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Importance: Macrosomia represents the most significant risk factor of shoulder dystocia (SD), which is a severe and emergent complication of vaginal delivery. They are both associated with adverse pregnancy outcomes., Objective: The aim of this study was to review and compare the most recently published influential guidelines on the diagnosis and management of fetal macrosomia and SD., Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Department for Health and Wellbeing of the Government of South Australia on macrosomia and SD was conducted., Results: The ACOG and RANZCOG agree that macrosomia should be defined as birthweight above 4000-4500 g regardless of the gestational age, whereas the National Institute for Health and Care Excellence defines macrosomia as an estimated fetal weight above the 95th percentile. According to ACOG and RANZCOG, ultrasound scans and clinical estimates can be used to rule out fetal macrosomia, although lacking accuracy. Routine induction of labor before 39 weeks of gestation with the sole indication of suspected fetal macrosomia is unanimously not recommended, but an individualized counseling should be provided. Exercise, appropriate diet, and prepregnancy bariatric surgery are mentioned as preventive measures. There is also consensus among the reviewed guidelines regarding the definition and the diagnosis of SD, with the "turtle sign" being the most common sign for its recognition as well as the poor predictability of the reported risk factors. Moreover, there is an overall agreement on the algorithm of SD management with McRoberts technique suggested as first-line maneuver. In addition, appropriate staff training, thorough documentation, and time keeping are crucial aspects of SD management according to all medical societies. Elective delivery for the prevention of SD is discouraged by all the reviewed guidelines., Conclusions: Macrosomia is associated not only with SD but also with maternal and neonatal complications. Similarly, SD can lead to permanent neurologic sequalae, as well as perinatal death if managed in a suboptimal way. Therefore, it is crucial to develop consistent international practice protocols for their prompt diagnosis and effective management in order to safely guide clinical practice and improve pregnancy outcomes.

Abnormally prolonged labor, or labor dystocia, is a common complication of parturition. It is the indication for about half of unplanned cesarean deliveries in low-risk nulliparous women. Reducing the rate of unplanned cesarean birth in the USA has been a public health priority over the last two decades with limited success. Labor dystocia is a complex disorder due to multiple causes with a common clinical outcome of slow cervical dilation and fetal descent. A better understanding of the pathophysiologic mechanisms of labor dystocia could lead to new clinical opportunities to increase the rate of normal vaginal delivery, reduce cesarean birth rates, and improve maternal and neonatal health. We conducted a literature review of the causes and pathophysiologic mechanisms of labor dystocia. We summarize known mechanisms supported by clinical and experimental data and newer hypotheses with less supporting evidence. We review recent data on uterine preparation for labor, uterine contractility, cervical preparation for labor, maternal obesity, cephalopelvic disproportion, fetal malposition, intrauterine infection, and maternal stress. We also describe current clinical approaches to preventing and managing labor dystocia. The variation in pathophysiologic causes of labor dystocia probably limits the utility of current general treatment options. However, treatments targeting specific underlying etiologies could be more effective. We found that the pathophysiologic basis of labor dystocia is under-researched, offering wide opportunities for translational investigation of individualized labor management, particularly regarding uterine metabolism and fetal position. More precise diagnostic tools and individualized therapies for labor dystocia might lead to better outcomes. We conclude that additional knowledge of parturition physiology coupled with rigorous clinical evaluation of novel biologically directed treatments could improve obstetric quality of care., (© 2022. Society for Reproductive Investigation.)

