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PubMed2004

Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes.

OBJECTIVE: In severe shoulder dystocia, when initial maneuvers fail, either episiotomy or fetal manipulation (Rubin, Woods' screw, or posterior arm release) is recommended. We sought to compare maternal and neonatal outcomes between severe shoulder dystocia deliveries managed with episiotomy versus fetal manipulation. STUDY DESIGN: We identified severe shoulder dystocia deliveries from three databases: all shoulder dystocia deliveries (1993-2003 and 1994-1997) from two teaching institutions and litigated cases of shoulder dystocia-associated permanent brachial plexus palsy from multiple U.S. institutions. Pair-wise comparisons were made among three groups of deliveries: those managed by fetal manipulation without episiotomy (fetal manipulation-only), those managed by episiotomy without fetal manipulation (episiotomy-only), and those managed with both (episiotomy + fetal manipulation). Rates of brachial plexus palsy, neonatal depression, and anal sphincter trauma were compared among groups using chi 2 , with significance at P < .05. RESULTS: Among episiotomy-only, 13 of 22 (59.1%) sustained brachial plexus palsy, compared with 20 of 57 (35.1%) among fetal manipulation-only (P = .05). Twenty-eight of 48 (58.3%) in episiotomy + fetal manipulation had brachial plexus palsy, which did not differ from episiotomy-only (P = .95) but was higher than fetal manipulation-only (P = .02), suggesting that the addition of episiotomy conferred no benefit in averting neonatal injury. Anal sphincter trauma was significantly more common among episiotomy-only and episiotomy + fetal manipulation, compared with fetal manipulation-only. CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy.

Adult↗
PubMed2004

Dystocia in nulliparous patients monitored with fetal pulse oximetry.

OBJECTIVE: A critical analysis of the United States randomized controlled trial of fetal pulse oximetry concluded that nonreassuring fetal heart rate patterns used for study entry may have been a marker for dystocia. We prospectively studied nulliparous women in labor whose progress was monitored with fetal pulse oximetry to examine the relationship between nonreassuring fetal heart rate patterns and operative delivery for dystocia. STUDY DESIGN: A prospective nonrandomized observational cohort study compared two distinct classes of nonreassuring fetal heart rate patterns (class I: intermittent, mildly nonreassuring; class II: persistent, progressive, and moderate to severely nonreassuring) among nulliparous patients with the use of fetal pulse oximetry to confirm fetal well-being. Definitions of dystocia included the cessation of labor progress in the first (3 hours) or second (2 hours) stage of labor, despite adequate uterine activity that was assessed with an intrauterine pressure catheter. Independent review confirmed the classification of nonreassuring fetal heart rate patterns and study entry criteria. RESULTS: Two hundred seventy-four patients met study criteria and had sufficient information for fetal heart rate tracing interpretation. Two hundred thirty-seven patients (86.5%) were class II, and 37 patients (13.5%) were class I. The two classes of patients were comparable in a variety of obstetric, demographic, and perinatal variables. Twelve percent of all patients were delivered for nonreassuring fetal status. Significantly more class II patients (22%) were delivered by cesarean for dystocia than were class I patients (8%). Higher doses and a longer number of hours of oxytocin were required among class II patients. Significantly more occiput posterior positions were noted among all patients who underwent cesarean delivery for dystocia compared with other modes of delivery. CONCLUSION: Significantly nonreassuring fetal heart rate patterns predict cesarean delivery for dystocia among nulliparous patients with normally oxygenated fetuses in a setting of a standardized labor management protocol. This confirms the observations in the randomized controlled trial of fetal pulse oximetry in the United States and may provide insight into the treatment of nonprogressive labor in contemporary practice.

Cesarean Section↗
PubMed2003

Is maternal obesity a predictor of shoulder dystocia?

