Human shoulder development is adapted to obstetrical constraints.

In humans, obstetrical difficulties arise from the large head and broad shoulders of the neonate relative to the maternal birth canal. Various characteristics of human cranial development, such as the relatively small head of neonates compared with adults and the delayed fusion of the metopic suture, have been suggested to reflect developmental adaptations to obstetrical constraints. On the other hand, it remains unknown whether the shoulders of humans also exhibit developmental features reflecting obstetrical adaptation. Here we address this question by tracking the development of shoulder width from fetal to adult stages in humans, chimpanzees, and Japanese macaques. Compared with nonhuman primates, shoulder development in humans follows a different trajectory, exhibiting reduced growth relative to trunk length before birth and enhanced growth after birth. This indicates that the perinatal developmental characteristics of the shoulders likely evolved to ease obstetrical difficulties such as shoulder dystocia in humans.

Paternal and maternal birthweight and offspring risk of macrosomia at term gestations: A nationwide population study.

BACKGROUND: There is a paucity of data on whether parents' macrosomia (birthweight ≥4500 g) status influences the risk of macrosomia in the offspring. The role of maternal overweight in the generational effect of macrosomia is not known. OBJECTIVE: To estimate the risk of macrosomia by parental birthweight at term and evaluate if this risk varied with maternal body mass index (BMI, kg/m2) early in pregnancy. METHODS: We used data from the Medical Birth Registry of Norway on all singleton term births (37-42 gestational weeks) during 1967-2017. The primary exposure was parental macrosomia, and the outcome was macrosomia in the second generation. The secondary exposure was maternal BMI. We used binomial regression to calculate relative risk (RR) with a 95% confidence interval. We assessed potential unmeasured confounding and selection bias using a probabilistic bias analysis and performed analyses with and without imputation for variables with missing values. RESULTS: The data included 647,957 singleton parent-offspring trios born at term. The prevalence of macrosomia was 3.2% (n = 41,396) in the parental generation and 4.0% (n = 25,673) in the offspring generation. Macrosomia in parents was associated with an increased risk of macrosomia in offspring, with the RR for both parents were born macrosomic being 6.53 (95% confidence interval [CI] 5.31, 8.05), only mother macrosomic 3.37 (95% CI 3.17, 3.57) and only father macrosomic RR 2.22 (95% CI 2.12, 2.33). These risks increased by maternal BMI in early pregnancy: if both parents were born macrosomic, 17% of infants were macrosomic among mothers with normal BMI. If both parents were macrosomic and the mothers were obese, 31% of offspring were macrosomic. Macrosomia-related adverse outcomes did not differ with parental macrosomia status. CONCLUSIONS: Parents' weight at birth and maternal BMI appear to be strongly associated with macrosomia in the offspring delivered at term gestations.

Timing of induction of labor in suspected macrosomia: retrospective cohort study, systematic review and meta-analysis.

OBJECTIVE: Large-for-gestational-age (LGA) is associated with several adverse maternal and neonatal outcomes. Although many studies have found that early induction of labor (eIOL) in LGA reduces the incidence of shoulder dystocia (SD), no current guidelines recommend this particular strategy, due to concerns about increased rates of cesarean delivery (CD) and neonatal complications. The purpose of this study was to assess whether the timing of IOL in LGA fetuses affects maternal and neonatal outcomes in a single center; and to combine these results with the evidence reported in the literature. METHODS: This study comprised two parts. The first was a retrospective cohort study that included: consecutive patients with singleton pregnancy, an estimated fetal weight (EFW) ≥90th percentile on ultrasound (US) between 35+0 and 39+0 weeks of gestation (WG), who were eligible for normal vaginal delivery. The second part was a systematic review of literature and meta-analysis that included the results of the first part as well as all previously reported studies that have compared IOL to expectant management in patients with LGA. The perinatal outcomes were CD, operative vaginal delivery (OVD), SD, brachial plexus palsy, anal sphincter injury, postpartum hemorrhage (PPH), APGAR score, umbilical arterial pH, neonatal intensive care unit (NICU) admission, use of continuous positive airway pressure (CPAP), intracranial hemorrhage (ICH), phototherapy, and bone fracture. RESULTS: Retrospective cohort: of the 547 patients, 329 (60.1%) were induced and 218 (39.9%) entered spontaneous labor. Following covariate balancing, CD was significantly higher in the IOL group in comparison to the spontaneous labor group. This difference only became apparent beyond 40WG (hazard ratio: 1.9, p=0.030). The difference between both groups for shoulder dystocia was not statistically significant. Systematic review and metanalysis: 17 studies were included in addition to our own results giving a total sample size of 111,300 participants. When IOL was performed <40+0WG, the risk for SD was significantly lower in the IOL group (OR: 0.64, 95%CI: 0.42-0.98, I2 =19%). There was no significant difference in CD rate between IOL and expectant management after pooling the results of these 17 studies. However, when removing the studies in which IOL was done exclusively before 40+0WG, the risk for CD in the remaining studies (IOL not exclusively <40+0WG) was significantly higher in the IOL group (odds ratio [OR]: 1.46, 95% confidence interval [95%CI]: 1.02-2.09, I2 =56%). There were no statistically significant differences between IOL and expectant management for the remaining perinatal outcomes. Nulliparity, history of CD, and low Bishop score but not methods of induction were independent risk factors for intrapartum CD in patients who were induced for LGA. CONCLUSION: Timing of IOL in patients with suspected macrosomia significantly impacts perinatal adverse outcomes. IOL has no impact on rates of SD but does increase CD when considered irrespective of gestational age, but it may decrease the risk of SD without increasing the risk of other adverse maternal outcomes, in particular cesarean section when performed before 40+0 WG. (GRADE: Low/Very low). This article is protected by copyright. All rights reserved.

Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998-2015.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP. METHODS: Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg. RESULTS: Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg. CONCLUSIONS: Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Shoulder dystocia by severity in families: A nationwide population study.

INTRODUCTION: Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are scarce. It is unknown if shoulder dystocia tends to be passed on between generations. We aimed to assess the recurrence risk of shoulder dystocia by severity in the same woman and between generations on both the maternal and paternal side. We also assessed the likelihood of a second delivery and planned cesarean section after shoulder dystocia. MATERIAL AND METHODS: This was a population-based cohort study, using data from the Medical Birth Registry of Norway. To study recurrence in the same mother, we identified 1 091 067 pairs of first and second, second and third, and third and fourth births in the same mother. To study intergenerational recurrence, we identified an individual both as a newborn and as a mother or father in 824 323 mother-offspring pairs and 614 663 father-offspring pairs. We used Bayesian log-binomial multilevel regression to calculate relative risks (RR) with 95% credible intervals. RESULTS: In subsequent deliveries in the same woman the unadjusted RR of recurrence was 7.05 (95% credible interval 6.39-7.79) and 2.99 (2.71-3.31) after adjusting for possible confounders, including current birthweight. The RRs were higher with severe shoulder dystocia as exposure or outcome. With severe shoulder dystocia as both exposure and outcome, unadjusted and adjusted RR was 20.42 (14.25-29.26) and 6.29 (4.41-8.99), respectively. Women with severe and mild shoulder dystocia and those without had subsequent delivery rates of 71.1, 68.9 and 69.0%, respectively. However, the rates of planned cesarean section in subsequent deliveries for those without shoulder dystocia, mild and severe were 1.3, 5.2 and 16.0%, respectively. On the maternal side the unadjusted inter-generational RR of recurrence was 2.82 (2.25-3.54) and 1.41 (1.05-1.90) on the paternal side. Corresponding adjusted RRs were 1.90 (1.51-2.40) and 1.19 (0.88-1.61), respectively. CONCLUSIONS: We found a strong recurrence risk of shoulder dystocia, especially severe, in subsequent deliveries in the same woman. The inter-generational recurrence risk was higher on the maternal than paternal side. Women with a history of shoulder dystocia had more often planned cesarean section.

Incidence of shoulder dystocia and risk factors for recurrence in the subsequent pregnancy-A historical register-based cohort study.

INTRODUCTION: Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries. MATERIAL AND METHODS: The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery. RESULTS: During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery. CONCLUSIONS: The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.

Video analysis of real-life shoulder dystocia to assess technical and non-technical performance.

