Effects of high fidelity simulation model on midwives' shoulder dystocia management skills: An educational Intervention study.

Background: Shoulder dystocia is an emergency and risky situation that most likely directly involves midwives. Aim: The aim of this study is to determine the effects of simulation training with a high fidelity mannequin on midwives' shoulder dystocia management. Subjects and Methods: This study utilized a quantitative, quasi-experimental research design. No sample selection was made. The study included all midwives (n:16) working in the maternity unit of Manisa Province Hospital, Turkey. Management of shoulder dystocia was lectured both theoretically and practically, using a high fidelity simulation. Midwives' shoulder dystocia management skills and knowledge were evaluated before and after training using shoulder dystocia knowledge form and management skill checklist. Results: There was a statistically significant increase in their shoulder dystocia management knowledge scores and management skills after simulation-based shoulder dystocia training (P < 0.05). Before the training, the midwives (62.5%) mostly used the McRoberts maneuver and suprapubic pressure as the primary interventions in shoulder dystocia management. After training, all the midwives were able to apply secondary maneuvers (Wood's or Rubin's maneuvres or posterior arm delivery) along with the primary maneuvers, in accordance with the shoulder dystocia management algorithm. Conclusion: Using a high fidelity simulation model in training increased midwives' shoulder dystocia management skills and knowledge.

Manipulative Reduction for Abnormal Uterine Inclination in Vaginal Delivery.

OBJECTIVE: To investigate the manipulative reduction in abnormal uterine inclination in vaginal delivery. METHODS: With the independently developed uterine inclination surveyor, 40 primiparas with abnormal uterine inclination were randomly divided into two groups: treatment group (Group A, 20 cases) and control group (Group B, 20 cases). The general condition of the primipara, the labor stages, the changes in uterine inclination after treatment, postpartum hemorrhage at 2 hours, and the general condition of fetuses were observed to study the therapeutic value of manual reduction in abnormal uterine inclination. RESULT: In the control group, one uterine inclination was not corrected with the change in labor process, and the pregnancy was terminated due to stagnation of the active phase. In the first stage of labor, the time spent in the treatment group (393.4 ± 31.3 mins) was significantly lower than that in the control group (440.7 ± 34.9 mins) (P = 0.001). Compared with the control group (49.8 ± 6.5 mins), the treatment group (42.6 ± 7.2 mins) also exhibited a significantly shortened second stage of labor (P = 0.02). Sixteen cases (16/20) in the treatment group returned to normal after manual reduction, and 9 cases (9/20) in the control group returned to normal with the progression of natural labor. Manual reduction could be used as an option to treat abnormal uterine inclination (P = 0.01). There was no significant difference in the third stage of labor (P = 0.2), 2-hour postpartum hemorrhage (P = 0.35), Apgar score (P = 0.64), or body weight (P = 0.76) between the two groups. CONCLUSION: Manual reduction in the treatment of abnormal uterine inclination has obvious effects, shortens the birth process, and is safe for the fetus.

De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers - a prospective intervention study.

BACKGROUND: The use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin. METHODS: This prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery. RESULTS: After the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p < 0.001). Oxytocin was not always used in accordance with the guidelines, but a significant reduction in oxytocin rates from 63.3% to 54.1% (p < 0.001) was obtained. More women without dystocia according to the existing guidelines were augmented after the intervention (18.9% vs 8.4%, p < 0.001). Assessing all labors, the median duration of oxytocin treatment was reduced by 72% (from 90 to 25 min) without increasing the median duration of labor (385 min in both groups). There was a moderate reduction in operative vaginal deliveries from 26.9 to 21.5% (p = 0.04), and dystocia as an indication for these deliveries increased (p = 0.01). There was a moderate increase in caesarean sections from 6.7 to 10.2% (p = 0.05), but no increase in dystocia as an indication for these deliveries. Women receiving oxytocin were more likely to have an operative vaginal birth, even after adjusting for birth weight, epidural analgesia and labor duration, OR: 2.1 (CI 1.1-4.0) before and OR 2.7 (CI 1.6-4.5) after the intervention. CONCLUSIONS: Our intervention led to a significant reduction in the use of oxytocin. However, more than half of the women remained diagnosed with dystocia. Operative vaginal births seem to be associated with oxytocin treatment. Therefore, augmentation with oxytocin should be used with caution and only when medically indicated. Even more modified guidelines for augmentation than the ones applied in this study might be appropriate.