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Parturition is a natural process that gradually progresses from one stage to the next. However, around 5% of dairy cows will experience dystocia, which is considered to be a painful and stressful event. Studies have reported positive effects on cow performance and welfare after treatment with nonsteroidal anti-inflammatory drugs during the first postpartum days. The objectives were to assess the effects of acetylsalicylic acid administration after calving on (1) milk yield and components, (2) daily activity patterns, (3) reproductive performance, and (4) health in lactating dairy cows under certified organic management. Cows from 3 organic herds were enrolled. Within 12 h after parturition, cows were blocked by parity and calving ease and randomly assigned to 2 treatments: (1) aspirin (ASP; n = 278), in which cows received 4 consecutive treatments every 12 h with acetylsalicylic acid (100 mg/kg; 2 boluses) or (2) placebo (PLC, n = 285), in which cows received 4 treatments every 12 h with gelatin capsules (2 capsules) filled with water. Daily milk yield for the first 30 d in milk (DIM) and monthly milk yield, fat, protein, and somatic cell count (SCC) data from the first 5 Dairy Herd Improvement Association tests were collected. Activity patterns were measured using activity data loggers in the first 7 DIM. Clinical disease events (60 DIM) and fertility data were collected from on-farm computer records. Statistical analysis was performed using the MIXED (milk yield, components, and activity), LIFETEST (fertility), and GLIMMIX (health) procedures of SAS (SAS Institute Inc., Cary, NC). Overall, ASP cows produced 1.82 kg/d more milk than PLC cows during the first 30 DIM. Interestingly, cows that experienced dystocia and received ASP produced 4.48 kg/d more milk compared with cows in the PLC group that experienced dystocia. Cows treated with ASP had lower somatic cell count during the first 5 Dairy Herd Improvement Association tests. There were no differences in daily lying time, lying bouts, and lying bout duration between the ASP and PLC groups. However, cows in the ASP group had 587,64 steps/d more compared with PLC cows. In addition, ASP cows tended to require fewer days (ASP = 113.76 ± 4.99 d; PLC = 125.36 ± 4.74 d) and needed fewer services (ASP = 1.86 ± 0.21 services; PLC = 2.19 ± 0.24 services) to become pregnant compared with PLC cows. There were no differences in clinical disease events between treatments. Results from this study suggest that treating cows with ASP after calving may help improve milk yields and udder health, increase activity, and enhance fertility in dairy cattle under certified organic management., (Copyright © 2020 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

The second stage of labor, from full cervical dilatation to complete birth of the baby or babies, constitutes the time of greatest risk for the baby. Birth attendants at all levels require training in the skills necessary to overcome difficulties that may arise unexpectedly during the second stage, particularly poor progress, shoulder dystocia, and breech birth. The mother should receive emotional support and encouragement to bear down instinctively when she feels the urge to do so, in the position she feels enables her to push most effectively, but not the supine position. The baby's heart rate should be monitored after every second contraction. Recent guidelines such as those of the World Health Organization(WHO) recommend allowing 2-3 h for the second stage of labor. Uterine fundal pressure has not been shown to be effective, and may be dangerous. Choosing between cesarean section and assisted vaginal birth to overcome delayed second stage requires relevant