Interventions to Decrease Complications After Shoulder Dystocia: A Systematic Review and Bayesian Meta-Analysis.

Abstract

OBJECTIVE\nTo evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequelae of shoulder dystocia.\n\n\nDATA SOURCES\nElectronic databases (Medline OVID, Embase, CINAHL, and Scopus) were initially queried in June 2020 and updated on November 2020. Three concepts: Vaginal Birth, Shoulder Dystocia, and Simulation Training were introduced and refined using the controlled vocabulary of the database. There was no year of publication cutoff as part of the search strategy.\n\n\nSTUDY ELIGIBILITY CRITERIA\nWe included all studies which reported on the frequency of shoulder dystocia and associated complications during the pre- and post-implementation of interventional exercise to improve outcomes.\n\n\nSTUDY APPRASIAL AND SYNTHESIS METHODS\nTwo authors independently assessed the abstracts and full article for eligibility of all studies and evaluated the quality of included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed in deliveries complicated by shoulder dystocia, and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr).\n\n\nRESULTS\nOf the 372 articles reviewed, 16 publications-with 428,552 deliveries: 217,713 (50.8%) deliveries during the pre-intervention and 210,839 (49.2%) deliveries in the post-interventional period-were included in the meta-analysis. The proportion of neonatal brachial plexus palsy (NBPP) after shoulder dystocia decreased: from 12.1% to 5.7% (RR 0.37, 95% Cr 0.26-0.57, probability of reduction 100%). The overall proportion of NBPP, decreased but with less precision: 0.3% versus 0.1% (RR 0.53, 95% CI 0.21-1.26, probability of reduction 94%). Two reports followed newborns with brachial plexus palsy for at least 12 months. One study reported on persistent NBPP at 12 months among 1,148 shoulder dystocia cases noted a reduction from 1.9% to 0.2% persistent NBPP per shoulder dystocia (RR 0.13, 95% CI 0.04-0.49). In contradistinction, the study which reported on persistent NBPP at 12 months for all deliveries, noted that it did not change significantly: 0.3 vs. 0.2 per 1,000 births (RR 0.77, 95% CI 0.31-1.90). Following the institution of shoulder dystocia interventional exercises, the documentation of shoulder dystocia increased significantly: from 1.2% to 1.7% per vaginal delivery (RR 1.39, 95% Cr 1.19-1.65, probability of increase 100%).Compared to pre-exercise implementation, the cesarean delivery rate increased post-exercise implementation: 21.2% to 25.9% (RR 1.22, 95% CI 0.93-1.59, probability of increase 93%). An online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) we created permits calculations of the absolute risk reduction and increase attributable to the intervention vis-à-vis the number of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries.\n\n\nCONCLUSIONS\nIntroduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia; the data on persistence of NBPP beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and of cesarean deliveries.