Effect of the use of a video tutorial in addition to simulation in learning the maneuvers for shoulder dystocia.

The development of video tutorials is flourishing and may make it possible to maintain knowledge learned during instruction with simulation. The aim of this study was to assess the effect of adding a video tutorial to a lecture and simulation for learning the maneuvers and protocol for the management of shoulder dystocia. Student midwives and medical students attended a lecture class including instruction about maneuvers and a presentation of an algorithm for the management of shoulder dystocia. They were randomized into two groups. The video group was reminded every two weeks to watch a short tutorial. The control group was reminded to consult the slide show. At the end of two months, they were evaluated by graders. The practice, theory, and global scores of the students in the video group were significantly higher than those of the students in the control group (14.8 vs. 10.4; 5.6 vs. 3.4; and 9.3 vs. 7.0, P<0.001). The scores for the video group improved at the second simulation session, compared with the first (14.8 vs. 9.9; 5.6 vs. 2.9; and 9.3 vs. 7, P<0.001). The addition of a video tutorial improved learning compared to a standard lecture and simulation session alone.

Perceived changes in knowledge and confidence of doctors and midwives after the completion of the Standardized Trainings in Obstetrical Emergencies.

BACKGROUND AND OBJECTIVES: There are only few training programs in obstetric emergencies currently in use and only some of them were evaluated with an adequate sample of participants. Therefore, we present the evaluation of the novel Standardized Trainings in Obstetrical Emergencies (STrObE), conducted in Lithuania. The aim of this study was to analyze whether participants' self-reported knowledge and confidence increased after the trainings, and whether the impact of the trainings was long-lasting. MATERIALS AND METHODS: Data was collected across the majority of hospitals providing secondary and tertiary obstetrical care in Lithuania in 2015. A total of 650 obstetricians-gynecologists and midwives attended the trainings; 388 (response rate 59.7%) of them filled in the initial questionnaire before the trainings, 252 (64.9%) immediately after, 160 (41.2%) 6 weeks after, and 160 (41.2%) 6 months after the trainings, which was the final sample for the analyses. Participants used a Likert-type scale to evaluate their knowledge and confidence about management of urgent obstetrical situations: vacuum-assisted vaginal delivery, shoulder dystocia, postpartum hemorrhage, preeclampsia/eclampsia, early preterm labor, and dystocia. We assessed how participants' self-reported knowledge and confidence changed after the trainings (compared to before the trainings) and how long the effect was retained for. RESULTS: The mean score of self-reported knowledge in obstetrical emergencies increased immediately after the trainings comparing to the scores before the trainings (P<0.001) and it did not differ further between the three time points after the trainings (i.e. immediately, 6 weeks, and 6 months; P>0.05). The same pattern was observed for self-reported confidence scores. The increase in self-reported knowledge and confidence after the trainings was stable. Moreover, the self-reported knowledge and confidence gains were greater for those participants with lower work experience, although benefit was seen across all experience levels. CONCLUSIONS: STrObE improved participants' self-reported knowledge and confidence and lasting positive effects were observed for at least 6 months after the initial trainings. Moreover, the trainings were more beneficial for those with lower work experience, although they benefited all the participants.

Factores que influyen en la realización de una episiotomía en partos eutócicos / Factors affecting the performance of an episiotomy in spontaneous vaginal deliveries

