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.

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.

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.

The impact of lamb and ewe mortality associated with dystocia on Australian and New Zealand sheep farms: A systematic review, meta-analysis and bio-economic model.

Dystocia contributes to lamb and ewe mortality in the periparturient period but impacts for extensive sheep production systems remain poorly understood. Here we show that lamb and ewe mortality associated with dystocia has important impacts on sheep production in Australia and New Zealand, and quantify financial impacts for the Australian sheep industry. A systematic review of the literature identified 11 publications published since 1990 that reported sheep mortality due to dystocia in Australia or New Zealand. Assumptions for ewe breeding flock structure and reproductive performance were based on Australian sheep industry data. The proportion of lamb mortality attributable to dystocia (including stillbirths and perinatal deaths with evidence of hypoxic injury) pooled across all studies (pooled proportional mortality ratio) was 47 % (95 % Confidence Interval (CI): 38, 55). Pooled proportional mortality ratio for Australian studies was 53 % (95 %CI: 47, 60), and for New Zealand studies was 35 % (95 %CI: 19, 51). Pooled proportional mortality ratio was similar for lambs born to Merino and non-Merino ewes, although more data are needed to determine effects of ewe breed independent of other factors. Pooled proportional mortality ratio was higher for single lambs (59 %; 95 % CI: 55, 63) than twin (47 %; 41, 54) or triplet (49 %; 46, 52) lambs. However, the number of dystocia-associated mortalities is higher for twin-born lambs than for singles because total mortality is higher for twin-born lambs. It is estimated that approximately 7.7 million lamb deaths and 297,500 ewe deaths per year are attributable to dystocia in Australia for the national flock of 38 million breeding ewes. The whole-farm bio-economic Model of an Integrated Dryland Agricultural System (MIDAS) was used to determine the impacts of dystocia-associated ewe and lamb mortality on Australian farm profit. Dystocia is estimated to reduce Australian national farm profit by AU$780 million or $23.00 per ewe mated based on an assumed lamb sale price of AU$6.50 per kg carcass weight. These estimates do not include the costs of reduced productivity for surviving ewes and lambs, intervention, post-farmgate impacts, delayed genetic progress, or impacts on animal welfare and access into sheep meat and wool markets. Reducing dystocia through improved genetics and sheep management will improve animal welfare and farm profit.

Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study.

BACKGROUND: To date, no research has focused on the sonographic quantification of the degree of flexion of the fetal head in relation to the labor outcome in women with protracted active phase of labor. OBJECTIVE: This study aimed to assess the relationship between the transabdominal sonographic indices of fetal head flexion and the mode of delivery in women with protracted active phase of labor. STUDY DESIGN: Prospective evaluation of women with protracted active phase of labor recruited across 3 tertiary maternity units. Eligible cases were submitted to transabdominal ultrasound for the evaluation of the fetal head position and flexion, which was measured by means of the occiput-spine angle in fetuses in nonocciput posterior position and by means of the chin-to-chest angle in fetuses in occiput posterior position. The occiput-spine angle and the chin-to-chest angle were compared between women who had vaginal delivery and those who had cesarean delivery. Cases where obstetrical intervention was performed solely based on suspected fetal distress were excluded. RESULTS: A total of 129 women were included, of whom 43 (33.3%) had occiput posterior position. Spontaneous vaginal delivery, instrumental delivery, and cesarean delivery were recorded in 66 (51.2%), 17 (13.1%), and 46 (35.7%) cases, respectively. A wider occiput-spine angle was measured in women who had vaginal delivery compared with those submitted to cesarean delivery owing to labor dystocia (126±14 vs 115±24; P<.01). At the receiver operating characteristic curve, the area under the curve was 0.675 (95% confidence interval, 0.538-0.812; P<.01), and the optimal occiput-spine angle cutoff value discriminating between cases of vaginal delivery and those delivered by cesarean delivery was 109°. A narrower chin-to-chest angle was measured in cases who had vaginal delivery compared with those undergoing cesarean delivery (27±33 vs 56±28 degrees; P<.01). The area under the curve of the chin-to-chest angle in relation to the mode of delivery was 0.758 (95% confidence interval, 0.612-0.904; P<.01), and the optimal cutoff value discriminating between vaginal delivery and cesarean delivery was 33.0°. CONCLUSION: In women with protracted active phase of labor, the sonographic demonstration of fetal head deflexion in occiput posterior and in nonocciput posterior fetuses is associated with an increased incidence of cesarean delivery owing to labor dystocia. Such findings suggest that intrapartum ultrasound may contribute in the categorization of the etiology of labor dystocia.