skill and experience., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: This study sought to describe how the implementation of recent labour guidelines may affect the cesarean delivery rate in a population in Alberta., Methods: This retrospective study was conducted on primiparous women who were in labour with singleton term fetuses with cephalic presentation in Alberta from 2007 to 2016 (n = 181 738), and it used data from a perinatal database. Modelled cesarean delivery rates were calculated to determine the potential impact of the recent guidelines on the cesarean delivery rate by using the percentage of cesarean deliveries that occurred outside the threshold of the recent labour guidelines., Results: A total of 21.7% of the cesarean deliveries for dystocia occurred outside of the guidelines related to the first stage of labour arrest for spontaneous labour (n = 9282), and 45.4% occurred outside of the guidelines related to the first stage of labour arrest for induced labours (n = 11 712). A total of 69.0% of the cesarean deliveries for dystocia occurred outside of the failed induction of labour guidelines (n = 4921), and 55.4% occurred outside of the second stage labour arrest guidelines (n = 6632). Assuming that the labour arrest guidelines are effective at reducing the cesarean delivery rate 25% of the time, the cesarean delivery rate for primiparous women in labour would be reduced from 22.5% to 20.7%. Assuming a 75% adherence/effectiveness rate, the cesarean delivery rate would be reduced to 17.1%., Conclusion: The recent labour guidelines have the potential to have a substantial impact on the intrapartum cesarean delivery rate in primiparous women with singleton fetuses with cephalic presentation at term if the guidelines are put into practice., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Epidural anaesthesia is an effective form of pain relief during vaginal deliveries. However, neuraxial anaesthesia may slow the progression of labour. The assumption that epidurals lead to increased caesarean sections is also a topic of current debate. A holistic approach with the use of a birthing ball has been advocated as a potential modality to decrease labouring times and, therefore, reduce progression to caesarean section. Birthing balls aim to increase pelvic outlet opening, which facilitates labouring. Our aim is to review recent literature pertaining to birthing balls and their role in improving quality and outcomes of vaginal deliveries in patients with epidurals.IMPACT STATEMENT What is already known on the subject? Epidural anaesthesia may slow the progression of labour. It has been hypothesised that slowing progression of labour is associated with increased rates of vacuum and forceps delivery. Most common clinical indication for caesarean section is failure to progress during labour. Birthing Balls have been shown to quicken the progression of labour, theoretically reducing caesarean sections with those with epidurals. What do the results of the study add? Several studies have demonstrated a reduced duration of first and second stage of labour among women with epidural anaesthesia, but the existing literature is limited, and interpretation of results may be restricted by generalizability and inherent study biases. The objective of this article is to review existing literature and highlight the potential clinical utility of birthing balls in current obstetric practice. What are the implications of these findings for clinical practice and further research? Use of birthing balls has been advocated to decrease labouring time and therefore reduce progression to caesarean section. Larger studies or meta-analysis would be required to confirm potential benefits of birthing ball use.