INTRODUCTION: Managing obstetric shoulder dystocia requires swift action using correct maneuvers. However, knowledge of obstetric teams' performance during management of real-life shoulder dystocia is limited, and the impact of non-technical skills has not been adequately evaluated. We aimed to analyze videos of teams managing real-life shoulder dystocia to identify clinical challenges associated with correct management and particular non-technical skills correlated with high technical performance. MATERIAL AND METHODS: We included 17 videos depicting teams managing shoulder dystocia in two Danish delivery wards, where deliveries were initially handled by midwives, and consultants were available for complications. Delivery rooms contained two or three cameras activated by Bluetooth upon obstetrician entry. Videos were captured 5 min before and after activation. Two obstetricians assessed the videos; technical performances were scored as low (0-59), average (60-84), or high (85-100). Two other assessors evaluated non-technical skills using the Global Assessment of Team Performance checklist, scoring 6 (poor) to 30 (excellent). We used a spline regression model to explore associations between these two score sets. Inter-rater agreement was assessed using interclass correlation coefficients. RESULTS: Interclass correlation coefficients were 0.71 (95% confidence interval 0.23-0.89) and 0.82 (95% confidence interval 0.52-0.94) for clinical and non-technical performances, respectively. Two teams had low technical performance scores; four teams achieved high scores. Teams adhered well to guidelines, demonstrating limited head traction, McRoberts maneuver, and internal rotation maneuvers. Several clinical skills posed challenges, notably recognizing shoulder impaction, applying suprapubic pressure, and discouraging women from pushing. Two non-technical skills were associated with high technical performance: effective patient communication, with teams calming the mother and guiding her collaboration during internal rotational maneuvers, and situation awareness, where teams promptly mobilized all essential personnel (senior midwife, consultant, pediatric team). Team communication, stress management, and task management skills were not associated with high technical performance. CONCLUSIONS: Videos capturing teams managing real-life shoulder dystocia are an effective tool to reveal challenges with certain technical and non-technical skills. Teams with high technical performance are associated with effective patient communication and situational awareness. Future training should include technical skills and non-technical skills, patient communication, and situation awareness.

Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study.

BACKGROUND: Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia. METHODS: We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013-2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated. RESULTS: Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14-1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18-8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28-9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia. CONCLUSIONS: Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.

Maternal and neonatal complications of shoulder dystocia with a focus on obstetric maneuvers: A case-control study of 1103 deliveries.

INTRODUCTION: Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates. MATERIAL AND METHODS: The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized. RESULTS: Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24). CONCLUSIONS: The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.

Continuous glucose monitoring in individuals undergoing gestational diabetes screening.

BACKGROUND: Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus. OBJECTIVE: This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening. STUDY DESIGN: This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes. RESULTS: Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups. CONCLUSION: In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Reducing macrosomia-related birth complications in primigravid women: ultrasound- and magnetic resonance imaging-based models.

BACKGROUND: Many complications increase with macrosomia, which is defined as birthweight of ≥4000 g. The ability to estimate when the fetus would exceed 4000 g could help to guide decisions surrounding the optimal timing of delivery. To the best of our knowledge, there is no available tool to perform this estimation independent of the currently available growth charts. OBJECTIVE: This study aimed to develop ultrasound- and magnetic resonance imaging-based models to estimate at which gestational age the birthweight would exceed 4000 g, evaluate their predictive performance, and assess the effect of each model in reducing adverse outcomes in a prospectively collected cohort. STUDY DESIGN: This study was a subgroup analysis of women who were recruited for the estimation of fetal weight by ultrasound and magnetic resonance imaging at 36 0/7 to 36 6/7 weeks of gestation. Primigravid women who were eligible for normal vaginal delivery were selected. Multiparous patients, patients with preeclampsia spectrum, patients with elective cesarean delivery, and patients with contraindications for normal vaginal delivery were excluded. Of note, 2 linear models were built for the magnetic resonance imaging- and ultrasound-based models to predict a birthweight of ≥4000 g. Moreover, 2 formulas were created to predict the gestational age at which birthweight will reach 4000 g (predicted gestational age); one was based on the magnetic resonance imaging model, and the second one was based on the ultrasound model. This study compared the adverse birth outcomes, such as intrapartum cesarean delivery, operative vaginal delivery, anal sphincter injury, postpartum hemorrhage, shoulder dystocia, brachial plexus injury, Apgar score of <7 at 5 minutes of life, neonatal intensive care unit admission, and intracranial hemorrhage in the group of patients who delivered after the predicted gestational age according to the magnetic resonance imaging-based or the ultrasound-based models with those who delivered before the predicted gestational age by each model, respectively. RESULTS: Of 2378 patients, 732 (30.8%) were eligible for inclusion in the current study. The median gestational age at birth was 39.86 weeks of gestation (interquartile range, 39.00-40.57), the median birthweight was 3340 g (interquartile range, 3080-3650), and 63 patients (8.6%) had a birthweight of ≥4000 g. Prepregnancy body mass index, geographic origin, gestational age at birth, and fetal body volume were retained for the optimal magnetic resonance imaging-based model, whereas maternal age, gestational diabetes mellitus, diabetes mellitus type 1 or 2, geographic origin, fetal gender, gestational age at birth, and estimated fetal weight were retained for the optimal ultrasound-based model. The performance of the first model was significantly better than the second model (area under the curve: 0.98 vs 0.89, respectively; P<.001). The group of patients who delivered after the predicted gestational age by the first model (n=40) had a higher risk of cesarean delivery, postpartum hemorrhage, and shoulder dystocia (adjusted odds ratio: 3.15, 4.50, and 9.67, respectively) than the group who delivered before this limit. Similarly, the group who delivered after the predicted gestational age by the second model (n=25) had a higher risk of cesarean delivery and postpartum hemorrhage (adjusted odds ratio: 5.27 and 6.74, respectively) than the group who delivered before this limit. CONCLUSION: The clinical use of magnetic resonance imaging- and ultrasound-based models, which predict a gestational age at which birthweight will exceed 4000 g, may reduce macrosomia-related adverse outcomes in a primigravid population. The magnetic resonance imaging-based model is better for the identification of the highest-risk patients.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study.

