Oestrogen and progesterone concentrations in intrapartum cows with insufficient cervix dilation.

The cervix is an important organ that has to dilate sufficiently at delivery to allow the foetus to transition to extrauterine life. Insufficient dilatation of the cervix (IDC) is a frequent cause of dystocia in cattle. The mechanisms underlying cervical opening and the pathogenesis of IDC are still widely unclear. Systematic studies on the relationship between IDC and steroid hormones have been limited and have yielded inconsistent findings. This study aimed to measure oestrogen and progesterone (P4) concentrations in intrapartum cows presented with dystocia due to IDC and in a comparison (C) group of cows with eutocic delivery. Before any obstetrical procedures, and right after the initial evaluation, blood samples were taken from IDC and C animals. Concentrations of P4, oestradiol-17ß (E2), free total oestrogens (FTE) and conjugated total oestrogens (CTE) were measured by established radioimmunoassays. Concentrations of P4 (p = .538), FTE (p = .065) and CTE (p = .605) were not statistically different between C and IDC groups. However, E2 levels in group C were significantly lower when compared to those in the IDC group (p = .013), which is inconsistent with the function of oestrogens in cervical dilatation. The correlation analysis demonstrated significant positive correlations between the pairs P4 versus FTE, P4 versus E2 and FTE versus E2 in group C and between the pair FTE versus E2 in group IDC. In conclusion, the results suggest that local activities of steroids relevant to the aetiology of IDC are not reflected by concentrations in the systemic circulation or that other factors are clearly more important.

Comparison of serum concentrations of pregnancy-associated glycoproteins and estrone sulphate during pregnancy in eutocia and dystocia beef cattle.

Preventing dystocia can stabilise beef cattle management. This study aimed to investigate the relationship between serum pregnancy-associated glycoproteins (PAGs) S-N values and estrone sulphate (E1S) concentrations during pregnancy and the calf birth weight in beef cattle and to evaluate their usefulness as new predictive parameters for dystocia due to foetal overgrowth. Thirty-eight pregnant Japanese Black cattle were used. Blood samples were collected at 40, 70, 100, 150, 200, 250, 280, and 285 days after artificial insemination (AI), and birth weight of the offspring was measured. Serum PAGs S-N values and E1S concentrations were measured, and the area under the curve (AUC) and the ratio of change based on 70 days after AI were calculated, followed by calculation of the correlation coefficient with the birth weight of the offspring and comparison between the eutocia (n = 32) and dystocia (n = 6) groups. The birth weight of the offspring was moderately positively correlated with the AUC of serum PAGs S-N values and E1S concentrations in the second (r = 0.425, P < 0.01) and third (r = 0.595, P < 0.01) trimesters, respectively. The ratio of change in serum E1S concentrations between 70 and 280 days after AI was greater (P < 0.05) in the dystocia group (1276.6 ±â€¯229.1 %) than in the eutocia group (852.6 ±â€¯69.6 %). These results suggest that blood PAGs S-N values at mid-pregnancy (100-199 days after AI) and the ratio of changes in blood E1S concentrations between 70 and 280 days after AI may be new parameters for predicting dystocia.

Perinatal mortality in German dairy cattle: Unveiling the importance of cow-level risk factors and their interactions using a multifaceted modelling approach.

