Diagnosis and Management of Macrosomia and Shoulder Dystocia: A Comprehensive Review of Major Guidelines.

Importance: Macrosomia represents the most significant risk factor of shoulder dystocia (SD), which is a severe and emergent complication of vaginal delivery. They are both associated with adverse pregnancy outcomes. Objective: The aim of this study was to review and compare the most recently published influential guidelines on the diagnosis and management of fetal macrosomia and SD. Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Department for Health and Wellbeing of the Government of South Australia on macrosomia and SD was conducted. Results: The ACOG and RANZCOG agree that macrosomia should be defined as birthweight above 4000-4500 g regardless of the gestational age, whereas the National Institute for Health and Care Excellence defines macrosomia as an estimated fetal weight above the 95th percentile. According to ACOG and RANZCOG, ultrasound scans and clinical estimates can be used to rule out fetal macrosomia, although lacking accuracy. Routine induction of labor before 39 weeks of gestation with the sole indication of suspected fetal macrosomia is unanimously not recommended, but an individualized counseling should be provided. Exercise, appropriate diet, and prepregnancy bariatric surgery are mentioned as preventive measures. There is also consensus among the reviewed guidelines regarding the definition and the diagnosis of SD, with the "turtle sign" being the most common sign for its recognition as well as the poor predictability of the reported risk factors. Moreover, there is an overall agreement on the algorithm of SD management with McRoberts technique suggested as first-line maneuver. In addition, appropriate staff training, thorough documentation, and time keeping are crucial aspects of SD management according to all medical societies. Elective delivery for the prevention of SD is discouraged by all the reviewed guidelines. Conclusions: Macrosomia is associated not only with SD but also with maternal and neonatal complications. Similarly, SD can lead to permanent neurologic sequalae, as well as perinatal death if managed in a suboptimal way. Therefore, it is crucial to develop consistent international practice protocols for their prompt diagnosis and effective management in order to safely guide clinical practice and improve pregnancy outcomes.

Feline breeding and pregnancy management: What is normal and when to intervene.

PRACTICAL RELEVANCE: Cats are common pets worldwide. Successful breeding of cats starts with the selection of suitable breeding animals, and care should be taken to avoid inbreeding. Keeping cats in smaller groups reduces stress and facilitates management. CLINICAL CHALLENGES: Breeding cats is challenging in many ways. Group housing is a common scenario, and care should be taken not to have groups that are too large, because of the risk of stress and infectious diseases. Feline pregnancy and parturition both vary in length, which is one reason why it may be challenging to diagnose dystocia. In queens with pyometra, a vaginal discharge may not be evident due to their meticulous cleaning habits. AUDIENCE: This review is aimed at clinicians in small animal practice, especially those in contact with cat breeders. PATIENT GROUP: Reproductive emergencies occur in both intentionally and unintentionally bred cats, and more often in young or middle-aged queens. Pyometra tends to be a disease of older queens. EVIDENCE BASE: Evidence is poor for many conditions in the breeding queen, and information is extrapolated from the dog or based on case reports and case series.

Treatment-seeking for vaginal fistula in sub-Saharan Africa.

BACKGROUND: There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high. METHODS: The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved. CONCLUSION: Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Forceps delivery for non-rotational and rotational operative vaginal delivery.

Forceps are a commonly used instrument for assisting vaginal birth. Accepted indications include prolonged labour, suspected foetal distress and maternal medical conditions that benefit from a shortened second stage of labour. Maternal and offspring outcomes of forceps-assisted birth have been extensively reported in observational studies, but randomised trial evidence is limited. Forceps-assisted delivery has a lower failure rate than vacuum-assisted delivery but is associated with a higher incidence of maternal pelvic floor trauma. Second-stage caesarean section is associated with less foetal-neonatal trauma than forceps-assisted delivery but markedly reduces the chance of a subsequent vaginal birth. This review outlines the existing evidence on prevention, indications and contraindications for forceps-assisted birth (non-rotational and rotational), short- and long-term complications for mother and baby, alternatives to use of forceps and how to manage an abandoned forceps-assisted birth. The essential components of informed consent are also discussed.