Introduction: Fetal overgrowth is an acknowledged risk factor for abnormal labor course and maternal and perinatal complications. The objective of this study was to evaluate whether the use of antenatal ultrasound-based customized fetal growth charts in fetuses at risk for large-for-gestational age (LGA) allows a better identification of cases undergoing caesarean section due to intrapartum dystocia., Material and Methods: An observational study involving four Italian tertiary centers was carried out. Women referred to a dedicated antenatal clinic between 35 and 38 weeks due to an increased risk of having an LGA fetus at birth were prospectively selected for the study purpose. The fetal measurements obtained and used for the estimation of the fetal size were biparietal diameter, head circumference, abdominal circumference and femur length, were prospectively collected. LGA fetuses were defined by estimated fetal weight (EFW) >95th centile either using the standard charts implemented by the World Health Organization (WHO) or the customized fetal growth charts previously published by our group. Patients scheduled for elective caesarean section (CS) or for elective induction for suspected fetal macrosomia or submitted to CS or vacuum extraction (VE) purely due to suspected intrapartum distress were excluded. The incidence of CS due to labor dystocia was compared between fetuses with EFW >95th centile according WHO or customized antenatal growth charts., Results: Overall, 814 women were eligible, however 562 were considered for the data analysis following the evaluation of the exclusion criteria. Vaginal delivery occurred in 466 (82.9 %) women (435 (77.4 %) spontaneous vaginal delivery and 31 (5.5 %) VE) while 96 had CS. The EFW was >95th centile in 194 (34.5 %) fetuses according to WHO growth charts and in 190 (33.8 %) by customized growth charts, respectively. CS due to dystocia occurred in 43 (22.2 %) women with LGA fetuses defined by WHO curves and in 39 (20.5 %) women with LGA defined by customized growth charts (p 0.70). WHO curves showed 57 % sensitivity, 72 % specificity, 24 % PPV and 91 % NPV, while customized curves showed 52 % sensitivity, 73 % specificity, 23 % PPV and 91 % NPV for CS due to labor dystocia., Conclusions: The use of antenatal ultrasound-based customized growth charts does not allow a better identification of fetuses at risk of CS due to intrapartum dystocia., (Copyright © 2020 Elsevier B.V. All rights reserved.)