Objetivo: Analizar los factores que condicionan la realización de episiotomía en partos eutócicos en el Hospital Universitario de La Ribera (HULR). Material y método: Estudio descriptivo, transversal y retrospectivo. Se recogieron datos de los partos eutócicos atendidos durante el año 2015. Se tabularon en una hoja de cálculo Excel y se analizaron con el paquete estadístico SPSS 17.0. Resultados: El número total de partos atendidos en el HULR durante 2015 fue de 1.814. De ellos, 1.116 fueron partos eutócicos (62%), de los cuales un 83% no precisó episiotomía. Por tanto, la tasa de episiotomías en partos eutócicos fue del 17%. Se encontró una relación estadísticamente significativa entre la realización de episiotomía y las variables primiparidad, uso de analgesia epidural, parto estimulado/inducido y posición de parto en litotomía. No se encontró relación estadísticamente significativa con la edad materna, el peso del recién nacido, el profesional que atendió el parto o la aparición de desgarros. Conclusiones: Conocer los factores que se asocian con la realización de episiotomías en el HULR puede ser determinante para restringir su uso a las situaciones estrictamente necesarias. Se proponen ciertas medidas al respecto, como el uso de posiciones alternativas durante el expulsivo, el inicio del parto espontáneo cuando sea posible, el respeto a los tiempos de expulsivo en los casos de analgesia epidural y la elaboración de un documento de consenso sobre las indicaciones de la episiotomía (AU)

Objective: To analyze the factors that condition the performance of an episiotomy in spontaneous vaginal deliveries at La Ribera University Hospital (HULR). Material and method: A descriptive, cross-sectional and retrospective study was carried out. Data about spontaneous vaginal deliveries attended during 2015 were collected. Data were tabulated in Excel spreadsheet and analyzed with SPSS 17.0 statistical package. Results: Data from 1,116 spontaneous vaginal deliveries were analyzed (62% of the total). In 83% of these cases no episiotomy was performed. A statistically significant relationship was found between the performance of episiotomy and the variables: primiparity, use of epidural analgesia, stimulated/induced labour and lithotomy position. There was no statistically significant relationship to maternal age, weight of the new-born, health care professional, or perineal trauma appearance. Conclusions: Knowing the factors that are associated with the performance of episiotomy in our delivery room is determinant to restrict its use to those situations strictly necessary. The following measures have been proposed: the use of alternative positions during the second stage of labour, spontaneous onset of labour when possible, to respect the duration of second stage of labour in cases of epidural analgesia, and the elaboration of a consensus document on episiotomy indications (AU)

Shoulder Dystocia: Quality, Safety, and Risk Management Considerations.

Shoulder dystocia is a term that evokes terror and fear among many physicians, midwives, and health care providers as they recollect at least 1 episode of shoulder dystocia in their careers. Shoulder dystocia can result in significant maternal and neonatal complications. Because shoulder dystocia is an urgent, unanticipated, and uncommon event with potentially catastrophic consequences, all practitioners and health care teams must be well-trained to manage this obstetric emergency. Preparation for shoulder dystocia in a systematic way, through standardization of process, practicing team-training and communication, along with technical skills, through simulation education and ongoing quality improvement initiatives will result in improved outcomes.

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.

[The Jacquemier's maneuver: An overview of midwives knowledge and practices in a third level maternity hospital]. / La manœuvre de Jacquemier : évaluation des connaissances et des pratiques des sages-femmes d'une maternité de niveau 3.

OBJECTIVES: Shoulder dystocia is an uncommon but serious complication occurring in 0.2 to 3% of deliveries. We carried out a study in order to assess the midwives experience, knowledge and practices on shoulder dystocia, at the maternity hospital of Saint-Denis, Reunion Island. METHODS: The first part is a confidential questionnaire addressed to midwives working in the delivery unit. The second part is a retrospective desk review of shoulders dystocia which occurred from 2004 to 2014. RESULTS: (1) The population was made up of 28 midwives, having between 1 to 27 years of experience. Seventy-five percent of them had been faced with shoulder dystocia, and 62% had realized Jacquemier's maneuver. However, only 25% received this maneuver training. Less than a third of them answered correctly to at least 7 from the 8 theoretical questions about the Jacquemier's maneuver. (2) We studied 34 shoulders dystocia, occurring between 36+5 to 41+2 gestational weeks, mostly with no risk factors found. Mac Roberts' maneuver is used as first-line in 88% of situations. Jacquemier's maneuver is used in 52.9% of cases (5.9% as first-line, 47% as second-line). In 26.4% of situations, the midwife is not able to reduce the dystocia. She usually carries out a combination of maneuvers. The gynecologist is asked only for 23.5% of dystocia and he usually uses Jacquemier's maneuver (70% of situations). CONCLUSION: The Jacquemier's maneuver is rarely practiced (uncommon situation, lack of training). Simulation trainings should be put in place, because neonatal sequels can be avoided.

Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study.

BACKGROUND: In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians. METHODS: The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania's largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis. RESULTS: Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case. CONCLUSIONS: For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.

Preventing primary cesarean births: midwifery care.

The incidence of cesarean birth in the United States is alarmingly high and cesareans are associated with added morbidities for women and newborns. Thus strategies to prevent cesarean particularly for low-risk, nulliparous women at term with a singleton fetus are needed. This article addresses evidence-based practices that may be used during intrapartum to avoid primary cesarean, including patience with progress in labor, intermittent auscultation, continuous labor support, upright positions, and free mobility. Second-stage labor practices, such delayed pushing and manual rotation of the fetus, are also reviewed. This package of midwifery-style care practices can potentially lower primary cesarean rates.

Evaluation of healthcare professionals' understanding of eponymous maneuvers and mnemonics in emergency obstetric care provision.

OBJECTIVE: To evaluate whether eponymous maneuvers and mnemonics taught for the management of shoulder dystocia, vaginal breech delivery, and uterine inversion were remembered and understood in practice. METHODS: A questionnaire was distributed to obstetricians and midwives collecting information about the HELPERR and PALE SISTER mnemonics. Three extended matching questions evaluated participants' knowledge of the correct maneuvers, with their matching eponyms, used in the management of shoulder dystocia, vaginal breech delivery, and uterine inversion. RESULTS: Of the 112 participants, 90% were familiar with the HELPERR mnemonic, with 79% using it in their practice. Of those who used it, only 32% could correctly decipher it (P = 0.032). PALE SISTER was mostly unfamiliar. The percentages of correct maneuvers used for managing shoulder dystocia, breech delivery, and uterine inversion were 84.6%, 58.3%, and 28.6%, respectively. However, the eponyms were correctly matched to their maneuvers in only 33.3%, 14.3%, and 0% of cases, respectively (P < 0.01). CONCLUSION: The meanings of the mnemonics for obstetric emergencies were frequently recalled incorrectly. This, together with the poor correlation between knowledge of maneuvers and their eponyms, limits their usefulness and indicates that teaching should focus on learning without relying on mnemonics and eponyms.

Optimization of competency in obstetrical emergencies: a role for simulation training.

PURPOSE: In obstetrical emergency situations, optimal management requires the immediate coordinated actions of a multi-disciplinary and multi-professional team. This study investigated the influence of simulation training on four specific skills: self-confidence, handling of emergency situation, knowledge of algorithms and team communication. METHODS: Clinical algorithms were first presented to the participants. Training for six emergency situations (shoulder dystocia, postpartum haemorrhage, pre-eclampsia, maternal basic life support, neonatal resuscitation and operative vaginal birth) was performed using high- and low-fidelity simulation mannequins. General impression of the simulation training and the four above-mentioned skills were evaluated anonymously through a self-assessment questionnaire with a five-point Likert scale immediately after the training and 3 months later. RESULTS: From November 2010 to March 2012, 168 participants, distributed over six one-day courses, took part in the training. 156 participants returned the questionnaire directly after the course (92.9 %). The questionnaire return rate after 3 months was 36.3 %. The participants gave higher Likert scale answers for the questions on the four specific skills after 3 months compared to immediately after the course. The improvement was statistically significant (p ≤ 0.05) except for the question regarding team communication. CONCLUSION: Implementation of simulation training strengthens the professional competency.

Insufficient pain relief in vacuum extraction deliveries: a population-based study.