Guidelines for labor assessment: failure to progress?

The ongoing debate about what models of cervical dilatation and fetal descent should guide clinical decision-making has sown uncertainty among obstetric practitioners. We previously argued that the adoption of recently published labor assessment guidelines promoted by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine may have been premature. Before accepting any new clinical approaches as the standard of care, their underlying hypotheses should be thoroughly tested to ensure they are at least equivalent (or, preferably, superior) to existing management paradigms. Some of the apparent urgency to subscribe to new clinical tactics has been fueled by legitimate concerns about the rise in the cesarean delivery rate over the past several decades. A major contributor to this change in practice patterns is that more cesarean deliveries are being done for diagnoses that fall under the rubric of dystocia than ever before. As a consequence, traditional labor curves-fundamental for assessing labor progress-and the practice paradigms associated with them have received intense scrutiny as a possible contributor to this delivery trend. Moreover, the recent proposal of new labor curves and accompanying management guidelines has, understandably, fed the appetite to correct a perceived problem. However, the cesarean delivery rate rose most rapidly during decades when there was no major change in traditional labor curves or in the guidelines for their interpretation. Also, during the years since the new guidelines were first published, there has been no major fall in cesarean delivery frequency. This raises the question of whether there was truly a fundamental flaw in the traditional labor management paradigms or whether their proper interpretation and use had been somehow forgotten, ignored, or corrupted. More important, existing studies have shown that application of the new guidelines often (but not always) results in a modest fall in the cesarean delivery rate, but that this change may be accompanied by significant increases in maternal and neonatal morbidity. These results strongly suggest more caution in the adoption of the American College of Obstetricians and Gynecologists / Society for Maternal-Fetal Medicine labor assessment recommendations. They are based on a hypothesis that has yet to undergo thorough evaluation of its risks and benefits.

Genetic and environmental analysis of diseases with major economic impact in Israeli Holsteins.

Incidences of ketosis, metritis, mastitis, and retained placenta were studied in Israeli Holstein cows calving between 2008 and 2017. These diseases were selected based on their economic impact. Ketosis, metritis, and retained placenta were scored dichotomously. Mastitis was scored as absent, a single occurrence during the lactation, or more than 1 occurrence. Ketosis and metritis were recorded during the first 21 d after calving, retained placenta during the first 5 d after calving, and mastitis up to 305 d in milk. The effects of herd-year-season, calving age, month of calving, gestation length, and occurrence of dystocia were included in the first-parity analysis models. All effects were significant for metritis and retained placenta. For ketosis, all effects were significant, except for gestation length. For mastitis, only the effects of herd-year-season and calving age were significant. Variance components were computed by the multitrait animal model. The 4 diseases were analyzed jointly based on first-parity records, and each disease was analyzed separately for parities 1 to 3 with the different parities considered separate traits. The 4 disease traits in first parity were also analyzed jointly with the 6 major traits included in the Israeli breeding index: milk, fat, and protein production; somatic cell score; female fertility; and longevity. Heritability was highest for metritis and lowest for mastitis, but all heritabilities were <0.07, similar to previous studies. For all 4 diseases, genetic correlations among the first 3 parities were >0.65, and all residual correlations were <0.07. Selection of herd-years assumed to have more accurate recording of mastitis did not result in higher heritability estimates. Genetic correlations between the disease traits and milk, fat, and protein production were economically unfavorable, while correlations between the disease traits and somatic cell score, female fertility, and longevity were economically favorable. Expected genetic changes in the disease traits after 10 yr of selection with the current Israeli breeding index were all <1%, except for ketosis, which was predicted to increase by 1.5%. Inclusion of these traits in a proposed index with the disease traits constituting 7% of the index would result in only marginal improvements for the disease traits and adversely affect genetic gain for fat and protein production. Thus, inclusion of these traits in the breeding index cannot be justified economically.

Prevalence and causes of cesarean births among women residing at high altitude in Lhasa, Tibet: A retrospective observational study of 7365 women.