OBJECTIVE: To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI). DESIGN: Retrospective observational study. SETTING: Helsinki University Women's Hospital, Finland. SAMPLE: Deliveries with SD. METHODS: Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed. RESULTS: During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm. CONCLUSIONS: Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

Increased incidence of shoulder dystocia but a declining incidence of obstetric brachial plexus palsy in vaginally delivered infants.

INTRODUCTION: Obstetric brachial plexus palsy (OBPP) is a serious form of neonatal morbidity. The primary aim of this population-based registry study was to examine temporal trends, 1997-2019, of OBPP in infants delivered vaginally in a cephalic presentation. The secondary aim was to examine temporal changes in the incidence of associated risk factors. MATERIAL AND METHODS: This was a population-based registry study including singleton, cephalic, vaginally delivered infants, 1997-2019, in Sweden. To compare changes in the incidence rates of OBPP and associated risk factors over time, univariate logistic regression was used and odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The incidence of OBPP in infants delivered vaginally in a cephalic presentation decreased from 3.1 per 1000 births in 1997 to 1.0 per 1000 births in 2019 (OR 0.31, 95% CI 0.24-0.40). Conversely, the incidence of shoulder dystocia increased from 2.0 per 1000 in 1997 to 3.3 per 1000 in 2019 (OR 1.64, 95% CI 1.34-2.01). Over time, the proportion of women with body mass index of 30 kg/m2 or greater increased (14.5% in 2019 compared with 8.0% in year 1997, OR 1.96, 95% CI 1.89-2.03), more women had induction of labor (20.5% in 2019 compared with 8.6% in 1997, OR 2.74, 95% CI 2.66-2.83) and epidural analgesia (41.2% in 2019 compared with 29.0% in 1997, OR 1.72, 95% CI 1.68-1.75). In contrast, there was a decrease in the rate of operative vaginal delivery (6.0% in 2019, compared with 8.1% in 1997, OR 0.72, 95% CI 0.69, 0.75) and in the proportion of infants with a birthweight greater than 4500 g (2.7% in 2019 compared with 3.8% in 1997, OR 0.70, 95% CI 0.66-0.74). The decline in the incidence of these two risk factors explained only a small fraction of the overall decrease in OBPP between 1997-2002 and 2015-219. CONCLUSIONS: The incidence of OBPP in vaginally delivered infants in a cephalic presentation at birth decreased during the period 1997-2019 despite an increase in important risk factors including shoulder dystocia.

The proposal of the novel fetal shoulder dystocia graduation: a clinical-based opinion.