Perinatal mortality (PM) is a common issue on dairy farms, leading to calf losses and increased farming costs. The current knowledge about PM in dairy cattle is, however, limited and previous studies lack comparability. The topic has also primarily been studied in Holstein-Friesian cows and closely related breeds, while other dairy breeds have been largely ignored. Different data collection techniques, definitions of PM, studied variables and statistical approaches further limit the comparability and interpretation of previous studies. This article aims to investigate the factors contributing to PM in two underexplored breeds, Simmental (SIM) and Brown Swiss (BS), while comparing them to German Holstein on German farms, and to employ various modelling techniques to enhance comparability to other studies, and to determine if different statistical methods yield consistent results. A total of 133,942 calving records from 131,657 cows on 721 German farms were analyzed. Amongst these, the proportion of PM (defined as stillbirth or death up to 48 hours of age) was 6.1%. Univariable and multivariable mixed-effects logistic regressions, random forest and multimodel inference via brute-force model selection approaches were used to evaluate risk factors on the individual animal level. Although the balanced random forest did not incorporate the random effect, it yielded results similar to those of the mixed-effect model. The brute-force approach surpassed the widely adopted backwards variable selection method and represented a combination of strengths: it accounted for the random effect similar to mixed-effects regression and generated a variable importance plot similar to random forest. The difficulty of calving, breed and parity of the cow were found to be the most important factors, followed by farm size and season. Additionally, four significant interactions amongst predictors were identified: breed-calving ease, breed-season, parity-season and calving ease-farm size. The combination of factors, such as secondiparous SIM breed on small farms and experiencing easy calving in summer, showed the lowest probability of PM. Conversely, primiparous GH cows on large farms with difficult calving in winter exhibited the highest probability of PM. In order to reduce PM, appropriate management of dystocia, optimal heifer management and a wider use of SIM in dairy production are possible ways forward. It is also important that future studies are conducted to identify farm-specific contributors to higher PM on large farms.

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.

A rare case of adventitious placentation (diffuse semi-placenta) in a Jersey cow.

Placental abnormalities more frequently occur during pregnancy of somatic cell clones and may lead to pregnancy loss or dystocia. Adventitious placentation, or diffuse semi-placenta, is determined by the development of areas of accessory placentation between the cotyledons due to the abnormal growth of placentomes.After a full-term pregnancy, a 3-year-old Jersey heifer was referred for dystocia which resulted in the delivery of a dead calf. The cause of dystocia was found to be foetal malposition, while the placenta was physiologically expelled after dystocia resolution.Grossly, cotyledons appeared reduced in size and number in one placental horn, while the surface of the other horn was covered with microplacentomes. Numerous villous structures without trophoblastic coating were highlighted after histopathology. The dominant sign was an inflammatory reaction. The findings were consistent with inter-cotyledonal placentitis, which led to adventitial placentation.Diffuse semi-placenta compensates for the inadequate development of placentomes and may occur as a congenital or acquired defect. The outcome depends on its severity: in the worst scenario, pregnancy may not proceed beyond midterm and may be complicated by hydrallantois. In the case under examination, the dimensions of the cotyledons (from 2 to 10 cm) allowed for the natural course of pregnancy.

Dystocia in cattle and horses: a compilation of historical artworks dedicated to Professor Gerhard Sand (1861-1921).

Professor Gerhard Sand (1861-1921) was the first professor of veterinary obstetrics at the Royal Veterinary and Agricultural University, Copenhagen, Denmark. He began teaching the theory and practice of obstetrics to veterinary students in 1887 and spent the following years until his death in 1921 developing the veterinary obstetrics teaching program. During this period, veterinary obstetrics was established as an independent discipline at the Royal Veterinary and Agricultural University. Professor Sand's teaching had a major impact on the field of veterinary obstetrics in Scandinavia. He was devoted to teaching veterinary obstetrics and produced a number of obstetrical illustrations, some of which showed different causes of dystocia, mainly fetal malpresentation in cattle and horses. Professor Sand created the illustrations with the intention of publishing a handbook of obstetrics, but due to illness and an early death, this work was never completed. This compilation of historical artworks of dystocia in cattle and horses includes some of these illustrations and is published to honour Professor Sand, with the intention of making his illustrations widely available for the teaching of veterinary obstetrics.

Prescriptive and proscriptive lessons for managing shoulder dystocia: a technical and videographical tutorial.

This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment.

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Patient characteristics, surgery outcomes, presumed aetiology and other characteristics of fistula surgeries and related procedures supported by Fistula Foundation from 2019 to 2021: a multicentre, retrospective observational study.