OBJECTIVE: Currently, there is paucity of data on the rate of vaginal deliveries and cesarean section among women in Tibet. In this study, we carried out an observational study of 7365 consecutive pregnant women in Lhasa, Tibet who gave birth at our tertiary care institution between 2012 and 2015. MATERIALS AND METHODS: In this retrospective study, we reviewed the hospital records for demographic data, obstetric history, and the number of vaginal and emergency cesarean section deliveries. The overall and annual rate of vaginal and cesarean section deliveries was calculated. Causes, indications or risks for cesarean section were also analyzed. RESULTS: During the review period, 7365 neonates were delivered at our hospital, including 1690 (23.0%) deliveries via cesarean section. The yearly rate of cesarean section progressively declined from 26.7% in 2012 to 18% in 2015 (P < 0.001). Furthermore, the annual rate of emergency cesarean section declined 53.9%between 2012 and 2015(P < 0.001). Fetal risk factors (39.9%) and maternal risk factors (40.3%) were the major causes of cesarean section in the women. Social factors as a cause of cesarean section fluctuated between 7.9% and 11.1%. CONCLUSION: This study has demonstrated a steady decline in the annual rate of cesarean section in women in Tibet between 2012 and 2015. A decrease in the rate of emergency cesarean section contributed substantially to this decline. Moreover, approximately 10% caesarian sections were performed without clear indications, highlighting the need for strengthening prenatal counseling for pregnant women in Tibet.

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

BACKGROUND: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.

Evaluation of the McMahon Competence Assessment Instrument for Use with Midwifery Students During a Simulated Shoulder Dystocia.

INTRODUCTION: Intrapartum emergencies occur infrequently but require a prompt and competent response from the midwife to prevent morbidity and mortality of the woman, fetus, and newborn. Simulation provides the opportunity for student midwives to develop competence in a safe environment. The purpose of this study was to determine the inter-rater reliability of the McMahon Competence Assessment Instrument (MCAI) for use with student midwives during a simulated shoulder dystocia scenario. METHODS: A pilot study using a nonprobability convenience sample was used to evaluate the MCAI. Content validity indices were calculated for the individual items and the overall instrument using data from a panel of expert reviewers. Fourteen student midwives consented to be video recorded while participating in a simulated shoulder dystocia scenario. Three faculty raters used the MCAI to evaluate the student performance. These quantitative data were used to determine the inter-rater reliability of the MCAI. RESULTS: The intraclass correlation coefficient (ICC) was used to assess the inter-rater reliability of MCAI scores between 2 or more raters. The ICC was 0.86 (95% confidence interval, 0.60-0.96). Fleiss's kappa was calculated to determine the inter-rater reliability for individual items. Twenty-three of the 42 items corresponded to excellent strength of agreement. DISCUSSION: This study demonstrates a method to determine the inter-rater reliability of a competence assessment instrument to be used with student midwives. Data produced by this study were used to revise and improve the instrument. Additional research will further document the inter-rater reliability and can be used to determine changes in student competence. Valid and reliable methods of assessment will encourage the use of simulation to efficiently develop the competence of student midwives.

Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis.

STATEMENT: Mastery of shoulder dystocia management skills acquired via simulation training can reduce neonatal brachial plexus injury by 66% to 90%. However, the correlation between simulation drills and reduction in clinical injuries has been inconsistently replicated, and establishing a causal relationship between simulation training and reduction of adverse clinical events from shoulder dystocia is infeasible due to ethical limitations. Nevertheless, professional liability insurance carriers increasingly are mandating simulation-based rehearsal and competency assessment of their covered obstetric providers' shoulder dystocia management skills-a high-stakes demand that will require rapid scaling up of access to quality shoulder dystocia simulation. However, questions remain about differing simulation training schemes and instructional content used among clinically effective and ineffective educational interventions. This review of original research compares curricular content of shoulder dystocia simulation and reveals several critical gaps: (1) prescriptive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus is inconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterally directed traction on the head or to observe a brief hands-off period before attempting traction is infrequently explicit. (3) Neither relative effectiveness nor potential interaction between prescriptive and proscriptive elements of instruction has been examined directly. (4) Reliability of high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competence is unknown. Further study is needed to address these gaps and inform efficient and effective implementation of clinically translatable shoulder dystocia simulation.