Vacuum extraction for non-rotational and rotational assisted vaginal birth.

Vacuum-assisted birth is a safe mode of birth in the presence of a skilled provider. Vacuum extraction can avoid prolonged second stage of labour, birth asphyxia in the presence of foetal distress or maternal pushing where contraindicated. Vacuum-assisted births - particularly those in midpelvic rotational births - have been increasingly traded for caesarean births, although the latter are generally associated with potentially a greater risk to women and (future) children. In this article, (contra)indications and the basics of vacuum technique are elaborated. A specific section is dedicated to vacuum extraction for rotational birth. If these techniques are known, trained and practiced by obstetric care givers, then vacuum extraction has tremendous potential to make childbirth safer.

USE OF COMPUTED TOMOGRAPHY-GUIDED PERCARAPACIAL OVOCENTESIS IN THE MANAGEMENT OF DYSTOCIA IN AN EASTERN BOX TURTLE ( TERRAPENE CAROLINA).

Computed tomography (CT)-guided percarapacial ovocentesis in an Eastern box turtle ( Terrapene carolina) was performed after medical management failed to resolve dystocia related to an irregular, oversized egg (38 × 30 × 35 mm). A 2.38-mm Steinmann pin was drilled through the carapace at the dorsal aspect of the seventh marginal scute, allowing introduction of an 18-ga needle through the carapace and oviduct into the egg using CT guidance. Contents of the egg (8 ml) were evacuated and CT reconstructions confirmed involution. The animal was administered oxytocin immediately after the procedure and passed the collapsed egg within 3 hr. The animal displayed no adverse effects from the procedure and the carapacial wound healed quickly without complication. CT-guided needle aspiration and biopsy techniques are common in human medicine, but less frequently utilized in veterinary medicine. This technique represents a novel, minimally invasive approach to ovocentesis that was used as an alternative to surgical intervention, in this case to resolve dystocia.

Distocia de ombro: proposta de um novo algorítmo para conduta em partos em posições não supinas / Shoulder dystocia: proposal for a new algorithm of management in births in non-supine positions

Distocia de ombro é um evento imprevisível e profissionais habilitados para assistir ao parto devem estar capacitados para diagnosticar e instituir manobras efetivas para sua resolução. Tais manobras têm por objetivo aumentar a pelve funcional, reduzir o diâmetro biacromial e melhorar a relação feto-pélvica, facilitando o desprendimento do concepto dentro de sete minutos do diagnóstico, para prevenir complicações. Vários algoritmos têm sido propostos, com o desenvolvimento de mnemônicos para treinamento profissional, sendo o mais famoso o do Advanced Life Support in Obstetrics (ALSO), conhecido como HELPERR(em inglês) ou ALEERTA (em português). No entanto, estes são úteis quando a parturiente se encontra em decúbito dorsal. Propõe-se um novo protocolo, considerando os benefícios associados aos partos em posição não supina e a necessidade de iniciar a conduta das manobras menos para as mais invasivas. O mnemônico proposto é A SAIDA e consiste em: A = chamar ajuda, avisar parturiente, aumentar agachamento; S = pressãosuprapúbica; A = alterar posição para quatro apoios (manobra de Gaskin); I = manobras internas (Rubin II, Wood,parafuso invertido); D = desprender ombro posterior; A = avaliar manobras de resgate...

Shoulder dystocia is an unpredictable event and skilled birth attendants should be trained to diagnose and implement effective maneuvers to solve it. These maneuvers aim to increase the functional pelvis, to reduce biacromial diameter and to improve the relationship between the pelvis and the fetus, favoring the conceptus release within seven minutes of the diagnosis, in order to prevent complications.Several algorithms have been proposed including mnemonics for professional training, being the most famous the one developed by Advanced Life Support in Obstetrics (ALSO), known as HELPERR (in English) or ALEERTA(in Portuguese). However, these sequences of maneuvers are useful when the mother is in a supine position.A new protocol is proposed, considering the benefits of deliveries in non-supine positions, as well as the need for implementing less invasive maneuvers first. The proposed mnemonic is A SAÍDA and consists of A = ask for help, acquaint the mother, augment the squat; S = suprapubic pressure; A = alter the position to all fours (Gaskinmaneuver); I = internal maneuvers (Rubin II, Wood, inverted spin); D = deliver the posterior arm; A = assess theneed for rescue maneuvers...

