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PubMed2000

Management of shoulder dystocia.

OBJECTIVE: We sought to determine the management of shoulder dystocia currently practiced by physicians in the Middle Tennessee region and the frequency of use of the all-fours (Gaskin) maneuver in clinical practice. METHODS: A questionnaire was developed and sent to physicians in the Middle Tennessee area, asking how they would manage shoulder dystocia in specific practice scenarios. RESULTS: The methods most commonly used to manage shoulder dystocia are episiotomy, the McRoberts maneuver, and suprapubic pressure. Twenty-four percent of practitioners listed more than four options for the management of shoulder dystocia. Only 8% of those surveyed claimed knowledge of and use of the all-fours maneuver. CONCLUSION: Educational programs should be developed to inform practitioners of additional options for the management of shoulder dystocia.

Algorithms↗
PubMed2001

Features of shoulder dystocia in a busy obstetric unit.

OBJECTIVE: To assess the incidence and complications of shoulder dystocia and whether those complications could be avoided. STUDY DESIGN: Retrospective analysis of shoulder dystocia between 1996 and 1999 to determine whether macrosomia, diabetes, height of head at full dilatation, length of second stage or instrumental delivery could predict shoulder dystocia. Fetal asphyxia, brachial plexus injury, maneuvers used to free the shoulders and experience of the attendant were also assessed. RESULTS: There were 56 cases of shoulder dystocia in 24,000 births, 59% after spontaneous delivery. McRoberts maneuver was used in 48 deliveries but sufficed as a solitary procedure in nine cases. The addition of suprapubic pressure was sufficient for 25 patients and 27 when bilateral episiotomy was also used. Corkscrew procedures were required in 12 patients. Midwives were involved in 35 cases and required assistance in 27. Macrosomia > 4,000 g was a feature in 20 infants and diabetes in 6. Neither the height of the head nor the length of the second stage was helpful. There were 13 cases of Erb's palsy, seven after vacuum delivery and six after spontaneous delivery. Eight of these cases were associated with McRoberts procedure and suprapubic pressure, two with no procedure and three with the corkscrew procedure. CONCLUSION: If all infants > 4,000 g had been delivered by cesarean section, there still would have been 36 cases of shoulder dystocia. If the ultrasonically estimated weight were used to select patients for cesarean section, seven cases would have been diagnosed. To lessen the degree and incidence of fetal injury, labor ward staff are urged to become as familiar as possible with the techniques of freeing the shoulders.

Asphyxia Neonatorum↗
PubMedDate not supplied

[Investigations about kind and frequency of mechanical dystocia in ewes with special regard to the vaginal prolapse ante partum].

The incidence of dystocia from ewes in nine lambing periods (1992-2000) was recorded at an obstetrical clinic. First we analysed parturition difficulties in normal pregnant sheep (group 1, n = 229). In the second group parturitions of ewes with vaginal prolapse ante partum were investigated (n = 129). In group 1 maternal causes of dystocia occurred more often than fetal ones (50% maternal, 45% fetal). In maternal parturition difficulties ringwomb was the dominating reason (64%), while abnormal presentations, position and/or posture of the lambs occurred most frequently in fetal dystocia (67%). But there was no statistical influence of age and number of parturitions in both groups. The average of the first notice of prolapsed vaginal tissue was 11 days before lambing. There was a predominance in the affection of sheep at first and second pregnancy (52%). Only 26% of the group 2 sheep had a spontaneous delivery. In 58% of the cases a dystocia was diagnosed. A preterm caesarean section had carried out in 12%, five ewes died before parturition because of septicemia (4%). Sheep suffering from vaginal prolapse ante partum showed maternal caused dystocia significant more frequently than members of group 1 (p < 0.001), with ringwomb as dominating reason (70%). The number of born lambs was significant higher in group 2 than in group 1 (p = 0.019).

Age Factors↗
PubMed2003

[The incidence of cervical dystocia and disorders of cervical involution in the post partum cow].