In placental mammals, a poor fit between the physical dimensions of the fetus and maternal pelvis increases the likelihood of obstructed labour. This problem is especially relevant to humans, as our species demonstrates both unique adaptations in pelvic shape and structure associated with bipedalism, and fetal encephalization. Natural selection is expected to have favoured adaptations that reduce the chances of such mismatch within individual mother-offspring dyads. Here, I hypothesise that the cultural practice of consanguineous marriage may have been favoured, on account of increasing the genetic similarity between mothers and offspring and hence the correlation between maternal and fetal physical dimensions. These benefits could be amplified if consanguineous marriage was accompanied by assortative mating for height. An additional benefit of consanguineous marriage for childbirth is the slight reduction in birth size of such offspring compared to non-consanguineous unions. Although the offspring of consanguineous unions have elevated risks of morbidity and mortality, these risks are moderate and the practice could still have been favoured by selection if the reduction in maternal mortality was greater than the increased mortality among individual offspring. This hypothesis could be tested directly by investigating whether rates of obstructed labour are lower in individuals and populations practising consanguineous marriage. At a broader level, phylogenetic analysis could be conducted to test whether consanguineous marriage appears to have originated in the areas where intensive agriculture was first practiced, as adult height typically fell in such populations, potentially exacerbating the risk of obstructed labour., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Prolonged length of labor is associated with increased maternal and neonatal complications. Therefore, great attention has been given to interventions aimed at reducing the length of labor. One such intervention is the peanut ball, a large elongated exercise ball placed between a woman's legs during labor., Objective: The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to assess the effect of the use of peanut ball in reducing length of labor., Study Design: Data sources: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library were searched from inception until January 2019., Selection Criteria: Selection criteria included RCTs of laboring women with singleton gestations in cephalic presentation at term (≥37weeks) who were randomized to either use of peanut ball or control group (no peanut ball)., Data Collection and Analysis: Four trials with 648 nulliparous and multiparous women in spontaneous or induced labor were identified and included. 330 women were randomized to the intervention (peanut ball between the knees during labor) and 318 women to the control. Summary measures were reported as mean difference (MD) with 95% of confidence interval (CI) using the random effects model of DerSimonian and Laird. The primary outcome was total length of labor. PROSPERO Registration Number: CRD42018082438 RESULTS: Total length of labor was 79min shorter in the peanut ball group, but this was not significant (MD -79.1 min, 95% CI -204.9, 46.7). Peanut ball use showed trends toward higher incidence of spontaneous vaginal deliveries (RR 1.1, 95% CI 1.0, 1.2) and lower incidence of cesarean deliveries (RR 0.8, 95% CI 0.6, 1.0)., Conclusions: Peanut ball use was not associated with a significant decrease in total length of labor. Since there were trends toward reductions in length of labor, an increased incidence in spontaneous vaginal deliveries, and lower incidence of cesarean deliveries, more research is needed., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Assessment of pelvic configuration is an important factor in the prediction of a successful vaginal birth. However, manual evaluation of the pelvis is practically a vanishing art, and imaging techniques are not available as a real-time bed-side tool. Unlike the obstetrical conjugate diameter (OC) and inter spinous diameter (ISD), the pubic arch angle (PAA) can be easily measured by transperineal ultrasound. Objectives: Three-dimensional computed tomography bone reconstructions were used to measure the three main birth canal diameters, evaluate the correlation between them, and establish the normal reference range for the inlet, mid-, and pelvic outlet. Study design: Measurements of the PAA, obstetric conjugate (OC), and ISD were performed offline using three-dimensional post processing reconstruction in bone algorithm application of the pelvis on examinations performed for suspected renal colic in nonpregnant reproductive age woman. The mean of two measurements was used for statistical analysis which included reproducibility of measurements, regression curve estimation between PAA, OC, and ISD, and calculation of the respective reference range centiles for each PAA degree. Results: Two hundred ninety-eight women comprised the study group. The mean ± SD of the PAA, ISD, and OC were 104.9° (±7.4), 103.8 mm (±7.3), and 129.9 mm (±8.3), respectively. The intra- and interobserver agreement defined by the intraclass correlation coefficient (ICC) was excellent for all parameters (range 0.905-0.993). A significant positive correlation was found between PAA and ISD and between PAA and OCD (Pearson's correlation = 0.373 ( p  < .001), and 0.163 ( p  = .022), respectively). The best regression formula was found with quadratic regression for inter spinous diameter (ISD): 34.122778 + (0.962182*PAA - 0.002830*PAA 2 ), and linear regression for obstetric conjugate (OC): 110.638397 + 0.183156*PAA. Modeled mean, SD, and reference centiles of the ISD and OCD were calculated using the above regression models as function of the PAA. Conclusions: We report significant correlation between the three pelvic landmarks with greatest impact on the prediction of a successful vaginal delivery: the PAA which is easily measured sonographically and the ISD and OC which are not measurable by ultrasound. This correlation may serve as a basis for future studies to assess its utility and prognostic value for a safe vaginal delivery.