OBJECTIVE: To explore the relationship between maternal obesity and shoulder dystocia while controlling for the potential confounding effects of other variables associated with obesity. METHODS: We performed a case-control study of provincial delivery records audited by the Northern and Central Alberta Perinatal Outreach Program. Risk factors evaluated were selected based on previously published studies. Cases and controls were drawn from 45,877 live singleton cephalic vaginal deliveries weighing more than 2500 g between January 1995 and December 1997. There were 413 cases of shoulder dystocia (0.9% incidence). Controls (n = 845) were randomly chosen from the remainder of the target population to create a 1:2 case/control ratio. Univariate analysis with calculation of odds ratios (ORs) was used to determine which of the chosen risk factors were significantly related to the incidence of shoulder dystocia. Multivariable regression analyses were then used to determine the independently associated variables, and the adjusted ORs were obtained for each relevant risk factor. RESULTS: Maternal obesity was not significant as an independent risk factor for shoulder dystocia after adjusting for confounding variables (adjusted OR 0.9; 95% confidence interval [CI] 0.5, 1.6). Fetal macrosomia was the single most powerful predictor. The adjusted ORs were 39.5 (95% CI 19.1, 81.4) for birth weight greater than 4500 g and 9.0 (95% CI 6.5, 12.6) for birth weight between 4000 and 4499 g. CONCLUSION: The strongest predictors of shoulder dystocia are related to fetal macrosomia. For obese nondiabetic women carrying fetuses whose weights are estimated to be within normal limits, there is no increased risk of shoulder dystocia.

Comorbidity↗
PubMed2006

Shoulder dystocia at noninstrumental vaginal delivery.

This study examines the relationship between episiotomy and the occurrence of shoulder dystocia among noninstrumental vaginal deliveries. Analysis of data from a retrospective database was used to study noninstrumental vaginal deliveries in New Jersey during the years 1996 to 2001. The episiotomy group and nonepisiotomy group were analyzed separately using univariate and multivariate analysis. Among 358,664 deliveries, rate of shoulder dystocia was 1.0% (n = 3596). Thirty-five percent of deliveries were assisted by episiotomy. Rate of dystocia was 1.42% with the use of episiotomy, and 0.81% when episiotomy was not used. This increased rate with episiotomy was noted across all of the racial groups, all birthweight categories, and all of the risk factor subgroups analyzed. There was a gradual decrease in the use of episiotomy from 37.30 to 26.03% without a corresponding increase in the rate of dystocia. Among noninstrumental deliveries, the rate of shoulder dystocia is higher in the episiotomy group. Decrease in the use of episiotomy has not resulted in an increase in the occurrence of dystocia.

Adolescent↗
PubMed1993

Effect of early amniotomy on the risk of dystocia in nulliparous women. The Canadian Early Amniotomy Study Group.

BACKGROUND: Early amniotomy has been advocated as a means of preventing dystocia, but its efficacy has not been studied prospectively. The purpose of this multicenter study was to determine whether routine early amniotomy reduces the risk of dystocia for nulliparous women in spontaneous labor. METHODS: We studied 925 nulliparous women in labor, who were stratified according to the degree of cervical dilatation (< 3 cm vs. > or = 3 cm) and randomly assigned to either early rupture of the membranes (amniotomy group) or conservative management of labor (conservative-management group). Dystocia was defined as a period of at least four hours after dilatation of the cervix to 3 cm had been reached during which the mean rate of cervical dilatation was less than 0.5 cm per hour. RESULTS: Dystocia was significantly less frequent in the amniotomy group than in the conservative-management group (34 percent vs. 45 percent; relative risk, 0.8; 95 percent confidence interval, 0.6 to 0.9). The median length of time from randomization to full dilatation was 136 minutes shorter in the amniotomy group, and there was a trend toward less frequent use of oxytocin among the women assigned to amniotomy (36 percent vs. 41 percent; relative risk, 0.9; 95 percent confidence interval, 0.8 to 1.0). In a stratified analysis, the frequency of dystocia associated with amniotomy was reduced only among women with > or = 3 cm initial dilatation. The cesarean-section rate was similar in the two groups (amniotomy, 12 percent; conservative management, 11 percent). There were no statistically significant differences in outcome between the infants delivered by the women in the two groups; the measures of an adverse outcome included admission to a neonatal intensive care unit, five-minute Apgar score below 7, and arterial cord-blood pH below 7.2. CONCLUSIONS: Early amniotomy is an effective method of shortening the duration of labor and reducing the frequency of dystocia among nulliparous women in labor, but it does not lower the rate of cesarean section.