The aim of this study was to obtain information on the frequency of cervical dystocia and involution disorders of the canalis cervicalis after difficult dystocia and to characterise factors possibly influencing these pathological conditions. Therefore 317 difficult births in the cow (extraction: 123; foetotomy: 82; caesarean section: 112) and the involution of the cervical canal were documented during the first ten days post partum. In total a cervical dystocia could be diagnosed 53 times (16.7% related to the total number of births). This kind of birth disorder is regularly followed by a caesarean section (p < 0.001). Animals who show a narrowness in the cervix were older than the cows without cervical dystocia (p < 0.05). The same correlation could be detected for the number of births. Animals with delivery problems associated with the cervix had already given birth to more calves than cows who were not affected by cervical disorders (p < 0.01). 58 cows developed a disorder of the cervical involution (18.3% related to the total number of deliveries). This puerperal disorder can be frequently observed after foetotomy (p < 0.001). A correlation between the incidence of disorders of cervical involution and the age or the parity of the animals could not be detected. In the same way, cows with a diagnosis of a cervical dystocia did not develop more frequently disorders of cervical involution than animals who showed a physiological dilation of the cervical canal intra partum.

Age Factors↗
PubMed2004

[Shoulder dystocia--risk factors and fetal outcome].

The purpose of this retrospective study is to evaluate the perinatal outcome in cases with birth injuries, suggesting shoulder dystocia. This survey involves 92 cases of live newborns (gestational age between 37 and 42 weeks) with shoulder injuries. Another control group of 120 cases of live mature newborns without any shoulder injuries is studied for comparison. There are no significant differentialities between those two groups, regarding age, parity, weight and height of the parturients. Shoulder dystocia is most frequently found in newborns of 3500-4000 g birthweight. Antepartum, risk factors for shoulder dystocia are: diabetes, obesity of the mother and chronological postterm pregnancy. Intrapartum, the evaluated risk factors prove to be unreliable because the same were found in as many as one half of the non-traumatic vaginal deliveries. In 27% of the cases, shoulder dystocia occurs most probably after the passage of the shoulder through the pelvic inlet. The most frequent type of shoulder injury is fracture of the clavicle (90.2%), followed by paresis of the brachial plexus (7.6%). Severe shoulder dystocia both from obstetrical and neonatological point of view is found in 2-3% of the cases.

Adult↗
PubMed1992

Progesterone concentrations in maternal and fetal serum are lower during functional dystocia than in normal labor.

Concentrations of progesterone and estradiol (E2) were measured in parturient serum and in fetal cord serum during normal labor and in women with functional dystocia. In the study group, there were no cases of cephalopelvic disproportion. In oxytocin-resistant dystocia, the course of labor could not be corrected with oxytocin. To ascertain the effect of oxytocin, we included a number of women whose labor had been induced with oxytocin, followed by normal cervical dilatation and descent of the fetus. All the parturients were grouped retrospectively into those with normal labor and those with dystocia, based on previous definitions. The serum concentrations of progesterone in both the fetal cord and maternal vein were found to be significantly lower in the oxytocin-resistant dystocia group than in women in spontaneous normal labor and those with oxytocin-induced labor and normal progression (P less than .05-.005). Oxytocin had no evident effect on the serum concentration of either progesterone or E2, nor did concentrations vary following epidural blockade. Serum E2 concentrations in the maternal vein were similar in all delivery groups. Fetal cord E2 serum concentrations were similar in all vaginal deliveries. Women with the most severe oxytocin-resistant dystocia, delivered by cesarean, had significantly lower serum concentrations of E2 in fetal cord serum compared with the vaginally delivered women (P less than .001).

Dystocia↗
PubMed1990

Shoulder dystocia-a review at the Department of Obstetrics and Gynaecology, Alexandra Hospital, Singapore.

Shoulder dystocia is associated with a high incidence of perinatal morbidity, mortality and maternal morbidity. The present study was undertaken to review all the cases of shoulder dystocia at the Department of Obstetrics and Gynaecology, Alexandra Hospital during a 11-year period from January 1978 until December 1988. The incidence of shoulder dystocia in this series was 1:1739 deliveries or 0.05%. The constant awareness of the possibility of rapid development of shoulder dystocia with its potentially dangerous consequences should always be kept in mind. Shoulder dystocia drills should be held regularly in the resident training programme.

Dystocia↗
PubMed1990

[Shoulder dystocia; a retrospective study].