For more than 50 years, the methylation of mammalian actin at histidine 73 has been known to occur 1 . Despite the pervasiveness of His73 methylation, which we find is conserved in several model animals and plants, its function remains unclear and the enzyme that generates this modification is unknown. Here we identify SET domain protein 3 (SETD3) as the physiological actin His73 methyltransferase. Structural studies reveal that an extensive network of interactions clamps the actin peptide onto the surface of SETD3 to orient His73 correctly within the catalytic pocket and to facilitate methyl transfer. His73 methylation reduces the nucleotide-exchange rate on actin monomers and modestly accelerates the assembly of actin filaments. Mice that lack SETD3 show complete loss of actin His73 methylation in several tissues, and quantitative proteomics analysis shows that actin His73 methylation is the only detectable physiological substrate of SETD3. SETD3-deficient female mice have severely decreased litter sizes owing to primary maternal dystocia that is refractory to ecbolic induction agents. Furthermore, depletion of SETD3 impairs signal-induced contraction in primary human uterine smooth muscle cells. Together, our results identify a mammalian histidine methyltransferase and uncover a pivotal role for SETD3 and actin His73 methylation in the regulation of smooth muscle contractility. Our data also support the broader hypothesis that protein histidine methylation acts as a common regulatory mechanism.

Objective: Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia., Study Design: We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required., Results: We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia., Conclusion: In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Purpose of this study was to investigate differences between primiparous term pregnancies, one leading to vaginal delivery (VD) and the other to acute cesarean section (CS) due to labor dystocia in the first stage of labor. We particularly wanted to assess the influence of body mass index (BMI) on CS risk., Methods: A retrospective case-control study in a tertiary delivery unit with 5200 deliveries annually. Cases were 296 term primiparous women whose intended vaginal labor ended in acute CS because of dystocia. Controls were primiparas with successful vaginal delivery VD (n = 302). The data were retrieved from medical records. Multiple logistic regression analyses were used to assess the associations between BMI and covariates on labor dystocia., Results: In the cases ending with acute CS, women were older (OR 1.06 [1.03-1.10]), shorter (OR 0.94 [0.91-0.96]) and more often had a chronic disease (OR 1.60 [1.1-2.29]). In this group fetal malposition (OR 42.0 [19.2-91.9]) and chorioamnionitis (OR 10.9 [5.01-23.6]) were more common, labor was less often in an active phase (OR 3.37 [2.38-4.76]) and the cervix was not as well ripened (1.5 vs. 2.5 cm, OR 0.57 [0.48-0.67] on arrival at the birth unit. BMI was higher in the dystocia group (24.1 vs. 22.6 kg/m 2 , p < 0.001), and rising maternal pre-pregnancy BMI had a strong association with dystocia risk. If BMI increased by 1 kg/m 2 , the risk of CS was 10% elevated. Among obese primiparas, premature rupture of membranes, chorioamnionitis and induction of labor were more common. Their labors were less often in an active phase at hospital admission. Severely obese primiparas (BMI ≥ 35 kg/m 2 ) had 4 hours longer labor than normal-weight parturients., Conclusions: Labor dystocia is a multifactorial phenomenon in which the possibility to ameliorate the condition via medical treatment is limited. Hospital admission at an advanced stage of labor is recommended. Pre-pregnancy weight control in the population at reproductive age is essential, as a high BMI is strongly associated with labor dystocia.