Adult↗
PubMed1988

Factors affecting dystocia and birth weight in Grati cattle in Pujon, East Java.

This paper discusses factors affecting dystocia and birth weight in Grati cattle in three villages in the Pujon district, East Java. Records of birth weight, dystocia score, village, season, parity, sex, artificial versus natural service, and age and weight of dam, were obtained from 268 parturitions. Village and weight of the dam had a significant effect on birth weight but not on dystocia. Parity had a significant effect on dystocia score. More abnormal births occurred with AI using exotic bulls. Calves from an abnormal birth were on average more than three kg heavier. First parity births combined with Al with exotic bulls had a particularly high incidence of dystocia. It is concluded that farmers in Pujon can reduce the incidence of dystocia in heifers by using local bulls only.

Animals↗
PubMed1998

Epidural labor analgesia and the incidence of cesarean delivery for dystocia.

UNLABELLED: We performed this retrospective study to examine the changes in cesarean delivery rates associated with the establishment of a labor epidural service. In April 1993, St. Louis Regional Medical Center established an on-demand labor epidural service. We obtained demographic data for all patients and reviewed the operative records of all patients undergoing cesarean section who delivered 12 mo before and 16 mo after the start of the labor epidural service. We compared labor epidural rates and total and nulliparous dystocia cesarean delivery rates before and after the epidural service started and among patients who did and did not receive labor epidural analgesia when it was available. Included were 3195 patients who delivered before and 3733 patients who delivered after epidural analgesia became available. Labor epidural rates were 1.2% vs 29.4% for the Before group versus the After group (P < 0.001). Total (9.1% vs 9.7%) and nulliparous dystocia (5.7% vs 6.4%) cesarean delivery rates did not significantly change with the availability of epidural analgesia. However, the total (11.6% vs 8.8%; P = 0.009) and dystocia (8.0% vs 1.0%; P = 0.001) cesarean delivery rates were higher among patients who received epidural analgesia when it was available. We conclude that epidural labor analgesia is associated with, but does not cause, cesarean delivery for dystocia. IMPLICATIONS: Increased epidural analgesia use did not change the overall dystocia cesarean delivery rate, although dystocia was more common among women who chose an epidural analgesia. Consequently, limiting epidural availability will not affect cesarean delivery rates. The evidence does not support advising patients that epidural labor analgesia increases the risk of cesarean delivery.

Adolescent↗
PubMed1999

The influence of the obstetrician in the relationship between epidural analgesia and cesarean section for dystocia.

BACKGROUND: The association between epidural analgesia for labor and the risk of cesarean section for dystocia remains controversial The authors hypothesized that if epidural analgesia were an important factor in determining cesarean section rates, then obstetricians with higher rates of utilization of epidural analgesia for labor would have higher rates of cesarean section for dystocia. METHODS: The frequency of use of epidural analgesia and frequency of occurrence of various patient risk factors for cesarean section were calculated for 110 obstetricians caring for > or = 50 low-risk parturients. These frequencies were compared by linear regression to obstetricians' rates of cesarean section for dystocia. Stepwise regression was used to attempt to predict obstetricians' cesarean rates from the incidence of various patient and provider risk factors. RESULTS: There was no relationship between frequency of epidural analgesia and rate of cesarean section for dystocia across practitioners (R2 = 0.019; P = 0.156). Weighting each obstetrician's data for the number of patients cared for during the study period did not change this result. Stepwise linear regression only modestly predicted obstetricians' cesarean section rates for dystocia, yielding a model containing 12 variables not including epidural analgesia (gestational age, induction of labor, maternal age, provider volume, nulliparity, and seven interactions; adjusted R2 = 0.312; P < 0.0001). CONCLUSIONS: The frequency of use of epidural analgesia does not predict obstetricians' rates of cesarean section for dystocia. After accounting for a number of known patient risk factors, obstetrical practice style appears to be a major determinant of rates of cesarean section.

Adult↗
PubMed1995

Obstructed labor and shoulder dystocia.