A retrospective study was made of the incidence in The Netherlands in 1987 of shoulder dystocia in women delivered vaginally of a child with cephalic presentation and a birth weight of 2,500 g or more. Patient data were obtained from the LVR (Landelijke Verloskundige Registratie, National Obstetric Registration). Shoulder dystocia, coded in the LVR form as 'problems with the shoulders', was reported for 844 out of 54,820 parturitions (1.5%). Study of files of the St. Joseph Hospital, Eindhoven, for the period 1983-1987 revealed a frequency of shoulder dystocia of 1.5% (56 out of 3,642 births), in good agreement with the nationwide incidence. The concordance between the LVR code 'problems with the shoulders' and shoulder dystocia as mentioned in the childbirth reports of our hospital was 94%. It is pointed out that familiarization with the manipulations for shoulder dystocia is desirable, and that these should be carried out in a fixed sequence.

Brachial Plexus↗
PubMed1988

Outcome of trial of labor in patients with a single previous low transverse cesarean section for dystocia.

The purpose of this prospective investigation was to evaluate the outcome of trial of labor in women with a history of a single low transverse cesarean section for dystocia in comparison with the outcome in women with a history of cesarean delivery for a reason other than dystocia. During the study period, 89 of 131 patients (68%) with a history of dystocia had a successful trial of labor, compared with 78 of 96 women (81%) who had cesarean delivery for a reason other than dystocia (P less than .025). Within the former group, 79% of women who originally had surgery while still in the latent phase of labor had a successful trial of labor, compared with 61% (.05 less than P less than .10) of patients who had an arrest of dilation in the active phase of labor and 65% (not significant) of those who had an arrest of descent. The only serious complication among study patients was a single instance of uterine scar dehiscence (0.5%). We conclude that approximately two-thirds of patients with a previous cesarean delivery for dystocia will have a successful trial of labor. Of these women, those individuals whose initial operation was performed in the latent phase of labor appear to have the best prognosis for subsequent vaginal delivery.

Abdomen↗
PubMed1994

[Planned delivery by oxytocin infusion in relation to cephalic dystocia].

To investigate the effect of initiating labor by oxytocin infusion on the outcome of delivery in cephalic presentation, the dystocia rate and final modes of delivery were analyzed in 3,090 cases of head presentation using oxytocin infusion and 2,982 cases with spontaneous onset of labor as control group. The results showed that 562 of the cases using oxytocin developed cephalic dystocia, a rate of 18.2%, while 371(12.4%) of the control group had dystocia. Besides, cephalic dystocia, rates of episiotomy, vacuum extraction and cesarean section were all significantly higher in the oxytocin group than those in the control (P < 0.005). Data also showed that the higher dosage, the more frequency and the longer time of pitocin infusion the higher the rate of dystocia.

Dystocia↗
PubMed1998

Dystocia: is it a major indication for caesarean section?

OBJECTIVE: To find out the indications for caesarean sections, the contribution of "dystocia" to the overall caesarean section rates, and to find ways to reduce dystocia-induced caesarean sections. METHOD: This was a retrospective study where all caesarean sections performed in 1995 at the Princess Badeea Teaching Hospital in North Jordan (the main teaching and referral hospital in the area) were reviewed. RESULTS: The caesarean section rate for 1995 was 8.4%. Dystocia was the main indication in 13.4% of all caesarean sections in that year. In 80.2% of patients who delivered because of dystocia labour started spontaneously. Thus if we advocate active management of labour, especially in nulliparous women who start labour spontaneously due to dystocia, we may reduce caesarean section and many repeat caesarean sections could be avoided. CONCLUSIONS: Applying a policy of active management of labour in nulliparous women may be the most useful approach to reduce caesarean section rates in modern obstetric practice.

Cesarean Section↗
PubMed1993

Pelvic growth, calf birth weight and dystocia in Holstein x Hereford heifers.