OBJECTIVES: Obstetric fistula is a devastating childbirth injury primarily caused by prolonged, obstructed labour. It leaves women incontinent, severely stigmatised and isolated. Fistula repair surgery can restore a woman's health and well-being. Fistula Foundation, a non-profit organisation, works in partnership with local hospitals and community organisations in Africa and Asia to address key barriers to treatment and to increase the number of women receiving surgical care. This paper presents data on fistula and fistula repair surgery across a large global network of hospitals supported by Fistula Foundation. The data were collected between 2019 and 2021. DESIGN: Multicentre, retrospective, observational, descriptive study. SETTING AND PARTICIPANTS: The study analysed deidentified data from 24 568 surgical repairs supported by Fistula Foundation to treat women with obstetric fistula at 110 hospitals in 27 countries. RESULTS: The data highlight patient characteristics and key trends and outcomes from obstetric fistula repair surgeries and related procedures. Of those surgeries, 87% resulted in a successful outcome (fistula dry and closed) at the time of discharge, highlighting the effectiveness of fistula repair in restoring continence and improving quality of life. Over the period studied, the number of supported surgeries increased by 14%, but there remains an urgent need to strengthen local surgical capacity and improve access to treatment. Women suffered an average of 5.7 years before they received surgery and only 4% of women sought care independently. This underscores the importance of enhancing community awareness and strengthening referral networks. CONCLUSIONS: This research provides essential insight from a vast, global network of hospitals providing highly effective fistula repair surgery. Further investment is needed to strengthen surgical capacity, increase awareness of fistula and remove financial barriers to treatment if stakeholders are to make significant progress towards the United Nations' ambitious vision of ending fistula by 2030.

Resource setting impacts neonatal but not maternal survival in bitches treated for dystocia: 243 cases (2015-2020).

OBJECTIVE: To compare maternal and fetal outcomes of dystocia managed surgically and nonsurgically at referral hospitals (RHs) versus community medicine clinics (CMCs), determine the rate of C-section, and evaluate the incidence of hypoglycemia and hypocalcemia in bitches presented with dystocia. ANIMALS: Bitches presented with dystocia at 2 RHs and 2 CMCs. METHODS: Information on signalment, presence of hypoglycemia and/or hypocalcemia, diagnostic imaging performed, nonsurgical and surgical interventions performed, maternal and fetal outcomes, and total cost of care was obtained from the electronic medical records of bitches presenting for dystocia between October 2015 and October 2020. Descriptive statistics were performed and outcome compared between RHs and CMCs using a Fisher exact test, with a P < .05 considered significant. RESULTS: 230 bitches were evaluated with 243 separate episodes of dystocia, with 183 (75%) episodes treated at an RH and 60 (25%) at a CMC. There was a low incidence of hypoglycemia (5% [9/178]) and ionized hypocalcemia (1% [2/164]). Seventy-three percent (177/243) of bitches underwent surgical intervention, 25% (61/243) received nonsurgical management, and 2% (5/243) transferred to their primary veterinarian. There was no difference in survival for bitches operated at an RH compared with a CMC. However, bitches operated at an RH were more likely (P = .04) to be discharged with at least 1 live neonate. CLINICAL RELEVANCE: In bitches diagnosed with dystocia, hypoglycemia and hypocalcemia were rare. The majority of bitches underwent a C-section. The setting where the C-section was performed did not impact maternal survival.

Dystocia frequency and causes in horses with pregnancy disorders or a history of dystocia: A prospective study.

Dystocia typically presents a life-threatening condition for both the mare and the foal. This prospective long-term study aimed to ascertain whether mares with prior pregnancy disorders or a history of dystocia were at a higher risk of experiencing subsequent dystocia in comparison to those without such medical antecedents. To achieve this goal, the authors analysed 207 parturitions and 164 mares over a 10-year period. Of these, 57 were associated with pregnancy disorders or prior dystocia (Group 1), while 150 parturitions followed uneventful pregnancies in mares that had not yet experienced dystocia (Group 2). Mares in Group 1 were significantly more likely to develop dystocia than those in Group 2 (p = .0180; odds ratio = 2.98). Foetal causes of dystocia were more prevalent than maternal causes (p < .0389). Maternal mortality stood at 0.5%, and neonatal mortality reached 1.9%. The results demonstrate that mares are at significantly higher risk of developing dystocia after experiencing pregnancy disorders or parturition complications during previous pregnancies, emphasizing the need for systematic birth monitoring.

The improvement and retention of skills in shoulder dystocia management with the use of high-fidelity simulation: The SAFE (SimulAtion high-FidElity) study.