Dystocia of labor has become one of the leading indications for operative delivery during the past few years. Dystocia of the first stage of labor complicates 8-11% of all vertex delivery, and in the second stage of delivery it is at least as common. Dystocia may result in part from three factors: uterine activity, the fetus, and the pelvis. In each case of abnormal labor, assessment should be made according to those criteria. Shoulder dystocia is an infrequent, unanticipated, and unpredictable nightmare for the obstetrician. Although it is difficult to predict shoulder dystocia, effort should be made to prevent it. Tight glucose control in the management of diabetic patients will reduce the incidence of macrosomic fetuses. Cesarean section should be considered for diabetic women carrying fetuses with estimated fetal weight of greater than 4250g and for non-diabetic women carrying fetuses with estimated fetal weight of greater than 4500g. In all cases good clinical judgement can reduce the rate of shoulder dystocia. However, in some cases it remains a problem for the obstetrician and because it occurs so rarely, the care provider may have limited skills to manage this condition.

Dystocia↗
PubMed1976

The incidence of dystocia in Dorset Horn ewes.

The incidence of dystocia was recorded in flocks of Dorset Horn ewes lambing in winter, spring or summer and grazed at 8, 12 or 16 ewes per hectare over a ten-year period. The mean incidence of dystocia was 34% of ewes lambing. Significantly more ewes experience a difficult birth at winter (35%) and spring (39%) than summer (26%) lambings. Neither stocking rates nor pre-lambing ewe bodyweight were related to the incidence of dystocia. The incidence of dystocia was significantly greater in 2-year-old ewes than in any other age group. Foetal size was of major importance in the occurrence of dystocia. Approximately 60% of single and twin born lambs that had birth weights greater than 4.5 kg had a difficult birth whereas in lambs weighing less than 3.2 kg only about 10% were affected. Thirty-six per cent of all perinatal mortality was attributable to dystocia. Approximately 27% of single and 73% of twin presentations in assisted births were abnormal, 31% of all lambs assisted had 1 or both legs retained, 4% had posterior (including breech) presentations and the remaining 8% were of varied forms of malpresentation. Significantly more single male than female lambs experienced a difficult birth and the mean birth weights of single, twin and triplet born lambs that had a difficult birth were greater than the birth weights of singles, twins and triplets born normally.

Animals↗
PubMed1990

Twinning in cattle: III. Effects of twinning on dystocia, reproductive traits, calf survival, calf growth and cow productivity.

An evaluation of natural twinning in beef cattle revealed that cows birthing twins had shorter (P less than .01) gestation lengths, more (P less than .01) retained placentas, more (P less than .01) dystocia, more (P less than .01) days to estrus, lower (P less than .01) conception rates and more (P less than .01) days to pregnancy than cows birthing singles. Days to estrus, conception rate and days to pregnancy were not affected by number of calves reared (1 vs 2) in cows birthing twins. Survival at birth was greater (P less than .01) for single- than for twin-born calves, but twins and singles did not differ (P greater than .05) in postnatal survival. When dystocia was experienced, calf survival at birth was 95% vs 73% for singles vs twins compared with 99% vs 92% when no dystocia was experienced. Calves born twins were lighter (P less than .01) at birth, 100 d and 200 d, but twins and singles did not differ in postweaning gains. Total calf weights at 100 d per cow calving were 12% greater (P less than .01) in cows birthing twins vs singles when twin calves reared by foster dams were excluded. The potential increase in cow productivity for total calf weight at 100 d is 40% if calf survival rates of twins with dystocia relative to survival rates of twins without dystocia were comparable to survival rates of singles with and without dystocia, and if cows birthing twins were fed and managed to obtain conception rates equal to those of cows birthing singles. Identification of cows gestating twins to provide for their higher prepartum nutritive requirements and calving assistance at parturition is necessary to make twinning in cattle an economically viable technology.

Age Factors↗
PubMed1996

Effects of twinning on dystocia, calf survival, calf growth, carcass traits, and cow productivity.