The pelvic area was measured in 129 Holstein x Hereford heifers at 10, 16 and 22 months of age. The heifers were fed an all forage diet. Pelvic growth was not linear over time, changing from an increase of 0.27 +/- 0.2 cm(2)/day during the first 6 months of the study to 0.13 +/- 0.13 cm(2)/day during the last 6 months (P<0.01). The relationship of pelvic area to body weight, height at hooks, and distance from hooks to pins did not change with age, and a moderate correlation between the pelvic area and these other measures (R=0.20 to 0.80) was noted. The pelvic area was measured within 24 hours after calving in 76 of the heifers. The rate of increase of pelvic area/day increased significantly (P < 0.01) in the month prior to calving from 0.14+/-0.13 cm(2) to 1.15 +/- 0.88 cm(2). As a result, the pelvic area at calving had a moderate correlation (R=0.29 to 0.52) to the pelvic area prior to calving. Logistic regression and discriminant analysis techniques were used to model the influence of the pelvic area and calf birth weight on the incidence of dystocia. Ratio of the pelvic area at calving to calf birth weight significantly (P < 0.01) influenced the incidence of dystocia. Logistic regression techniques were not superior to discriminant analysis; both correctly predicted 73% of the cases. Pelvic area measurement at any time other than calving was not associated with dystocia (P >0.05). Pelvic area and calf birth weight are important determinants of dystocia in heifers. The high degree of variation noted in pelvic growth, in particular during the month prior to calving, resulted in low correlation between pelvic area at calving and the precalving measurement. Therefore, we were not able to predict dystocia by measuring the pelvic area prior to calving.

Journal Article↗
PubMedDate not supplied

Shoulder dystocia and operative vaginal delivery.

Our objective was to determine the factors involved in the development of shoulder dystocia in association with operative vaginal delivery. In this prospective study, patients who were candidates for operative vaginal delivery were randomized either to forceps (N = 315) or vacuum with M-cup (N = 322) and timed from initial placement of instrument to final delivery. Data were gathered prior to and after instrumental delivery. Statistics used were Pearson chi square, Fisher's exact, analysis of variance, and multiple logistic regression. There were a total of 21 patients with shoulder dystocia in both groups (3.3% incidence). Discriminant factors that did nor meet significance included use of epidural analgesia (P = .12), station (P = .99), previous vaginal delivery (P = .99), fetal gender (P = .54), indication for operative vaginal delivery (P = .63), > 45 degrees rotation (P = .68), use of episiotomy (P = .62), maternal weight (P = .26), and maternal diabetes (P = .08). Nearly attaining significance in univariate analysis was randomization to vacuum (P = .052). Significant factors included gestational age (P = .03), time required to effect delivery (P = .007), and birthweight (P = .0001). When these factors were subjected to stepwise multiple logistic regression, three factors remained as significant associations with shoulder dystocia: randomization to vacuum (P = .04), time for delivery (P = .03), and birthweight (P = .0001). In this operative vaginal delivery trial, shoulder dystocia was strongly associated with large fetal size, longer time to delivery, and the use of vacuum for delivery.

Birth Injuries↗
PubMed2005

Shoulder dystocia: a comparison of patients with and without diabetes mellitus.

BACKGROUND: The study was aimed to compare pregnancies complicated with shoulder dystocia, of patients with and without diabetes mellitus. METHODS: A comparison of all singleton, vertex, term deliveries between the years 1988-1999, complicated with shoulder dystocia with and without diabetes mellitus was performed. Statistical analysis was done using receiver operating characteristic curve analysis. RESULTS: Using a receiver operating characteristic curve analysis, the area under the curve for birth weight was 0.92 (95% CI 0.90-0.93). However, for birth weight of 4,000 g the sensitivity was only 56% with specificity of 95%. While comparing shoulder dystocia between patients with (n=38) and without diabetes mellitus (n=207), neonates of the diabetic patients were significantly heavier (mean birth weight 4,244.2+/-515.1 vs. 4,051.6+/-389.5; P=0.008) and had higher rate of Apgar scores lower than 7 at 1 min (50.0% vs. 25.9%; P=0.030), but not at 5 min (2.6% vs. 2.0%; P=0.083) when compared to the non-diabetic group. No significant differences were noted regarding perinatal mortality between the groups (0% vs. 4.3%; P=0.362). CONCLUSIONS: The newborn of the diabetic mother complicated with shoulder dystocia does not appear to be at an increased risk for perinatal morbidity compared with the newborn of the non-diabetic mother.

Adult↗
PubMed1987

Temporal variation in rates of cesarean section for dystocia: does "convenience" play a role?

