Shoulder dystocia: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

Shoulder dystocia (SD) is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. It complicates 0.5-1% of vaginal deliveries. Risks of brachial plexus birth injury (level of evidence [LE]3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) increase with SD. Its main risk factors are previous SD and macrosomia, but both are poorly predictive; 50-70% of SD cases occur in their absence, and most deliveries when they are present do not result in SD. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of SD. Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for SD (Grade C). In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (Grade A). Women with gestational diabetes require diabetes care (diabetic diet, glucose monitoring, insulin if needed) (Grade A) because it reduces the risk of macrosomia and SD (LE1). Only two measures are proposed for avoiding SD and its complications. First, induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more (professional consensus). Second, cesarean delivery is recommended before labor in three situations and during labor in one: (i) estimated fetal weight (EFW) >4500g if associated with maternal diabetes (Grade C), (ii) EFW >5000g in women without diabetes (Grade C), (iii) history of SD associated with severe neonatal or maternal complications (professional consensus), and finally during labor, (iv) in case of fetal macrosomia and failure to progress in the second stage, when the fetal head station is above +2 (Grade C). In cases of SD, it is recommended to avoid the following actions: excessive traction on the fetal head (Grade C), fundal pressure (Grade C), and inverse rotation of the fetal head (professional consensus). The McRoberts maneuver, with or without suprapubic pressure, is recommended first (Grade C). If it fails and the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, it is preferable to attempt to deliver the posterior arm next (professional consensus). It appears necessary to know at least two maneuvers to perform should the McRoberts maneuver fail (professional consensus). A pediatrician should be immediately informed of SD. The initial clinical examination should check for complications, such as brachial plexus injury or clavicle fracture (professional consensus). If no complications are observed, neonatal monitoring need not be modified (professional consensus). The implementation of practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury. SD remains an unpredictable obstetric emergency. All physicians and midwives should know and perform obstetric maneuvers if needed, quickly but calmly.

Intrapartum care and substandard care: juridical recommendations to reduce the risk of liability.

PURPOSE: To develop juridical recommendations to reduce medical liability of the obstetrician, providing intrapartum care. METHODS: 107 legal proceedings of the past 40 years from Belgium, France and the Netherlands, involving medical negligence of the obstetrician during intrapartum care, were analyzed in depth. The legal databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (the Netherlands). A minority of the cases were retrieved through contacts with insurance companies (Belgium only) and courts. RESULTS: The judicial assessment of negligence is focused on four domains of expertise of the obstetrician: 36 % (38/107) recognizing a specific pathology, 33 % (35/107) interpreting fetal monitoring, 19 % (21/107) performing a forceps/vacuum-assisted delivery and 12 % (13/107) managing shoulder dystocia. The highest liability rate of 86 % (30/35) was reflected in the category of interpreting fetal monitoring. CONCLUSION: To reduce the liability rate of 66 %, several policy recommendations can be made. Respond to the first symptoms of obstetric complications (particularly placental abruption and uterine rupture). Secondly, respond to disturbing messages of the midwife concerning fetal distress and evaluate every deviation in fetal heart rate monitoring. Education concerning the interpretation of fetal monitoring is a must for every midwife and obstetrician. Use proper methods to monitor the heart rate to optimize the quality of the signal. The third recommendation is to be cautious about opting for a forceps/vacuum-assisted delivery, consider all circumstances. Consider the risk of failed instrumental delivery. And finally in relation to shoulder dystocia, recognize the risk factors by ordering further examinations to purchase a diagnosis.

Newborn calf vitality: risk factors, characteristics, assessment, resulting outcomes and strategies for improvement.

Dystocia is a stressful and traumatic event for both the cow and calf. As the prevalence of dystocia has increased over time, attention has been focused on maintaining the health and longevity of the cow. Lack of vitality in the newborn calf may go unnoticed and result in short or long-term implications for calf health and performance. A prolonged or assisted delivery may increase birth stress in calves causing a variety of effects including injury, inflammation, hypoxia, acidosis, pain and an inability to maintain homeostasis. Each of these effects can further contribute to a reduced state of vitality in the newborn calf. Newborn vitality is essential to the health, survival and welfare of the calf. If the calf is not vital at birth, it may be unwilling or unable to get up and suckle colostrum in a timely manner. Early colostrum intake improves passive transfer of immunoglobulins, energy uptake and thermoregulation. Intervention may be required to assist these calves such as respiratory and thermal support, manual feeding of colostrum or the administration of non-steroidal anti-inflammatory drugs to aid health and long-term survival. However, more research is needed to determine ways in which newborn calf vitality can be assessed and improved in order to reduce the increased risk of morbidity and mortality and long-term effects on performance.

Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.

BACKGROUND: We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications. METHODS: We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. RESULTS: The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01). However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01). Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P<0.001), although the rates of cesarean delivery were similar (31 percent and 32 percent, respectively; adjusted relative risk, 0.97; 95 percent confidence interval, 0.81 to 1.16; P=0.73). At three months post partum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group. CONCLUSIONS: Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman's health-related quality of life.

Surgical treatment of uterine torsion in a llama (Lama glama).

A multiparous llama was presented because of failure to proceed into the second stage of labor. Clockwise uterine torsion and a live fetus were identified by rectal and vaginal examinations. A cesarean operation was elected because of the prolonged first stage of labor and lack of cervical dilatation. Anesthesia was induced with a 10% guaifenesin solution administered intravenously via a pressurized pump followed by intubation and maintenance with 2% halothane. A ventral midline surgical approach exposed the uterus and the fetus was removed through a uterotomy. The placenta was manually stripped from the myometrial edges of the incision and the margins were oversewn using a continuous interlocking pattern. The uterus was then closed using a continuous Utrecht pattern and the uterus rotated 180 degrees back to its normal anatomical position. The abdomen was closed in 3 layers. Recovery of the llama was uneventful with the male cria able to nurse 6 hours post-operatively. Placental expulsion occurred approximately 48 hours after fetal removal.

Short stature and cephalopelvic disproportion in Burkina Faso, West Africa. Operations Research Team.

In order to reduce maternal mortality due to cephalopelvic disproportion (CPD), it is important to screen women for short stature, especially in rural areas of developing countries. We measured the height of 1733 women as they left the maternity services in Ouagadougou and recorded the type of delivery. Women less than 155 cm tall were 4.9 times more likely to have a cesarean section delivery. We propose simplified screening criteria for use by traditional birth attendants.