Performance and financial consequences of stillbirth in Holstein dairy cattle.

Stillbirth is an economically important trait on dairy farms. Knowledge of the consequences of, and the economic losses associated with stillbirth can help the producer when making management decisions. The objectives of this study were to determine the effects of stillbirth on productive and reproductive performance as well as financial losses due to stillbirth incidence in Iranian Holstein dairy farms. Economic and performance data were collected from nine Holstein dairy farms in Isfahan and Khorasan provinces of Iran from March 2008 to December 2013. The final data set included 160 410 calving records from 53 265 cows. A linear mixed model was developed to evaluate the effects of stillbirth on performance of primiparous and multiparous cows separately and overall. An economic model was used to estimate the economic losses due to stillbirth. The incidence of stillbirth cases per cow per year was 4.2% on average (3.4% to 6.8% at herd level). The least square means results showed that a case of stillbirth significantly (P0.05). Overall, a case of stillbirth reduced 305-day milk yield by 544.0±76.5 kg/cow per lactation. Stillbirth had no significant effects on 305-day fat and protein percentages in either primiparous or multiparous cows. Overall, cows that gave birth to stillborn calves had significantly increased days open by 14.6±2.6 days and the number of inseminations per conception by 0.2 compared with cows that gave birth to live calves (P<0.01). In general, the negative productive and reproductive effects associated with stillbirth were smaller and non-significant for primiparous cows compared with multiparous cows. The financial losses associated with stillbirth incidence averaged US$ 938 per case (range from $US 767 to $US 1189 in the nine investigated farms). The loss of a calf was not the only cost associated with stillbirth, as it accounted for 71.0% of the total cost. The costs of dystocia (7.6%) and culling and replacement expenses (6.3%) were the next most important costs associated with stillbirth. These results can be used to assess the potential return from management strategies to reduce the occurrence of stillbirths.

Implementation of a multicenter shoulder dystocia injury prevention program.

Although the evidence for supporting the effectiveness of many patient safety practices has increased in recent years, the ability to implement programs to positively impact clinical outcomes across multiple institutions is lagging. Shoulder dystocia simulation has been shown to reduce avoidable patient harm. Neonatal injury from shoulder dystocia contributes to a significant percentage of liability claims. We describe the development and the process of implementation of a shoulder dystocia simulation program across five academic medical centers and their affiliated hospitals united by a common insurance carrier. Key factors in successful roll out of this program included the following: involvement of physician and nursing leadership from each academic medical center; administrative and logistic support from the insurer; development of consensus on curriculum components of the program; conduct of gap and barrier analysis; financial support from insurer to close necessary gaps and mitigate barriers; and creation of dashboards and tracking performance of the program.

Obstetric Outcomes of First- and Second-Generation Pakistani Immigrants: A Comparison Study at a Low-Risk Maternity Ward in Norway.

This population-based study compares obstetric outcomes of first- and second-generation Pakistani immigrants and ethnic Norwegians who gave birth at the low-risk maternity ward in Baerum Hospital in Norway from 2006 to 2013. We hypothesized that second-generation Pakistani immigrants are more similar to the ethnic Norwegians because of increased acculturation. Outcome measures were labor onset, epidural analgesia, labor dystocia, episiotomy, vaginal/operative delivery, postpartum hemorrhage, preterm birth, birth weight, transfer to a neonatal intensive care unit, and neonatal jaundice. Compared to first-generation Pakistani immigrants, the second-generation reported more health issues before pregnancy, and they had a higher proportion of preterm births compared to Norwegians. Newborns of first-generation immigrants were more often transferred to a neonatal intensive care compared to Norwegian newborns. Few intergenerational differences in the obstetric outcomes were found between the two generations. A high prevalence of consanguinity in second-generation immigrants suggests the maintenance of a traditional Pakistani marriage pattern.

Farmer views on calving difficulty consequences on dairy and beef farms.