BACKGROUND: Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to significantly poor perinatal outcome, especially permanent disability or perinatal death. CONTENT: To better objectify the graduation and to include other important clinical parameters, we believe it is appropriate to present a proposal for a complete perinatal weighted graduation of shoulder dystocia, based on several years of numerous other and our own clinical and forensic studies and thematic biobibliography. Obstetric maneuvers, neonatal outcome, and maternal outcome are three components, which are evaluated according to the severity of 0-4 proposed components. Thus, the gradation is ultimately in four degrees according to the total score: I. degreee, score 0-3: slightly shoulder dystocia with simple obstetric interventions, but without birth injuries; II. degree, score 4-7: mild shoulder dystocia resolved by external, secondary interventions and minor injuries; III. degree, score 8-10: severe shoulder dystocia with severe peripartum injuries; IV. degree, score 11-12: extremely difficult, severe shoulder dystocia with ultima ratio interventions applied and resulting extremely severe injuries with chronic disability, including perinatal death. SUMMARY: As a clinically evaluated graduation, it certainly has an applicable long-term anamnestic and prognostic component for subsequent pregnancies and access to subsequent births, as it includes all relevant components of clinical forensic objectification.

Impact of fetal manipulation on maternal and neonatal severe morbidity during shoulder dystocia management.

PURPOSE: There are few data on maternal and neonatal morbidities associated with shoulder dystocia (SD), depending on the use of fetal manipulation (FM). A prior 5-year study was conducted in our center in 2012 for this purpose. Our objective was to compare severe maternal and neonatal morbidities according to FM execution in a larger cohort. METHODS: We conducted a retrospective study between 2007 and 2020. SD was considered when additional maneuvers were required to complete a delivery. Severe maternal morbidity was defined as the occurrence of obstetric anal sphincter injury (OASI). Severe neonatal morbidity was defined as Apgar < 7 at 5 min and/or cord arterial pH < 7.1 and/or or a permanent brachial plexus palsy. We studied these data in the FM group compared to the non- FM group. RESULTS: FM was associated with increased OASI rates (21.1% vs. 3.8%, OR = 6.72 [2.7-15.8]). We found no significant difference in severe neonatal morbidity. Maternal age > 35 and FM appear to be associated with the occurrence of OASI, with ORa = 13.3 [1.5-121.8] and ORa = 5.3 [2.2-12.8], respectively. FM was the only factor associated with the occurrence of severe neonatal morbidity (ORa = 2.3 [1.1-4.8]. The rate of episiotomy was significantly decreased (20% versus 5% p < 0.05) and there was an increase in the rate of SD managed with FM in our center. CONCLUSION: FM is the only factor associated with an increased risk of OASI. In case of failure of non-FM maneuvers, the rapid implementation of FM maneuvers resulted in no difference regarding severe neonatal morbidity.

Action competence in obstetric emergencies-can this be achieved via e-learning? Interprofessional blended learning module on diagnostics and emergency treatment of shoulder dystocia.

BACKGROUND: Due to the rarity of shoulder dystocia, an obstetric emergency, it is difficult even for experts to develop the appropriate routine in this emergency. Regular further training is therefore recommended for obstetricians and midwives. Evidence is lacking on the extent to which e-learning as a teaching method can be successfully used to acquire these skills and put them into practice. The purpose of this study is to demonstrate how the learning objectives for shoulder dystocia, listed in the National Competence Based Learning Objectives Catalog for Medicine (NKLM, Germany) can be successfully taught in medical studies using a blended learning concept (e-learning and practical application on a birth simulator). METHODS: After completing an e-learning course, final year medical students and midwife trainees demonstrated their action competence for shoulder dystocia procedure on a birth simulator. This transfer of the theoretical knowledge to the case study was assessed using an evaluation form oriented to the recommendations for action. RESULTS: One hundred sixty medical students and 14 midwifery trainees participated in the study from April to July 2019. Overall, 95.9% of the study participants met the required standards, i.e. achieved very good to adequate performance (Ø good) in simulation training. CONCLUSIONS: E-learning with annotated high-quality learning videos is an excellent way to transfer theoretical knowledge about shoulder dystocia procedures into medical practice on a birth simulator. The learning objectives required by the NKLM for shoulder dystocia can be successfully conveyed to students via the applied blended learning concept.

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong.

INTRODUCTION: Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019. METHODS: This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods. RESULTS: The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045). CONCLUSION: More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019.

Antenatal risk score for prediction of shoulder dystocia with focus on fetal ultrasound data.