BACKGROUND: Shoulder dystocia is a relatively uncommon but serious childbirth-related emergency. AIM: To explore the improvement and retention of skills in shoulder dystocia management through high-fidelity simulation training. METHODS: The SAFE (SimulAtion high-FidElity) study was a prospective cohort study that utilised a high-fidelity birth simulator. Registered midwives and final year midwifery students were invited to participate in a one-day workshop at 6-monthly intervals. There was a 30-minute initial assessment, a 30-minute theoretical and hands-on training, and a 30-minute post-training assessment on shoulder dystocia management. Pre-training and post-training values for the predetermined outcomes were compared. In each workshop we assessed the proportion of successful simulated births, the performance of manoeuvres to manage shoulder dystocia, the head-to-body birth time, the fetal head traction force, the quality of communication, the perception of time-to-birth, and the self-reported confidence levels. FINDINGS: The baseline workshop recruited 101 participants that demonstrated a significant increase in the proportion of successful simulated births (8.9% vs 93.1%), and a two-fold to three-fold increase in the score of manoeuvres, communication, and confidence after training. Those with low pre-training levels of competency and confidence improved the most post-training at baseline. There was a retention of manoeuvres, communication skills and confidence at 6 months. There was no reduction in fetal head traction force over time. Those being proficient before initial training retained and performed best at the 6-month follow-up. CONCLUSION: The SAFE study found a significant improvement in skills and confidence after the initial high-fidelity simulation training that were retained after 6 months.

Climatic and calf-related risk factors associated with failure of transfer of passive immunity in Holstein calves in a hot environment.

This retrospective observational study aimed to assess the effect of temperature-humidity index (THI) at calving and in the last trimester of pregnancy and calve-related factors affecting passive transfer of maternal immunoglobulin using Brix refractometry in Holstein calves. Blood samples from 4411 Holstein calves from a single large dairy farm in spring 2022 were used. A subset of data containing 6318 calvings was used to determine the effect of climatic conditions on the occurrence of agammaglobulinemia. Risk factors predictive of failure of passive transfer (FPT) were calculated using multiple logistic models. Females were 1.4 times more likely not to have FPT (56%; Brix% > 8 equivalent to ≥ 10 g/L IgG) than males (47.2%). Calves born as singles increased the likelihood of not presenting FPT (52.6%) than calves born as twins (42.9%). Calves from cows with no dystocic delivery had a lower risk for FPT (odds ratio = 2.3) than calves from cows with dystocia. Agammaglobulinemia was 1.5 and 1.8 times more likely to occur in calves with THI ≥ 80 and ≥ 82 in the last trimester of gestation and at calving, respectively, than in calves not experiencing heat stress. Agammaglobulinemia was twice as likely to occur in male than in female calves. Calves with birth weight ≥ 37 kg and gestation length ≥ 275 kg were less likely to present agammaglobulinemia than lighter calves and calves with shorter gestation periods. This study raises questions for management practices in Holstein calves undergoing in utero heat stress and around calving to avoid agammaglobulinemia.

