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.

Repeat measurement of cervical length after successful tocolysis.

OBJECTIVE: To measure the ultrasonographic cervical length in undelivered women after successful tocolysis for preterm labor, and to determine whether this could improve the predictive value of cervical length measured before initiation of tocolysis on the risk of preterm delivery. METHODS: This was a prospective study of patients admitted and treated for uterine contractions at 24(+0) to 33(+6) weeks of gestation with a cervical length of 26 mm or less by transvaginal ultrasonography on admission. Intravenous tocolysis was stopped when delivery was delayed by 48 hours, and cervical length was remeasured before discharge. The primary outcome was preterm delivery, defined by a delivery before 37 weeks. Predictive analysis was based on logistic models, with estimated odds ratios and 95% confidence interval. RESULTS: One hundred and nine patients were included in the study. The median (first, third quartile) cervical length on admission was 18 (13, 22) mm. The median (first, third quartile) variation in cervical length after tocolysis was stopped was 3 (0, 8) mm, and ranged from -13 to 26 mm. The median (first, third quartile) time interval from tocolysis to delivery was 53.0 (35.0, 70.0) days, with 45 (41.3%) patients delivered before 37 weeks. After adjustment for cervical length before admission and parity and gestational age on admission, the assessment of the variation in cervical length after successful tocolysis did not improve the predictive value of transvaginal sonography for the risk of preterm delivery (odds ratio 0.97; 95% confidence interval 0.90-1.03; P = .27). CONCLUSION: To repeat ultrasonographic cervical length measurement after successful tocolysis for preterm labor is useless.