BACKGROUND: Shoulder dystocia is one of the most threatening complications during delivery, and although it is difficult to predict, individual risk should be considered when counseling for mode of delivery. OBJECTIVE: This study aimed to develop and validate a risk score for shoulder dystocia based on fetal ultrasound and maternal data from 15,000 deliveries. STUDY DESIGN: Data were retrospectively obtained of deliveries in 3 tertiary centers between 2014 and 2017 for the derivation cohort and between 2018 and 2020 for the validation cohort. Inclusion criteria were singleton pregnancy, vaginal delivery in cephalic presentation at ≥37+0 weeks' gestation, and fetal biometry data available within 2 weeks of delivery. Independent predictors were determined by multivariate regression analysis in the derivation cohort, and a score was developed on the basis of the effect of the predictors. RESULTS: The derivation cohort consisted of 7396 deliveries with a 0.91% rate of shoulder dystocia, and the validation cohort of 7965 deliveries with a 1.0% rate of shoulder dystocia. Among all women, 13.8% had diabetes mellitus, and 12.1% were obese (body mass index ≥30 kg/m2). Independent risk factors in the derivation cohort were: estimated fetal weight ≥4250 g (odds ratio, 4.27; P=.002), abdominal-head-circumference ≥2.5 cm (odds ratio, 3.96; P<.001), and diabetes mellitus (odds ratio, 2.18; P=.009). On the basis of the strength of effect, a risk score was developed: estimated fetal weight ≥4250 g=2, abdominal-head-circumference ≥2.5 cm=2, and diabetes mellitus=1. The risk score predicted shoulder dystocia with moderate discriminatory ability (area under the receiver-operating characteristic curve, 0.69; P<.001; area under the receiver-operating characteristic curve, 0.71; P<.001) and good calibration (Hosmer-Lemeshow goodness-of-fit; P=.466; P=.167) for the derivation and validation cohorts, respectively. With 1 score point, 16 shoulder dystocia cases occurred in 1764 deliveries, with 0.6% shoulder dystocia incidence and a number needed to treat with cesarean delivery to avoid 1 case of shoulder dystocia of 172 (2 points: 38/1809, 2.1%, 48; 3 points: 18/336, 5.4%, 19; 4 points: 10/96, 10.5%, 10; and 5 points: 5/20, 25%, 4); 40.8% of the shoulder dystocia cases occurred without risk factors. CONCLUSION: The presented risk score for shoulder dystocia may act as a supplemental tool for the clinical decision-making regarding mode of delivery. According to our score model, in pregnancies with a score ≤2, meaning having solely estimated fetal weight ≥4250 g, or abdominal-head-circumference ≥2.5, or diabetes mellitus, cesarean delivery for prevention of shoulder dystocia should not be recommended because of the high number needed to treat to avoid 1 case of shoulder dystocia. Conversely, in patients with a score of ≥4 with or without diabetes mellitus, cesarean delivery may be considered. However, in 40% of the shoulder dystocia cases, no risk factors had been present.

Fetal magnetic resonance imaging at 36 weeks predicts neonatal macrosomia: the PREMACRO study.