The purpose of this study is to test the hypothesis that convenience for the physician plays a role in the rate of cesarean section performed because of dystocia. Three time periods were defined (night, 12 midnight to 7:59 AM; day, 8 AM to 5:59 PM; evening, 6 PM to 11:59 PM) based on the work commitments and daily routines of the obstetrician. Rates of cesarean section for dystocia were determined for each of the three time periods. An evening peak in the cesarean section rate is partially but not entirely explained by an evening increase in the proportion of patients in prolonged labor. When patients were stratified according to labor duration (less than 12, 12 to 15, and greater than 16 hours), a persistent evening excess in the rate of cesarean section for dystocia was observed for patients whose labor duration was less than 16 hours. Although this is interpreted as being consistent with the hypothesis of physician convenience, the magnitude of this effect on the overall rate of cesarean section for dystocia is small.

Cesarean Section↗
PubMed1989

The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women.

Epidural analgesia in labor is generally accepted as safe and effective and therefore has become increasingly popular. However, little is known regarding the effect of epidural analgesia on the incidence of cesarean section for dystocia in nulliparous women. During the first 6 months of 1987 we studied 711 consecutive nulliparous women at term, with cephalic fetal presentations and spontaneous onset of labor. Comparison of 447 patients who received epidural analgesia in labor with 264 patients who received either narcotics or no analgesia was performed. The incidence of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%). There remained a significantly increased incidence (p less than 0.005) of cesarean section for dystocia in the epidural group after selection bias was corrected and the following confounding variables were controlled by multivariate analysis: maternal age, race, gestational age, cervical dilatation on admission, use of oxytocin, duration of oxytocin use, maximum infusion rate of oxytocin, duration of labor, presence of meconium, and birth weight. The incidence of cesarean section for fetal distress was similar (p greater than 0.20) in both groups. There were no clinically significant differences in frequency of low Apgar scores at 5 minutes or cord arterial and venous blood gas parameters between the two groups. This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women.

Analgesia, Epidural↗
PubMed1994

Comparing clinician-applied loads for routine, difficult, and shoulder dystocia deliveries.

OBJECTIVE: Our goal was to examine and compare clinician-applied loads during simulated vaginal delivery. STUDY DESIGN: We developed a birthing model and a microcomputer data acquisition system and used them to measure clinician-applied extraction forces, moment, and rates for three perceived categories of delivery. In 39 experiments, clinicians simulated delivery of the fetal shoulders during vaginal delivery for routine, difficult, and shoulder dystocia deliveries. RESULTS: Clinicians averaged 84 N combined force and 473 N-cm neck-bending moment for routine deliveries, 122 N and 697 N-cm for difficult deliveries, and 163 N and 700 N-cm for shoulder dystocia deliveries (p < 0.002). No force or moment parameter was associated with clinician gender or experience. Force levels exceeding 100 N are reached for many clinicians (74% and 82%) for difficult and shoulder dystocia deliveries and for some clinicians (31%) for routine deliveries (p < 0.0001). CONCLUSION: We conclude that simulating shoulder dystocia in the laboratory may be useful in measuring extraction forces and neck-bending moment and that birthing models can be used to train clinicians in force, moment, and rate perception.

Delivery, Obstetric↗
PubMed1995

Are labor abnormalities more common in shoulder dystocia?

OBJECTIVE: Our objective was to determine the association between labor abnormalities and shoulder dystocia. STUDY DESIGN: All consecutive cases of shoulder dystocia from January 1986 to August 1994 were reviewed (n = 276). For purposes of comparison a control group of vaginally delivered patients was randomly selected in a 2:1 ratio (n = 600). Charts were reviewed for demographic information, labor and delivery events, and neonatal outcome. RESULTS: Labor abnormalities were comparable in the shoulder dystocia and control groups, both in the active phase and in the second stage. When patients with diabetes and those with macrosomic infants were analyzed separately, no significant differences in labor abnormalities were identified. The rate of operative vaginal delivery was significantly higher in the shoulder group, and one third of the operative deliveries were midpelvic. In addition, the induction rate was higher in the shoulder group. CONCLUSIONS: Our data suggest that labor abnormalities may not serve as clinical predictors for subsequent development of shoulder dystocia, thus emphasizing the unpredictability of this condition.

Adult↗