Objective: To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units., Design: Mixed-methods implementation evaluation., Setting/local Problem: Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action., Participants: Key informants were labor and delivery unit staff who implemented SPPC safety strategies., Intervention/measurements: The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation., Results: Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation., Conclusion: Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances., (Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

New interest in home birth have recently arisen in women at low risk pregnancy. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. We aimed to quantify pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos). We did a systematic review of maternal and neonatal morbidity following planned home (PHB) versus planned hospital birth (PHos). We included prospective, retrospective, cohort and case-control studies of low risk pregnancy outcomes according to planning place of birth, identified from January 2000 to June 2017. We excluded studies in which high-risk pregnancy and composite morbidity were included. Outcomes of interest were: maternal and neonatal morbidity/mortality, medical interventions, and delivery mode. We pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol is registered with PROSPERO, protocol number CRD42017058016. We included 8 studies of the 4294 records identified, consisting in 14,637 (32.6%) in PHB and 30,177 (67.4%) in PHos group. Spontaneous delivery was significantly higher in PHB than PHos group (OR: 2.075; 95%CI:1.654-2.063) group. Women in PHB group were less likely to undergo cesarean section compared with women in PHos (OR:0.607; 95%CI:0.553-0.667) group. PHB group was less likely to receive medical interventions than PHos group. The risk of fetal dystocia was lower in PHB than PHos group (OR:0.287; 95%CI:0.133-0.618). The risk of post-partum hemorrhage was lower in PHB than PHos group (OR:0.692; 95% CI.0.634-0.755). The two groups were similar with regard to neonatal morbidity and mortality. Births assisted at hospital are more likely to receive medical interventions, fetal monitoring and prompt delivery in case of obstetrical complications. Further studies are needed in order to clarify whether home births are as safe as hospital births., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To establish the degree of variation across hospitals in the use of Caesarean delivery for the indication of labour dystocia before and after accounting for maternal, fetal, and hospital characteristics., Methods: This study was a retrospective, population-based cohort study of nulliparous women delivering term singletons in cephalic position following labour. Delivery visits were extracted from three provincial perinatal registries in the Canadian provinces of Ontario, Alberta, and British Columbia, from 2008-2012. Crude hospital-specific rates of Caesarean delivery for labour dystocia were reported, and these rates were then stabilized to account for hospitals with low delivery volumes. Rates were then adjusted for maternal, fetal, and hospital characteristics using hierarchical logistic regression., Results: Among 403 205 women delivering at 170 hospitals, the overall Caesarean delivery rate was 21.0%, and the rate of Caesarean delivery for labour dystocia was 12.7%, indicating that 60% of all Caesarean deliveries were performed in part for this indication. The middle 95% of hospitals had Caesarean delivery rates for labour dystocia ranging from 4.5% to 24.7%. Differences in maternal case mix and hospital characteristics explained only a small proportion of this variation (95% central range 6.3%-21.7%)., Conclusion: Considerable inter-hospital variation in rates of Caesarean delivery for labour dystocia remained after accounting for differences in maternal and hospital factors. Reporting systems that monitor variation in inter-institutional rates should incorporate stabilization and adjustment for case-mix differences and consider indication-specific rates of Caesarean delivery to more fairly compare hospital performance and better target interventions to reduce Caesarean delivery for specific indications., (Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Although the evidence for supporting the effectiveness of many patient safety practices has increased in recent years, the ability to implement programs to positively impact clinical outcomes across multiple institutions is lagging. Shoulder dystocia simulation has been shown to reduce avoidable patient harm. Neonatal injury from shoulder dystocia contributes to a significant percentage of liability claims. We describe the development and the process of implementation of a shoulder dystocia simulation program across five academic medical centers and their affiliated hospitals united by a common insurance carrier. Key factors in successful roll out of this program included the following: involvement of physician and nursing leadership from each academic medical center; administrative and logistic support from the insurer; development of consensus on curriculum components of the program; conduct of gap and barrier analysis; financial support from insurer to close necessary gaps and mitigate barriers; and creation of dashboards and tracking performance of the program., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: io compare two-step method ot shoulder delivery with one-step for the maternal and neonatal outcomes., Materials and Methods: This was a randomized controlled clinical trial. Women scheduled for vaginal delivery without severe complications were enrolled and randomly arranged into two groups. Women in study group were delivered by two-step method for shoulder delivery, that is to wait for at least one contraction after head delivery, and naturally delivery of shoulder. Women in controlled group were delivered by one-step method, that is after the head was delivered, gentle press of head was applied to facility shoulder delivery. Maternal and neonatal outcomes as Apgar score, rate of shoulder dystocia, and postpartum bleeding were recorded. Interval of head to shoulder was timed in second., Results: The study group had lower rate of shoulder dystocia than that in control group (X²= 4.27,p =0.03), no increasing of asphyxia, and postpartum bleeding. The average interval of head to shoulder in study group was longer than that in control group. There was no difference in interval between shoulder dystocia vs. normal birth group, neither was there a difference in interval between asphyxia babies and normal babies group. By two-step method, the mean value of head to shoulder interval was 59.025 seconds, 95% CI (20.000-150.000 seconds), mean+2xSD = 148.927 seconds. In one-step group, mean was 44.172 seconds, 95% CI= (10.000~105.000 seconds), mean +2xSD = 94.812 seconds., Conclusion: Two-step method of shoulder delivery had a lower rate of shoulder dystocia than one-step method, no increasing of neonatal asphyxia and postpartum bleeding. The longer interval of head to shoulder did not relate to shoulder dystocia and asphyxia. The normal value of head to shoulder interval might be longer than 60 seconds.