This paper reports results from a long-term experiment with a primary objective to increase twinning rate in cattle at the Roman L. Hruska U.S. Meat Animal Research Center. Survival of singles was 13% higher (P < .01) than that of twins at birth, and the difference in survival in favor of singles was of similar magnitude at 72 h (12.9%, P < .01), 150 d (14.8%, P < .01), and 200 d (15.2%, P < .01). Survival of calves with no dystocia was higher than survival of calves with dystocia: 8.6% (P < .01) at birth, 10.8% (P < .01) at 72 h, 12% (P < .01) at 150 d, and 12.2% (P < .01) at 200 d. The effect of dystocia on survival was greater (P < .01) in twins than in singles at birth and at 72 h. Least squares means for dystocia were 20.4% in singles compared with 42.2% in twins. Most of the dystocia in singles resulted from a traction requirement (84.7%) of normal presentations, whereas most of the dystocia in twins (77.8%) resulted from malpresentations, with 59.2% of the malpresentations accompanied with a requirement for traction. Survival in singles ranged from 10.7% to 15.3% greater than in twins at different ages when there was no requirement for assistance in either singles or twins. Calves born as singles were 8.8 kg heavier (P < .01) at birth and 28 kg heavier (P < .01) at 200 d than calves born and reared as twins. Calf weight produced per cow calving was 53.1%, 54.7%, and 58.4% greater (P < .01) at birth, 150 d, and 200 d, respectively, in cows producing twins than in cows producing singles. Cows producing twins had 65.2% more (P < .01) live calves at 200 d than cows producing singles. Single male calves gained 74 g more per day than twin males from birth to 200 d, 45 g more (P < .01) per day from 200 d to slaughter and 57 g more (P < .01) per day from birth to slaughter. Differences between twin and single males in carcass traits were small. A sample of steers from the Twinning Project gained significantly faster and produced significantly more desirable carcasses than a sample of steers from a high performance reference population. Freemartins did not differ (P < .05) from normal females in growth traits, but freemartins had higher (P < .05) scores for marbling with a higher percentage (P < .05) of USDA Choice or better quality grade carcasses and lower estimated percentage retail product.

Analysis of Variance↗
PubMed1991

Genetic analysis of dystocia in dairy cattle.

Breeding values and genetic parameters for dystocia were estimated in Normande and Holstein breeds. Dystocia scores were related to an underlying continuous variable via a threshold model. The underlying linear model included the effects of calving season, sex of calf by parity of dam, sire of calf, grandsire of calf, dam within maternal grandsire and herd-year effects. Typical results were found for the environmental effects, with a strong influence of dam parity on dystocia, a strong influence of sex of calf, and a small effect of calving season. Herd-year variances were 32 and 40% of the residual variance in the Normande and Holstein breeds, respectively. Heritabilities for the Normande (Holstein) breed were .08 (.07) for direct effects and .11 (.07) for maternal effects. Correlations between sire and grandsire effects were .51 and .36 for the Normande and Holstein breeds, respectively. The corresponding correlations between direct and maternal effects were .15 and -.09. The results of this study show that a complete model for dystocia including the threshold concept and maternal effects can be applied for routine evaluation of dairy AI bulls. Maternal effects are important, and they should be considered in dystocia analysis, especially if nonrandom mating is present. Selection for reducing dystocia in calf and cow effects are not antagonistic.

Animals↗
PubMed1990

Diagnosis of dystocia and management with cesarean section among primiparous women in Ottawa-Carleton.

We carried out a chart review study to determine the rate of diagnosis of dystocia (abnormal progress) and the use of cesarean section to treat dystocia among 3887 primiparous women who gave birth to a single baby in the vertex presentation at four hospitals in Ottawa-Carleton in 1984. Of the 3740 women who had some labour 1127 (30.1%) were given a diagnosis of dystocia. Cesarean section for dystocia was done during all phases of labour (41% of procedures in the latent phase, 38% in the active phase and 21% in the second stage). The cesarean section rate varied among the hospitals from 11.8% to 19.6%. A total of 75% of the cesarean sections were for dystocia, disproportion or failed induction. The findings suggest that cesarean section is being done for disproportion without a trial of labour beyond the latent phase and for dystocia in the absence of fetal distress. If these practices were modified the cesarean section rate could be reduced from 16% to about 8%, the rate found in some other centres and that observed in Canada in the early 1970s.