Distocia de ombro: erro médico? Subsídios da literatura médica para uma defesa / Shoulder dystocia: medical error? Subsidies of medical literature for a defense

Cada vez mais os médicos e, principalmente, os obstetras são responsabilizados por eventos desfavoráveis ocorridos durante sua atividade profissional. Muitos advogados aproveitam esta ocorrência para denunciá-los com o intuito de ganhar causas milionárias. A distocia de ombros é um evento obstétrico incidental, imprevisível em muitos casos e que, na maioria das vezes, causa tocotraumatismo, principalmente no feto, levando muitos advogados a pedirem indenização reparatória, às vezes por toda a vida da criança afetada, o que implica um desgaste moral, profissional e patrimonial do obstetra, o qual não é o responsável por tal ocorrência. Este trabalho teve por finalidade colher dados da literatura e da medicina baseada em evidências para dar subsídios científicos para formar a defesa do profissional, que sofrer tal incidente.

Each new day, doctors and, mainly, obstetricians are responsible by occurred favorable events during its professional activity. Many lawyers try to take advantage of this occurrence, denouncing them with the intention of gaining millionaire causes. The shoulders' dystocia is an incidental and unexpected delivery event in many cases, that most of the time causes traumatic delivery, mainly fetal trauma, which leads many lawyers to ask for ensuing litigation indemnity, to the times for all the life of the child affected and that it implies in a moral consuming, professional and patrimonial of obstetrician, who is not the responsible for such occurrence. This paper has as a purpose to collect literature and medicine based on evidences data to give scientific subsidies to form the defense of the professional, who suffers such incident.

Medical management of canine and feline dystocia.

When dystocia is diagnosed in the bitch or queen, two forms of treatment exist: medical or surgical therapy. Medical management of dystocia has the advantage of aiding completion of the parturition process without surgery or anesthesia. However, since not all cases of dystocia can be managed medically, educated and careful decision making is required prior to instituting medical management in cases of dystocia. Improper medical treatment, especially when surgical management is clinically indicated, can result in compromise and even death of the dam and fetuses. This paper focuses on the decision making necessary prior to instituting medical management for cases of dystocia in both bitches and queens, and describes available therapeutics.

Rupture of the symphysis pubis during vaginal delivery followed by two subsequent uneventful pregnancies.

BACKGROUND: Rupture of the symphysis pubis during vaginal delivery is a rare but debilitating complication. Factors contributing to rupture are poorly defined. CASE: A healthy primigravida suffered a rupture of her symphysis pubis during an otherwise uncomplicated vaginal delivery. She experienced significant pain and difficulty walking for 6 months after the injury. Her 5-cm symphyseal separation was managed successfully with physical therapy and activity restriction. The patient's two subsequent deliveries (one vaginal and one via cesarean delivery) were uneventful. CONCLUSION: Severe symphyseal rupture during vaginal delivery can be managed without surgery. Risk factors for rupture are not well defined. Based on a literature review, there is a significant risk of repeat symphyseal rupture with subsequent vaginal delivery.

Fetal shoulder dystocia.

Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years, probably just because it has now been regularly registered at maternity wards as an obstetric complication. The risk factors for shoulder dystocia include fetal macrosomia, fetal malformations and tumors, maternal adiposity, excessive weight gain during pregnancy, diabetes mellitus, pathologic pelvis, multiparity, short maternal stature, advanced maternal age, postterm pregnancy, so-called midforceps delivery or vacuum extraction, prolonged delivery stage II, oxytocin labor induction, premature fetal expression according to Kristeller, and previous shoulder dystocia in macrosomatic children. The sequels of shoulder dystocia and obstetric maneuvers for incarcerated shoulder release include clavicular fracture, brachial plexus lesions, sternocleidomastoid muscle distension with or without hematoma, diaphragmatic paralysis, Horner's syndrome, peripartal asphyxia and consequential cerebral lesions (cerebral palsy), and peripartal death. Maternal complications due to shoulder dystocia are postpartal hemorrhage, cervical and vaginal lacerations, frequent infections during the puerperium, symphysiolysis and rupture of the uterus, and secondary cesarean section with related complications due to unsuccessful obstetric procedures or as continuation of Zavanelli's maneuver. McRoberts' maneuver (or Gaskin maneuver) is recommended as the initial procedure for shoulder release in case of shoulder dystocia. If it fails, other obstetric procedures such as Resnik's suprapubic pressure and Woods' grip with posteriorly placed arm release should be used, always with gross lateral episiotomy. The performance of all these obstetric procedures requires skilfull and highly experienced obstetrician and obstetric team as a whole.

