Robert B. Gherman

Improving resident competency in the management of shoulder dystocia with simulation training

OBJECTIVE: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia. METHODS: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the residents performance with a standardized evaluation sheet. Statistical analysis included the Student t test, χ2, and regression analysis, as appropriate. RESULTS: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P = .003). CONCLUSION: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia. LEVEL OF EVIDENCE: I

Brachial plexus palsy: An in utero injury?

Acquired brachial plexus injury historically has been linked with excessive lateral traction applied to the fetal head, usually in association with shoulder dystocia. Recent reports in the obstetric literature, however, have suggested that in utero forces may underlie a significant portion of these injuries. Brachial plexus palsies may therefore precede the delivery itself and may occur independent of the actions of the accoucheur. Thus we propose that the long-held notions of a traction-mediated pathophysiologic mechanism for all brachial plexus injuries warrant critical reappraisal.

Recurrent shoulder dystocia: a review.

UNLABELLED To assess the impact of dengue infection during pregnancy on birth outcomes, we conducted a systematic review of 30 published studies (19 case reports, 9 case series, and 2 comparison studies). Studies were identified by searching computerized databases using dengue and dengue hemorrhagic fever, cross-referenced with pregnancy, preterm birth or delivery, low birth weight, small-for-gestational age, spontaneous abortion, pre-eclampsia, eclampsia, or fetal death as search terms. The case reports examined showed high rates of cesarean deliveries (44.0%) and pre-eclampsia (12.0%) among women with dengue infection during pregnancy, while the case series showed elevated rates of preterm birth (16.1%) and cesarean delivery (20.4%). One comparative study found an increase in low birth weight among infants born to women with dengue infections during pregnancy, compared with infants born to noninfected women. Vertical transmission was described in 64.0% and 12.6% of women in case reports and case series (respectively), as well as in one comparative study. The authors conclude that there is a risk of vertical transmission, but whether maternal dengue infection is a significant risk factor for adverse pregnancy outcomes is inconclusive. More comparative studies are needed. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this educational activity, the participant should be better able to assess symptoms of dengue fever and locations where dengue fever occurs, describe possible perinatal complications of maternal dengue fever, and identify the limitations of available literature describing dengue fever in pregnancy.Objective. The goals of this review were to determine the incidence of recurrent shoulder dystocia and the incidence of brachial plexus injury in such cases. Materials and Methods. A search of PubMed was conducted between 1980 and March 2009. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results. The search yielded 191 publications, of which 9 provided complete data; these were used to calculate the incidence of recurrent shoulder dystocia. The rate of shoulder dystocia in the prior pregnancies was 1.64% (31,311/1,911,014). Among 10,591 known subsequent vaginal births, the rate of recurrent shoulder dystocia was 12% (OR, 8.25; 95% CI, 7.77, 8.76). Brachial plexus injury occurred significantly more often during recurrent shoulder dystocia than during the first shoulder dystocia (4% vs. 1%; OR, 3.59; 95% CI, 2.44, 5.29; or 45/1000 vs. 13/1000 births). Conclusion. About 12% of parturients with a history of shoulder dystocia have a recurrent dystocia in the subsequent pregnancy, a risk of about 1 in 8. Brachial plexus injury occurs in 19/1000 vaginal births during the first episode of shoulder dystocia, and in 45/1000 vaginal births after recurrent dystocia. Target Audience: Obstetricians & Gynecologist, Family Physicians Learning Objectives: After completion of this educational activity, the reader will be able to compare the risk of primary versus recurrent shoulder dystocia. Formulate counseling and treatment strategies for pregnant women who have had a prior pregnancy complicated by shoulder dystocia. Assess the strength of the evidence suggesting the risk of recurrent shoulder dystocia.

Brachial plexus palsy associated with cesarean section: an in utero injury?

OBJECTIVE Brachial plexus injury may be unrelated to manipulations performed at the time of delivery, occurring in the absence of shoulder dystocia and in the posterior arm of infants with anterior shoulder dystocia. To further support the hypothesis that some of these nerve injuries appear to be of intrauterine origin, we present a series of brachial plexus palsies associated with atraumatic cesarean delivery among fetuses presenting in the vertex position. STUDY DESIGN We performed a computerized search of all deliveries from 1991 to 1995 for the discharge diagnoses of brachial plexus injury and cesarean section. Inclusion criteria included cephalic presentation at the time of delivery and the absence of traumatic delivery. RESULTS We noted six cases of Erbs palsy, with four palsies in the anterior shoulder and two in the posterior arm. Among those five patients undergoing cesarean section because of labor abnormalities, two had uterine cavity abnormalities whereas one had a prolonged second stage of labor. One brachial plexus palsy occurred in the absence of active labor. All nerve injuries were persistent at age 1 year. CONCLUSIONS Brachial plexus palsy can be associated with cesarean delivery. Such palsies appear to be of intrauterine origin and are more likely to persist.

