perinatal neurological damage, associated with arrest of the shoulders at birth, the authors conducted a retrospective study in order to evaluate the predisposing role, if any, of the utilization of extraction instruments. The investigation revealed that 35% of all injuries occurred in neonates delivered by forceps, ventouse or sequential ventouse–forceps procedures. This frequency was several-fold higher than the prevailing instrument use in the practices of American obstetricians during the same years. A high rate of forceps and ventouse extractions was demonstrable in all birth weight categories. Average weight and moderately large for gestational age fetuses underwent instrumental extractions more often than grossly macrosomic ones. This circumstance indicates that forceps and ventouse are independent risk factors, unrelated to fetal size. Their use entailed central nervous system injuries significantly more often than did spontaneous deliveries. The findings suggest that extraction procedures may be as important as macrosomia among the factors that lead to neurological damage in the child in connection with shoulder dystocia. Because they augment the intrinsic dangers of excessive fetal size exponentially, the authors consider their use in case of ≥4,000 g estimated fetal weight inadvisable. Sequential forceps–ventouse utilization further doubles the risks and is, therefore, to be avoided in all circumstances.     

Waiting for postterm in healthy women,is it an accident waiting to happen?

Abstract

Objective: To establish whether postterm pregnancies are associated with adverse perinatal outcomes in a linear fashion.

Study design: A retrospective cohort study investigating perinatal outcomes in singleton term (≥37 weeks gestation) and postterm pregnancies was conducted. Deliveries occurred between the years 1988 and 2010. Parturients were classified into three groups according to their gestational age: 37–39?+?6, 40–41?+?6 and over 42 weeks’ gestation (postterm). Statistical analysis included multiple logistic regression model to control for possible confounders.

Results: Out of 202?462 deliveries, meeting the inclusion criteria, during the study period, 47.7% occurred at 37–39?+?6 weeks, 47.4% occurred at 40–41?+?6 weeks and 4.9% were postterm. Fertility treatments, diabetes mellitus, hypertensive disorders, intrauterine growth restriction (IUGR) and premature rupture of membranes (PROM) were less likely to be associated with postterm pregnancies. However, postterm was found as a significant risk factor for labor complications and adverse perinatal outcome including perinatal mortality. Using a multivariable logistic regression model, controlling for confounders such as maternal age and macrosomia, postterm was found to be an independent risk factor for perinatal mortality (adjusted OR?=?1.5; 95% CI?=?1.20–2.0; p?<?0.001).

Conclusion: Although postterm pregnancies were less likely to be associated with obstetrical risk factors and complications such as fertility treatments, diabetes mellitus, hypertensive disorders, IUGR and PROM, postterm is an independent risk factor for perinatal mortality.     

手法处理头位难产在少数民族偏远地区的意义

目的 探讨经阴道徒手旋转胎头处理头位难产的临床应用价值.方法 回顾性分析经阴道徒手旋转胎头处理头位难产的病例,分析其异常头先露、先露高低、宫口扩张及胎儿体重与徒手旋转胎头处理后分娩情况.结果 头位难产1356例,占分娩总数的20.56%.对其中1030例孕妇进行了经阴道徒手旋转纠正头先露异常,顺产842例,成功率81.75%;剖宫产141例(13.69%),阴道助产47例(4.56%),失败188例,失败率18.52%.持续性枕后位与枕横位徒手旋转胎头成功率明显高于前不均倾位及高直位(P<0.01);先露S+1以下徒手旋转胎头成功率明显高于S+1以上者(P<0.01);宫口开大4cm以上徒手旋转胎头成功率明显高于宫口开大4cm以下者(P<0.01);胎儿体重3750g以下时,徒手旋转胎头成功率明显高于胎儿体重3750g以上者(P<0.01).结论 重视头盆评分及产程观察,适时经阴道徒手旋转异常头先露,能有效提高头位难产的阴道分娩率,降低剖宫产率,对少数民族偏远地区有重要意义.     

Emergency Department Management of Shoulder Dystocia

Background

Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome.

Objective

To review multiple techniques for managing a shoulder dystocia in the ED.

Discussion

We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort.

Conclusions

Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.     

徒手旋转在头位难产产妇助产护理中的应用

目的:观察并分析在头位难产助产护理中对产妇应用徒手旋转的效果.方法:选取本院产科收治的84例头位难产产妇为研究对象,按入院顺序将其分为对照组(42例,常规助产护理)与观察组(42例,徒手旋转助产护理).评价两组的助产护理效果.结果:观察组产妇自然分娩率及新生儿Apgar评分显著高于对照组,第二产程时间、产后出血量以及新...     

Delivery of the posterior arm reduces shoulder dimensions in shoulder dystocia.

OBJECTIVE: To evaluate a possible reduction in shoulder diameter and circumference by extending the posterior arm during delivery, for an easier birth in cases of shoulder dystocia. METHODS: In this study of 33 neonates the bisacromial diameter and axilloacromial circumference were measured within 72 h of birth, first with the neonate's arms by its chest and then with 1 arm extended above its head. Reductions in diameter and circumference were evaluated. RESULTS: The mean +/- SD differences in bisacromial diameter and axilloacromial circumference were 1.9 +/- 0.69 cm and 2.52 +/- 1.18 cm, respectively. A greater reduction was observed in neonates with a greater shoulder diameter. CONCLUSION: In cases of shoulder dystocia, delivery of the posterior arm should significantly reduce shoulder dimensions, especially in larger fetuses, and prevent a need for excessive traction.     

Indication

Should the indications for therapies differ from one nation to the next? What are the reasons behind controversial therapeutic variations? What roles do cultural history and authoritarian conflict among clinicians play in the adoption of therapies? When I worked at a rural hospital in Kenya, a woman experiencing obstructed labor made me ponder many questions—but only after our emergency ended in the death of her newborn son. In recounting and learning from this episode, I listened to the disparate Kenyan voices of the patient, the hospital’s director, the consultant obstetrician, and to the even more controversial voices of evidence-based medicine. In reflecting on this process, I have learned at least 3 lessons—about the transmissibility of arrogance, the role of guests in other countries, and the nature of science.     

心理干预在产妇分娩期的应用

目的 探讨心理干预在产妇分娩期的应用价值。方法 将256例产前有各种心理障碍的产妇随机分为心理干预组（206例）和非心理干预组（320例），心理干预组采取群体心理辅导、放松疗法、暗示疗法或音乐疗法等；非心理干预组只作一般宣教，不作心理干预。观察两组难产发生情况。结果 心理干预组206例中发生难产29例（14．07％），非心理干预组320例中发生难产67例（20．94％），两组比较（P〈0．05），有显著性差异。结论 心理干预在产妇分娩期有重要的临床应用价值。