Assistência ao parto pélvico / Breech birth assistance

É imprescindível retomar o ensino da versão cefálica externa e das manobras tocúrgicas no parto pélvico vaginal, tanto em litotomia quanto na posição vertical. A adoção de protocolos rígidos para o parto pélvico vaginal planejado correlaciona-se com taxa de sucesso de aproximadamente 70% e taxas de resultados adversos inferiores a 7%. A morbimortalidade fetal e neonatal é semelhante à de cesárea planejada. Gestantes elegíveis para o parto pélvico vaginal devem concordar com a via de parto, possuir baixo risco de complicações e ser assistidas por profissionais com experiência em parto vaginal de apresentações anômalas e suas manobras obstétricas. Cesariana prévia e prematuridade entre 32 e 36 semanas não são contraindicações absolutas ao parto pélvico vaginal, devendo ser individualmente avaliadas na decisão da via de parto. Neonatologistas devem estar presentes no nascimento de fetos pélvicos, e um exame neonatal completo deve ser realizado. A rotação posterior do dorso fetal, o prolapso de cordão umbilical, a deflexão dos braços e/ou do polo cefálico e o encarceramento da cabeça derradeira são as principais distocias relacionadas à assistência ao parto pélvico por via vaginal. Todo profissional que assiste parto pélvico vaginal deve estar capacitado para a resolução adequada desses eventos. No parto pélvico vaginal em litotomia, as principais manobras para o auxílio ao desprendimento da pelve fetal são a tração inferior bidigital na prega inguinal e a manobra de Pinard; para o desprendimento do tronco fetal, as de Rojas, Deventer-Miler e Pajot; e para o desprendimento da cabeça derradeira, as de Mauriceau, Bracht, Champetier de Ribes e Praga e o parto vaginal operatório com o fórcipe de Piper. As posições não litotômicas no parto pélvico vaginal se associam à redução dos períodos de dilatação e expulsão, da taxa de cesariana, da necessidade de manobras para extração fetal e da taxa de lesões neonatais. No parto pélvico vaginal assistido na posição de quatro apoios, os aspectos a serem observados durante o desprendimento do corpo fetal incluem o tônus dos membros inferiores fetais, a rotação correta do tronco fetal (abdome fetal voltado para o dorso materno), o ingurgitamento vascular do cordão umbilical, a presença dos cotovelos e das pregas do tórax fetal e a dilatação anal materna. No parto pélvico vaginal assistido na posição de quatro apoios, mais da metade dos fetos se desprendem sem a necessidade de nenhuma manobra. Habitualmente, apenas duas manobras podem ser necessárias: uma para auxílio à saída dos ombros ("rotação 180°-90°") e outra para desprendimento da cabeça fetal ("Frank nudge").

Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report.

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries.

PURPOSE: Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb's and Klumpke's palsy and the use of ICD-10 code 066.0. METHODS: A retrospective, register-based case-control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006-2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes. RESULTS: The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb's palsy and increasing use of ICD-10 code O66.0. CONCLUSION: There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb's palsy and improved coding of shoulder dystocia.

Internal manual rotation in intrapartal arrest of fetal head engagement.

OBJECTIVE: The success of internal manual or digital rotation of the head in mechanical dystocia due to malpresentation, malposition or malrotation is presented in this paper on our own clinical material with reference of today's research and clinical recommendations. STUDY DESIGN: Through a retrospective bicentric clinical study, we investigated the success of internal head rotation in two University Clinics for gynecology and obstetrics from year 2017 to 2023. In 152 singleton term (37-42 weeks) in cases of persistens intrapartum arrest of the fetal head. After palpatory and ultrasonographically verified arrest of fetal head engagement, a therapeutic manual (Liepmann) or digital rotation was performed. RESULTS: In 152 cases, manual rotation was performed in 108 (71.05 %) and digital rotation in 44 (28.94 %) cases in 73 (48.02 %) primiparous and 79 (51.97 %) multiparous. Intrapartum identification by digital palpation was done in all cases, and the following are: persistent occipital posterior position in 68 (44.73%), persistent deep transverse head presentation in 12 (7.89%), persistent high (longitudinal) occipital presentation in 64 (42.10 %) and persistent anterior asynclitism in 8 (5.26 %) cases. Episiotomy was used in 36 (23.68%) cases. Vacuum extraction was completed in 14 (9.21 %) deliveries, and cesarean section due to unsuccessful internal rotation in 15 (9.8 %) cases (%) without other indication. We did not record any intrapartum complications or cardiotocographic abnormalities. Cervical lacerations were treated with sutures in 4 cases (2.63 %). Successful correction of internal rotation procedure with spontaneous vaginal delivery was found in 80.92 % of cases. If we exclude delivery assisted by vacuum extraction whose indications were fetal hypoxia or dystocia after successful internal head rotation procedure, then the success rate of this method was 90.13 %. CONCLUSION: Internal head rotation is a simple, safe and successful obstetric manual intervention that directly increases the rate of vaginal deliveries after correction of the birth mechanism anomaly and directly reduces the percentage of cesarean section. Manual or digital head rotation is an established midwifery/obstetric skill in several centers which, based on numerous clinical researches and experience, should become protocolized and included in the guidelines of professional associations.