Calving difficulty (CD) is a key functional trait with significant influence on herd profitability and animal welfare. Breeding plays an important role in managing CD both at farm and industry level. An alternative to the economic value approach to determine the CD penalty is to complement the economic models with the analysis of farmer perceived on-farm impacts of CD. The aim of this study was to explore dairy and beef farmer views and perceptions on the economic and non-economic on-farm consequences of CD, to ultimately inform future genetic selection tools for the beef and dairy industries in Ireland. A standardised quantitative online survey was released to all farmers with e-mail addresses on the Irish Cattle Breeding Federation database. In total, 271 farmers completed the survey (173 beef farmers and 98 dairy farmers). Both dairy and beef farmers considered CD a very important issue with economic and non-economic components. However, CD was seen as more problematic by dairy farmers, who mostly preferred to slightly reduce its incidence, than by beef farmers, who tended to support increases in calf value even though it would imply a slight increase in CD incidence. Farm size was found to be related to dairy farmer views of CD with farmers from larger farms considering CD as more problematic than farmers from smaller farms. CD breeding value was reported to be critical for selecting beef sires to mate with either beef or dairy cows, whereas when selecting dairy sires, CD had lower importance than breeding values for other traits. There was considerable variability in the importance farmers give to CD breeding values that could not be explained by the farm type or the type of sire used, which might be related to the farmer non-economic motives. Farmer perceived economic value associated with incremental increases in CD increases substantially as the CD level considered increases. This non-linear relationship cannot be reflected in a standard linear index weighting. The results of this paper provide key underpinning support to the development of non-linear index weightings for CD in Irish national indexes.

Dystocia in the cat evaluated using an insurance database.

Objectives The aim of this study was to describe the incidence of feline dystocia with respect to breed. Methods The data used were reimbursed claims for veterinary care insurance and/or life insurance claims in cats registered in a Swedish insurance database from 1999-2006. Results The incidence rates for dystocia were about 22 cats per 10,000 cat-years at risk, 67 per 10,000 for purebred cats and seven per 10,000 for domestic shorthair cats. The median age was 2.5 years. A significant effect of breed was seen. An incidence rate ratio (IRR) that was significantly higher compared with other purebred cats was seen in the British Shorthair (IRR 2.5), the Oriental group (IRR 2.2), Birman (IRR 1.7), Ragdoll (IRR 1.5) and the Abyssinian group (IRR 1.5). A significantly lower IRR was seen in the Norwegian Forest Cat (IRR 0.38), the Maine Coon (IRR 0.48), the Persian/Exotic group (IRR 0.49) and the Cornish Rex (IRR 0.50). No common factor among the high-risk breeds explained their high risk for dystocia. There was no effect of location; that is, the incidence rate did not differ depending on whether the cat lived in an urban or rural area. Caesarean section was performed in 56% of the cats with dystocia, and the case fatality was 2%. Conclusions and relevance The incidence rate for dystocia was of a similar magnitude in purebred cats as in dogs. The IRR varied significantly among breeds, and the main cause for dystocia should be identified separately for each breed. A selection for easy parturitions in breeding programmes is suggested.

Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes.

OBJECTIVES: To evaluate the effect of the occiput posterior (OP) position on dystocia and perinatal outcomes. METHODS: This was a prospective cohort study of 162 primiparous women. We performed intrapartum sonography, and fetal occiput positions were recorded. The relationships between the position of the occiput and the course of labor and perinatal outcomes were investigated. Statistical analysis was performed using SAS 9.2. RESULTS: Fifty-six of 162 fetuses were found to be in the OP position during the first stage of labor. Eight (80.0%) of 10 fetuses in the OP position during the second stage were among the 56 that were in OP position during the first stage. The rate of cesarean sections performed in the OP position group during the first stage was significantly higher than the rate in the non-OP position group (37.5% versus 8.5%, p < 0.0001). The duration of the second stage of labor was longer and neonatal complications occurred more frequently in the OP position group during the second stage than in the non-OP position group (77.9 ± 33.4 min versus 52.2 ± 26.6 min, p = 0.0104; 50.0% versus 17.2%, p = 0.0118). CONCLUSIONS: The OP position may be a useful predicator for labor dystocia that can lead to poor neonatal outcomes.

Evaluation of calving indicators measured by automated monitoring devices to predict the onset of calving in Holstein dairy cows.