The Zavanelli manoeuvre in shoulder dystocia: case report and review of published cases.

A case of severe shoulder dystocia is reported in which, after other methods had failed, cephalic replacement succeeded but was very difficult. The infant suffered severe damage. A review of methods to relieve shoulder dystocia is given, with special attention to published cases of the Zavanelli manoeuvre. It could only be used when all other methods fail.

Caesarean section and other methods for assisted delivery: comparison of effects on mare mortality and complications.

Data from 116 mares that had caesarean section or vaginal delivery at 2 university hospitals were analysed in 5 groups, as follows: dystocia corrected by caesarean section, Group DCS (n = 48); elective caesarean section, Group ECS (n = 10); caesarean section concurrently with colic surgery, Group CCS (n = 8); assisted vaginal delivery, Group AVD (n = 22); and controlled vaginal delivery under general anaesthesia, Group CVD (n = 28). Survival rate in all mares that had caesarean section, excluding Group CCS, was 88% (51/58). All mares in Group ECS survived and Group CCS had the lowest survival rate (38%). In 98 mares with dystocia, Groups DCS (15%) and AVD (14%) had significantly lower (P<0.05) mortality rates than Group CVD (29%). There were no differences between groups for duration of dystocia. The placenta was retained in 75 (65%) of 116 mares, and for a longer period following elective caesarean section than following assisted vaginal delivery. Multiple complications (> or = 3) were recorded in 6 mares in Group CVD but not in the other groups. Of the 102 foals delivered from 98 mares with dystocia, 11 (11%) were alive at delivery and 5 (5%) survived to discharge. Survival rate for foals was 38% in Group CCS, and 90% in Group ECS. Under conditions similar to those in this study, it is calculated that caesarean section is preferable to CVD if dystocia is protracted and great difficulty and trauma is involved, even if CVD allows delivery of the foal.

Rotación manual de la cabeza fetal en la distocia de posición transversa y oblicua posterior / Fetal cephalic manual rotation in dystocia of transverse position and oblique posterior

El objetivo que plantea este trabajo es reducir por medio de la rotación manual (RMC) del polo cefálico, el número de cesáreas causadas tanto por distocias de posición como por falta de encajamiento y evitar el riesgo de la rotación y extracción instrumental. Nuestra casuística está formada por 100 pacientes en las cuales se practicó la (RMC) en el segundo período del parto, en 59 multíparas y 41 primíparas; en 37 casos la posición fue transversa y en 63 oblicua posterior. Las indicaciones fueron dadas mayoritariamente por período expulsivo prolongado, abreviación del expulsivo, agotamiento materno, falta de encajamiento y sufrimiento fetal. El parto fue espontáneo en 57 casos: en 40 terminó por aplicaciones complementarias de fórceps con cabeza encajada en una variedad anterior, en su mayoría por sufrimiento fetal: hubo 3 fracasos, 2 occípito posteriores que no rotaron y hubo que rotarlas con el fórceps a occípito sacra y una cesárea por falta de encajamiento; los resultados fueron favorables en el 97 por ciento

Atención del parto de riesgo / Propuesta Normativa Perinatal / Attention of risk parturition

Contenido: Parto de riesgo: Atención. Admisión de la embarazada. Morbilidad y mortalidad materna post parto. El recién nacido del parto de reisgo. Anexos: Control de la integridad del binomio madre-hijo. Normas de seguridad institucional