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies ☆

OBJECTIVE To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia–related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n = 49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519 ± 94.3 g versus 4143.6 ± 56.5 g, P < .001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.

Shoulder Dystocia: Comparison of the ACOG Practice Bulletin with Another National Guideline

Our objective was to compare national guidelines regarding shoulder dystocia. Along with the American College of Obstetricians and Gynecologists (ACOG) practice bulletin on shoulder dystocia, guidelines from England, Canada, Australia, and New Zealand were reviewed. The Royal College of Obstetricians and Gynaecologists (RCOG) guideline agrees with the ACOG definition of shoulder dystocia, but there are variances in the management of suspected macrosomia and resolution of impacted shoulders. How recommendations are categorized differ also. Only 53% (20 of 38) of eligible references are cited by both publications. The two national guidelines on shoulder dystocia have differences and disagreements with each other, raising concerns about how the literature is synthesized and which is more comprehensive.

Experience with oral methylprednisolone in the treatment of refractory hyperemesis gravidarum.

OBJECTIVE Our purpose was to describe the effect of oral methylprednisolone on the course of refractory hyperemesis gravidarum. STUDY DESIGN Patients with intractable hyperemesis gravidarum were candidates for oral methylprednisolone. Forty-eight milligrams per day was given for 3 days followed by a tapering dose over 2 weeks. If vomiting recurred after 2 weeks of therapy or during tapering, the medication was restarted or extended but not longer than 1 month total. RESULTS Seventeen of 18 patients (94%) were free of vomiting and were able to tolerate a regular diet within 3 days. Seven did not have further symptoms during their pregnancies. Nine vomited during or after tapering, but 7 of these responded to extension or reinstitution of therapy. Four of 6 patients on total parenteral nutrition at the start of therapy had a complete response within 3 days. CONCLUSIONS A short course of oral methylprednisolone appears to be a reasonable therapeutic alternative for intractable hyperemesis.

Uterine Rupture Associated with Vaginal Birth after Cesarean Section: A Complication of Intravaginal Misoprostol?

Intravaginal misoprostol has become increasingly employed for labor induction among patients with an unfavorable Bishop’s score. Almost all of the reported studies have specifically excluded patients with prior uterine surgery. There has been, therefore, very little information concerning its usage among patients attempting vaginal birth after cesarean section. We report a patient with two prior low transverse uterine incisions who experienced uterine rupture after having received a single 25-μg intravaginal dose of misoprostol.

Shoulder dystocia without versus with brachial plexus injury: A case–control study

Objective. To delineate factors that differentiate shoulder dystocia with and without brachial plexus injury (BPI). Study design. A case–control study culled from an established shoulder dystocia database. Cases of shoulder dystocia-related BPI were identified and matched (1:1) with a control group of shoulder dystocia in which BPI did not result. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results. From 1980 to 2002, there were 89 978 deliveries with 46 cases of dystocia and BPI. The rate of dystocia with BPI was 0.5 per 1000 births and of permanent BPI, 0.9/10 000 deliveries. The two groups were similar for maternal demographics, diabetes, gestational age, induction, use of epidural, the duration of labor, operative vaginal delivery, rate of macrosomia, and maneuvers used to relieve the dystocia. Fracture of the clavicle occurred significantly less often among those without (2%) vs. with BPI (17%; OR 0.10, 95% CI 0.01, 0.88). Conclusions. Neither antepartum nor intrapartum factors can differentiate the patient who will have shoulder dystocia with vs. without BPI.

Neonatal brachial plexus palsy

The American College of Obstetricians and Gynecologists convened the Task Force on Neonatal Brachial Plexus Palsy to develop a comprehensive report summarizing a scientific literature on this subject. Clinically, neonatal brachial plexus palsy (NBPP) presents in a newborn as a weak or paralyzed upper extremity, with the passive range of motion greater than the active. The overall incidence of NBPP, both transient and persistent impairment, is 1.5 per 1,000 total births. Multiple reports in the peer-reviewed literature describe the occurrence of NBPP without concomitant clinically recognizable shoulder dystocia at the time of both vaginal and cesarean delivery. Chapter 1 of the report details the incidence of NBPP.