OBJECTIVE: To investigate the pain relief used in association with vacuum extraction assisted deliveries and to identify risk factors for not receiving pain relief during the procedure. DESIGN: Retrospective birth register study. SETTING: Nationwide study in Sweden. POPULATION: The study population consisted of all women (n = 62 568) with a singleton pregnancy who gave birth in gestational weeks 37(+0) to 41(+6) between 1999 and 2008 and were delivered by vacuum extraction. METHOD: Register study with data from the Swedish Medical Birth Register. MAIN OUTCOME MEASURES: Epidural blockade, spinal blockade, pudendal nerve blockade, infiltration of the perineum, no pain relief. RESULTS: In all, 32.4% primiparas and 51.4% multiparas who had a vacuum-assisted delivery had this without potent pain relief such as epidural blockade, spinal blockade or pudendal nerve block. When infiltration was added as a method for pain relief, 18% were still delivered without pain relief. Multiparas were more likely than primiparas to be delivered without potent pain relief, odds ratio (OR) 2.29 95% confidence interval (CI) (2.20-2.38). Compared with women delivered by vacuum extraction due to prolonged labor, those with signs of fetal distress were more likely to be delivered without potent pain relief (OR) 1.74, 95% (CI) (1.68-1.81). CONCLUSION: A considerable number of women are delivered by vacuum extraction without pain relief. The high proportion might reflect that clinical staff do not always consider pain relief to be of high priority in vacuum extraction deliveries or that they fear impaired pushing forces.

Preventive nursing of neonatal clavicular fracture in midwifery: a report of six cases and review of the literature.

PURPOSE: To summarize and analyze the obstetric factors and medical care for neonatal clavicle fracture during delivery. MATERIALS AND METHODS: In 4,456 vaginal deliveries, only six newborns were found with a clavicle fracture in our hospital from October 2002 to October 2011. RESULTS: Clinical findings showed that dystocia and improper midwifery manoeuvres are the two major reasons which lead to newborn clavicular fractures. CONCLUSION: More attention should be paid to non-violent traction and proper treatment of shoulder dystocia.

Managing the primary cesarean delivery rate.

One third of deliveries in the United States are by cesarean, a rate that far exceeds that recommended by professional organizations and experts. A dominant reason for the high overall cesarean rate is the rising primary cesarean rate. The high primary cesarean rate results from multiple factors, both clinical and nonclinical. This review outlines proposed interventions to lower the primary cesarean rate. We focus on those implementable at a facility level and would likely yield immediate results, including aligning provider incentives for vaginal birth, limiting elective induction of labor, and improving labor management of dystocia and abnormal fetal heart rate tracings.

Shoulder dystocia: a qualitative exploration of what works.

OBJECTIVE: to explore expert practitioners' methods of managing shoulder dystocia. DESIGN AND SETTING: a qualitative interpretive study enabled a descriptive, hermeneutic analysis of data collected. Data were collected via tape recorded interviews, transcribed and analysed to explore themes and meanings. PARTICIPANTS: five clinicians (four midwives and one obstetrician) who have significant experience in the management of shoulder dystocia and work in high risk maternity practice. IMPLICATIONS FOR PRACTICE: the results of this study demonstrate that the actions to be taken in the event of shoulder dystocia should be further examined and possibly reviewed. The three simple steps of McRoberts Manoeuvre - Suprapubic Pressure - Axillary Traction could revolutionise the way in which shoulder dystocia is managed.

[Use of acupuncture for labour augmentation]. / Akupunktur til vestimulering under fødslen.

INTRODUCTION: In Denmark, 45% of all primiparas and 12% of multiparas with uneventful pregnancies are augmented in order to treat dystocia. Augmentation using oxytocin is associated with uterine hyperstimulation, uterine rupture and foetal death. Currently, no studies show that acupuncture is effective for augmentation. MATERIAL AND METHODS: A single-blinded randomized controlled trial with women diagnosed with dystocia. In the acupuncture group, the women had acupuncture in SP6, KI3, KI6, BL60, LI4 and acupressure on BL67. The control group received no treatment. The primary outcome was progression in cervical dilatation within two hours. The secondary outcomes were length of labour, length of second stage, use of augmentation, use of analgesia, caesarean section rate and number of instrumental deliveries. RESULTS: A total of 84 women were randomised. There was no significant difference between the groups with regard to dilatation from randomization to effect assessment (p = 0.54). In the acupuncture group, the mean difference was 1.3 cm (0.69-1.91). In the control group, the mean difference was 1.56 (0.6-2.52). 27% of the women with dystocia delivered spontaneously without augmentation. No major side effects of acupuncture treatment were reported. CONCLUSION: This study showed no effect of acupuncture treatment for primary or secondary inertia.