Dystocias are common in dairy cows and often adversely affect production, reproduction, animal welfare, labor, and economics within the dairy industry. An automated device that accurately predicts the onset of calving could potentially minimize the effect of dystocias by enabling producers to intervene early. Although many well-documented indicators can detect the imminence of calving, research is limited on their effectiveness to predict calving when measured by automated devices. The objective of this experiment was to determine if a decrease in vaginal temperature (VT), rumination (RT), and lying time (LT), or an increase in lying bouts (LB), as measured by 3 automated devices, could accurately predict the onset of calving within 24, 12, and 6 h. The combination of these 4 calving indicators was also evaluated. Forty-two multiparous Holstein cows housed in tie-stalls were fitted with a temperature logger inserted in the vaginal cavity 7±2 d before their expected calving date; VT was recorded at 1-min intervals. An ear-attached sensor recorded rumination time every hour based on ear movement while an accelerometer fitted to the right hind leg recorded cow position at 1-min intervals. On average, VT were 0.3±0.03°C lower, and RT and LT were 41±17 and 52±28 min lower, respectively, on the calving day compared with the previous 4 d. Cows had 2±1 more LB on the calving day. Of the 4 indicators, a decrease in VT≥0.1°C was best able to predict calving within the next 24 h with a sensitivity of 74%, specificity of 74%, positive and negative predictive values of 51 and 89%, and area under the curve of 0.80. Combining the indicators enhanced the performance to predict calving within the next 24, 12, and 6 h with best overall results obtained by combining the 3 devices for prediction within the next 24 h (sensitivity: 77%, specificity: 77%, positive and negative predictive values: 56 and 90%, area under the curve: 0.82). These results indicate that a device that could simultaneously measure these 4 calving indicators could not precisely determine the onset of calving, but the information collected would assist dairy farmers in monitoring the onset of calving.

[Assessment of shoulder dystocia related knowledge among French obstetrics and gynecology residents]. / Dystocie des épaules : état des lieux de la formation initiale des internes en France.

OBJECTIVE: To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD). MATERIALS AND METHODS: Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics. RESULTS: Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied. CONCLUSION: Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.

Asociación entre el precio de los alimentos y la glucemia en adultos estadounidenses con diabetes de tipo 2 / The Association Between Food Prices and the Blood Glucose Level of US Adults With Type 2 Diabetes

OBJETIVOS: Calculamos la asociación entre el precio de diversas categorías de alimentos saludables y menos saludables y la glucemia en adultos estadounidenses con diabetes de tipo 2. MÉTODOS: Vinculamos la información de salud contenida en la Encuesta Nacional de Salud y Nutrición 1999-2006 y el precio de los alimentos a partir de la base trimestral de datos de precios de los alimentos. Aplicamos una regresión de los valores de glucemia con respecto al precio de los alimentos en el trimestre anterior, con control de la región del mercado y otras covariables. Examinamos asimismo si la asociación entre el precio de los alimentos y la glucemia variaba entre distintos grupos de ingresos. RESULTADOS: Tanto el precio de las frutas y verduras como el precio de los productos lácteos magros se asocian a la glucemia en las personas con diabetes de tipo 2. En concreto, un precio mayor de las frutas y verduras y de los productos lácteos se asocia a valores más altos de glu-cohemoglobina y de glucemia en ayunas tres meses después. La asociación entre el precio de los alimentos y la glucemia es mayor en las personas de ingresos bajos que en las de ingresos elevados, en la dirección esperada. CONCLUSIONES: Un precio mayor de los alimentos saludables se asocia a cifras más elevadas de glucemia en las personas con diabetes de tipo 2. Esta asociación fue especialmente pronunciada en las personas con diabetes de tipo 2 con ingresos bajos.

OBJECTIVES: We estimated the association between the price of healthy and less-healthy food groups and blood sugar among US adults with type 2 diabetes. METHODS: We linked 1999-2006 National Health and Nutrition Examination Survey health information to food prices contained in the Quarterly Food-at-Home Price Database. We regressed blood sugar levels on food prices from the previous calendar quarter, controlling for market region and a range of other covariates. We also examined whether the association between food prices and blood sugar varies among different income groups. RESULTS: The prices of produce and low-fat dairy foods were associated with blood sugar levels of people with type 2 diabetes. Specifically, higher prices for produce and low-fat dairy foods were associated with higher levels of glycated hemoglobin and fasting plasma glucose 3 months later. Food prices had a greater association with blood sugar for low-income people than for higherincome people, and in the expected direction. CONCLUSIONS: Higher prices of healthy foods were associated with increased blood sugar among people with type 2 diabetes. The association was especially pronounced among low-income people with type 2 diabetes.