Adult↗
PubMed2000

Review of shoulder dystocia at the Birmingham Women's Hospital.

A retrospective audit was performed of all deliveries between 1 January 1991 and 31 December 1995 at the Birmingham Women's Hospital, the main University Teaching Hospital in the West Midlands. This was performed by using the computer database of all hospital deliveries, at the Women's Hospital during the above-mentioned period, by entering a CCL code for shoulder dystocia. During that period of time there were 28 932 deliveries with a mean caesarean section rate of 16.7%. One hundred and fifty-four cases were identified, of which 134 case notes were available for review. The incidence of shoulder dystocia was 0.53%. Audit was performed of pre-pregnancy, antepartum and intrapartum risk factors, the severity of shoulder dystocia, the category of person delivering the baby, fetal outcome at birth and subsequent pregnancy outcome in cases of those with subsequent pregnancies. Overall, the majority of cases of shoulder dystocia were mild, and dealt with by midwives (101 cases 74%). No severe cases were encountered, however three out of eight moderate cases delivered by obstetricians had evidence of fetal trauma (one Erbs palsy and two limb fractures). Twenty women had a pregnancy after the pregnancy complicated by shoulder dystocia. Of these, 18 women delivered vaginally and there were two cases (10%) of repeat shoulder dystocia.

Journal Article↗
PubMed1987

Shoulder dystocia: predictors and outcome. A five-year review.

Shoulder dystocia is an uncommon complication of delivery with a high morbidity rate. Ninety-one cases were coded for shoulder dystocia at the Toronto General Hospital from 1980 through 1985. True shoulder dystocia was found in 24 cases, an incidence of 0.23%. There was no significant difference in average weight and percentage of macrosomia between cases of true shoulder dystocia and those merely coded as such. True shoulder dystocia was associated with a neonatal morbidity rate of 42%, consisting of a respiratory arrest and neurological and orthopedic damage. Fundal pressure, in the absence of other maneuvers, resulted in a 77% complication rate and was strongly associated with orthopedic and neurologic damage. Delivery of the posterior shoulder and the corkscrew maneuver were associated with good fetal outcome.

Delivery, Obstetric↗
PubMed1988

Shoulder dystocia: its incidence and associated risk factors.

A case-control study (73 cases, 146 controls) was conducted to evaluate maternal, obstetrical and fetal factors associated with shoulder dystocia. Several factors were identified that were associated with a higher incidence of shoulder dystocia. However, none of them accurately predict those deliveries that will be complicated by shoulder dystocia. Among the 73 shoulder dystocia cases there were no perinatal deaths and all birth-related injuries associated with shoulder dystocia were temporary except for two cases of mild muscular weakness among 12 brachial palsy cases.

Birth Injuries↗
PubMedDate not supplied

Management of anticipated and actual shoulder dystocia. Interpreting the literature.

Shoulder dystocia is a rare but serious obstetric complication that can result in significant neonatal and maternal morbidity and in costly litigation. Conflict exists in the literature regarding definition, incidence, predictability and preventability, relationship to neonatal injury, and appropriate management models. Anticipatory clinical interventions for potential shoulder dystocia have included ultrasound assessment of macrosomia; elective induction of labor; elective caesarean section; altered place of birth; and generous episiotomy/episioproctotomy. The authors note that these interventions often conflict with client desires and nurse-midwifery philosophy of birth, generate significant risks and costs in themselves, and do not address the poor predictability of shoulder dystocia. In recent literature, the safety and efficacy of maternal position change maneuvers (such as McRoberts maneuver, hands-knees position, and squatting) have been presented as methods to resolve most cases of shoulder dystocia. Despite the success of these more benign, external maneuvers, the episiotomy mandate remains in nearly all obstetric and midwifery texts and handbooks (1-8) and journal references (9-19). A literature review of related professional disciplines was undertaken to study these conflicts and to identify support for applying a philosophy of minimal, appropriate intervention to the complex issue of shoulder dystocia.

Delivery, Obstetric↗