BACKGROUND: Large-for-gestational-age fetuses are at increased risk of perinatal morbidity and mortality. Magnetic resonance imaging seems to be more accurate than ultrasound in the prediction of macrosomia; however, there is no well-powered study comparing magnetic resonance imaging with ultrasound in routine pregnancies. OBJECTIVE: This study aimed to prospectively compare estimates of fetal weight based on 2-dimensional ultrasound and magnetic resonance imaging with actual birthweights in routine pregnancies. STUDY DESIGN: From May 2016 to February 2019, women received counseling at the 36-week clinic. Written informed consent was obtained for this Ethics Committee-approved study. In this prospective, single-center, blinded study, pregnant women with singleton pregnancies between 36 0/7 and 36 6/7 weeks' gestation underwent both standard evaluation of estimated fetal weight with ultrasound according to Hadlock et al and magnetic resonance imaging according to the formula developed by Baker et al, based on the measurement of the fetal body volume. Participants and clinicians were aware of the results of the ultrasound but blinded to the magnetic resonance imaging estimates. Birthweight percentile was considered as the gold standard for the ultrasound and magnetic resonance imaging-derived percentiles. The primary outcome was the area under the receiver operating characteristic curve for the prediction of large-for-gestation-age neonates with birthweights of ≥95th percentile. Secondary outcomes included the comparative prediction of large-for-gestation-age neonates with birthweights of ≥90th, 97th, and 99th percentiles and small-for-gestational-age neonates with birthweights of ≤10th, 5th, and 3rd percentiles for gestational age and maternal and perinatal complications. RESULTS: Of 2914 women who were initially approached, results from 2378 were available for analysis. Total fetal body volume measurements were possible for all fetuses, and the time required to perform the planimetric measurements by magnetic resonance imaging was 3.0 minutes (range, 1.3-5.6). The area under the receiver operating characteristic curve for the prediction of a birthweight of ≥95th percentile was 0.985 using prenatal magnetic resonance imaging and 0.900 using ultrasound (difference=0.085, P<.001; standard error, 0.020). For a fixed false-positive rate of 5%, magnetic resonance imaging for the estimation of fetal weight detected 80.0% (71.1-87.2) of birthweight of ≥95th percentile, whereas ultrasound for the estimation of fetal weight detected 59.1% (49.0-68.5) of birthweight of ≥95th percentile. The positive predictive value was 42.6% (37.8-47.7) for the estimation of fetal weight using magnetic resonance imaging and 35.4% (30.1-41.1) for the estimation of fetal weight using ultrasound, and the negative predictive value was 99.0% (98.6-99.3) for the estimation of fetal weight using magnetic resonance imaging and 98.0% (97.6-98.4) for the estimation of fetal weight using ultrasound. For a fixed false-positive rate of 10%, magnetic resonance imaging for the estimation of fetal weight detected 92.4% (85.5-96.7) of birthweight of ≥95th percentile, whereas ultrasound for the estimation of fetal weight detected 76.2% (66.9-84.0) of birthweight of ≥95th percentile. The positive predictive value was 29.9% (27.2-32.8) for the estimation of fetal weight using magnetic resonance imaging and 26.2% (23.2-29.4) for the estimation of fetal weight using ultrasound, and the negative predictive value was 99.6 (99.2-99.8) for the estimation of fetal weight using magnetic resonance imaging and 98.8 (98.4-99.2) for the estimation of fetal weight using ultrasound. The area under the receiver operating characteristic curves for the prediction of large-for-gestational-age neonates with birthweights of ≥90th, 97th, and 99th percentiles and small-for-gestational-age neonates with birthweights of ≤10th, 5th, and 3rd percentiles was significantly larger in prenatal magnetic resonance imaging than in ultrasound (P<.05 for all). CONCLUSION: At 36 weeks' gestation, magnetic resonance imaging for the estimation of fetal weight performed significantly better than ultrasound for the estimation of fetal weight in the prediction of large-for-gestational-age neonates with birthweights of ≥95th percentile for gestational age and all other recognized cutoffs for large-for-gestational-age and small-for-gestational-age neonates (P<.05 for all).

Culturally adapted flowcharts in obstetric emergencies: a participatory action research study.

INTRODUCTION: Maternal mortality is a health problem in developing countries and is the result of several factors such as sociodemographic and economic inequalities and difficulties in accessing the health services. In addition, training strategies in obstetric emergencies targeting the non-medical personnel such as traditional midwives are scarce. The focus of this study is to develop learning and communication bridges on the management of obstetric emergencies and on policies of patients' referral to the biomedical health system in rural areas. METHODOLOGY: A Participant Action Research (PAR) study with a mixed methods approach was set up to elaborate culturally adapted flowcharts. The project lasted approximately 3,5 years, from September 2016 to January 2021. RESULTS: The study was conducted with 94 traditional midwives from southern Ecuador and is divided into 4 phases, namely: 1) Exploration: focus groups and interviews were conducted to document the management of obstetric emergencies through the presentation of "clinical case" scenarios in three important topics, namely: pre-eclampsia, shoulder dystocia and postpartum hemorrhage, 2) Planning: a number of reflective sessions were conducted between the researchers and the healers/midwives to elaborate flowcharts. 3) Action: the training was conducted in rooms dedicated to proficiency in the aforementioned topics and using the flowcharts, 4) Evaluation: 90% of the participants reported having used the flowcharts during the first year after the training. The most frequently used flowchart was that of pre-eclampsia for the recognition of warning signs during pregnancy control. CONCLUSION: This study documents common practices of pregnancy and delivery management by traditional midwives. Furthermore, cultural flowcharts were developed for and together with midwives to improve the clinical response to obstetric emergencies. The preliminary evaluation was favorable; the most frequently used flowchart concerned preeclampsia. In this process, establishing a partnership was crucial for successful intercultural collaboration.