Shobha H. Mehta

What factors are associated with neonatal injury following shoulder dystocia

Objective:To identify factors associated with the development of neonatal injury in the setting of shoulder dystocia.Study design:Medical record ICD-9 codes and a computerized perinatal database were reviewed to identify cases of shoulder dystocia from January 1996 to January 2001 in a tertiary care center. For confirmation of the diagnosis and collection of data, both maternal and neonatal charts were then reviewed and neonatal injuries categorized as either neurological (brachial plexus injury) or skeletal (clavicular fracture, humeral fracture). Shoulder dystocia cases were divided into groups based on the presence of neonatal injury at delivery or at discharge (with or without Erbs palsy). The group with neonatal injury was compared for demographic and obstetrical factors to the group without injury (control). χ 2 test, Mann–Whitney test and logistic regression were used as appropriate.Results:During this 5-year period, there were 25 995 deliveries and 206 (0.8%) confirmed cases of shoulder dystocia. Of these cases, 36 (17.5%) had neonatal injury diagnosed at delivery and 25 (12%) remained with significant residual injury at discharge. Of these there were 19 cases of Erbs palsy and six cases of clavicular fracture. No association was found between neonatal injury and maternal age, ethnicity, diabetes, operative vaginal delivery or number of obstetrical maneuvers. However, maternal body mass index >30 kg/m2, a second stage of labor >20 min and a birth weight >4500 g were all associated with an increased risk of neonatal injury at delivery and at discharge, including Erbs palsy. After logistic regression analysis, only a second stage of delivery >20 min remained significantly associated with neonatal injury at discharge.Conclusion:In our population, maternal obesity was associated with an increased risk of neonatal injury after shoulder dystocia. In addition, a short second stage of labor (<20 min) was associated with a lower rate of neonatal injury.

Being too large for gestational age precedes childhood obesity in African Americans.

OBJECTIVE The purpose of this study was to investigate the association between large-for-gestational-age (LGA) infants and the development of childhood obesity in an inner-city primarily African American population. STUDY DESIGN Maternal, neonatal, socioeconomic, and nutritional histories were collected for mothers with children who were 2-5 years old. Associations between Alexander and customized birthweight percentiles and body mass index for the age of the child were examined. RESULTS One hundred ninety-five mother-child pairs were enrolled; the childhood obesity rate was 18%. Increasing Alexander and customized birthweight percentiles were related to increasing obesity. LGA newborn infants were 2.5 times more likely to be obese in childhood than average size newborn infants. Maternal smoking was also associated with childhood obesity. CONCLUSION LGA infants have the highest likelihood of childhood obesity in this inner-city predominantly African American population. Customized growth percentiles perform best in the identification of the highest risk population.

Shoulder dystocia: Risk factors, predictability, and preventability

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16-48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common. The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.

Is maternal diabetes a risk factor for childhood obesity

Objective: Our objective is to determine if there is a relationship between diabetes during pregnancy and childhood obesity, in our inner-city, African–American population. Methods: Pertinent child, neonatal and maternal pregnancy and delivery data were collected from mothers of children age 2–5 years old. Outcome variable definition was based on children’s body mass index (BMI) subgroups; independent variable definition on birthweight subgroups based on customized growth percentiles. Covariates included pre and postnatal factors. Those covariates marginally related to diabetes (p < 0.2) by bivariate analyses, were allowed to compete in logistic regression, with p < 0.05 significant. Results: Four hundred and ninety-three patients were enrolled, of which 35 (7.1%) had diabetes during pregnancy. Children of diabetic mothers were more likely to be obese at age 2–5 years than those of non-diabetics (p = 0.004). Five of 20 covariates had p < 0.2 in bivariate setting. Following stepwise logistic regression, diabetes and maternal prepregnancy BMI were significant determinants of childhood obesity. When large-for-gestational age (LGA) was added into the model, diabetes was no longer significant (p = 0.105); only LGA (p = 0.008) and maternal prepregnancy BMI (p = 0.032) were significantly associated with childhood obesity. Conclusions: In our inner-city, primarily African–American population, diabetes in pregnancy is significantly related to childhood obesity at age 2–5 years. Well-controlled diabetes during pregnancy that avoids macrosomia may lead to prevention of future childhood obesity as well.

Shoulder dystocia and the next delivery: Outcomes and management

Objective. To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia. Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described. Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048). Conclusion. In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high—approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.

Pregnancy recruitment for population research: the National Children's Study vanguard experience in Wayne County, Michigan.

BACKGROUND To obtain a probability sample of pregnancies, the National Childrens Study conducted door-to-door recruitment in randomly selected neighbourhoods in randomly selected counties in 2009-10. In 2011, an experiment was conducted in 10 US counties, in which the two-stage geographic sample was maintained, but participants were recruited in prenatal care provider offices. We describe our experience recruiting pregnant women this way in Wayne County, Michigan, a county where geographically eligible women attended 147 prenatal care settings, and comprised just 2% of total county pregnancies. METHODS After screening for address eligibility in prenatal care offices, we used a three-part recruitment process: (1) providers obtained permission for us to contact eligible patients, (2) clinical research staff described the study to women in clinical settings, and (3) survey research staff visited the home to consent and interview eligible women. RESULTS We screened 34,065 addresses in 67 provider settings to find 215 eligible women. Providers obtained permission for research contact from 81.4% of eligible women, of whom 92.5% agreed to a home visit. All home-visited women consented, giving a net enrolment of 75%. From birth certificates, we estimate that 30% of eligible county pregnancies were enrolled, reaching 40-50% in the final recruitment months. CONCLUSIONS We recruited a high fraction of pregnancies identified in a broad cross-section of provider offices. Nonetheless, because of time and resource constraints, we could enrol only a fraction of geographically eligible pregnancies. Our experience suggests that the probability sampling of pregnancies for research could be more efficiently achieved through sampling of providers rather than households.

Neonatal brachial plexus injury: Obstetrical factors and neonatal management

Neonatal brachial plexus injury (BPI) is a birth outcome characterized by injury to the brachial plexus identified after delivery. Though uncommon, its potential occurrence following delivery is concerning for both the delivering clinician as well as the pediatric team. Considerable research looking at delivery factors, including forces applied at the time of delivery and management of the BPI after it has occurred, has led to a better understanding, if not a lower rate, of BPI. This information is reviewed below.

Delivery route preferences of urban women of low socioeconomic status

To identify the main determinants of mode of delivery preference among urban dwelling women of lower socioeconomic status (SES).