Fetal macrosomia is defined as birth weight >4000 g and is associated with several maternal and fetal complications such as maternal birth canal trauma, shoulder dystocia, and perinatal asphyxia. Early identification of risk factors could allow preventive measures to be taken to avoid adverse perinatal outcomes. Prenatal diagnosis is based on two-dimensional ultrasound formulae, but accuracy is low, particularly at advanced gestation. Three-dimensional ultrasound could be an alternative to soft tissue monitoring, allowing better prediction of birth weight than two-dimensional ultrasound. In this article, we describe the definition, risk factors, diagnosis, prevention, ultrasound monitoring, prenatal care, and delivery in fetal macrosomia cases., (Copyright © 2016. Published by Elsevier Ltd.)

Shoulder dystocia is an obstetrical emergency that may result in significant neonatal complications. It requires rapid recognition and a coordinated response. Standardization of care, teamwork and communication, and clinical simulation are the key components of patient safety programs in obstetrics. Simulation-based team training and institutional protocols for the management of shoulder dystocia are emerging as integral components of many labor and delivery safety initiatives because of their impact on technical skills and team performance.

Introduction: The route of delivery and the role of induction of labor in twin gestations are controversial. The aim of this study was to determine the efficacy of induction of labor in twin gestations., Methods: This retrospective population based cohort study included 4605 twin gestations divided into following groups: 1) spontaneous parturition (n = 2937, 63.78%); 2) induction of labor (n = 653, 14.2%) and 3) elective cesarean delivery (n = 1015, 22.04%)., Results: The rate of vaginal delivery in the labor induction group was 81% (529/653). In comparison to the other study groups, induction of labor in twins was independently associated with a 77% reduction in the risk of cesarean delivery (OR 0.23; 95% CI 0.18-0.31) and a 78% reduction in the risk of postpartum death for the second twin (OR 0.22; 95% CI 0.05-0.94). The rate of nulliparity, term delivery and labor dystocia was higher in the induction of labor group (p < 0.001 in all comparisons)., Conclusions: Our results suggest that induction of labor in twin gestation is successful and is independently associated with substantial reduction in the risk of cesarean delivery and postpartum death of the second twin.

Shoulder dystocia complicates ∼1% of vaginal births. Although fetal macrosomia and maternal diabetes are risk factors for shoulder dystocia, for the most part its occurrence remains largely unpredictable and unpreventable.

A prior history of delivery complicated by shoulder dystocia confers a 6-fold to nearly 30-fold increased risk of shoulder dystocia recurrence in a subsequent vaginal delivery, with most reported rates between 12% and 17%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, directing intervention efforts at the particular subgroup of women with a prior history of shoulder dystocia has merit. Potentially modifiable risk factors and individualized management strategies that may reduce shoulder dystocia recurrence and its associated significant morbidities are reviewed.

Since antepartum and intrapartum risk factors are poor at identifying women whose labor is complicated by shoulder dystocia, sonographic examination of the fetus holds promise. Though there are several measurements of biometric parameters to identify the parturient who will have shoulder dystocia, none are currently clinically useful. Three national guidelines confirm that sonographic measurements do not serve as appropriate diagnostic tests to identify women who will have shoulder dystocia with or without concurrent injury. In summary, biometric measurements of the fetus should not be used to alter clinical management with the aim of averting shoulder dystocia.

Macrosomic fetuses are at increased risk of obstetric complications, and notably shoulder dystocia, responsible for a severe neonatal morbidity. In case of fetal macrosomia, three options are: (i) the elective cesarean delivery, but this is recommended only when the estimated fetal weight is≥4500g for diabetic women and 5000g for non-diabetic women; (ii) the expectative management, but children with birth weight≥4500 had significantly increased risk of perinatal mortality, neonatal asphyxia, trauma, and cesarean delivery; (iii) the induction of labor which, reducing the possibility of fetal growth, reduce the risk of cesarean delivery for cephalopelvic disproportion and shoulder dystocia. As 2 former trials did not show maternal or neonatal benefit with induction of labor for fetal macrosomia, it was therefore not recommended. However, these 2 studies had small sample size (273 and 40 women) and a methodology limiting their ability to show a difference, justifying to achieve a large multicentre randomized controlled trial. This trial was performed by Boulvain et al. and the results published in 2015 in the Lancet. Inclusion criteria were: a singleton pregnancy in cephalic presentation and a suspected fetal macrosomia defined by an ultrasound estimated weight>95th percentile between 36 and 38 weeks. Women were randomly assigned to receive induction of labor within 3 days between 37 +0  and 38 +6  weeks of gestation, or expectant management. Expectant management continued until either spontaneous labour or diagnosis of a condition necessitating induction. The primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. Baseline characteristics were similar between groups. The mean birth weight (±SD) was 3831 (±324) g in the induction group 4118 (±392) g in the expectant group. Induction of labor significantly reduced the risk of shoulder dystocia or associated morbidity (8/407; 2 %) compared with expectant management (25/411; 6 %); P=0.004. The number needed to treat was 25 (95 % CI: 15-70). The incidence of caesarean section and operative vaginal delivery did not differ significantly between the groups. The likelihood of spontaneous vaginal delivery increased significantly in the induction of labor group (59 % vs. 52 %, RR: 1.14; 95 % CI: 1.01-1.29). In all, the results of the Boulvain et al. trial justify to propose an induction of labor in cases of suspected macrosomia>95th percentile: the induction of labor reduced the risk of severe shoulder dystocia, and does not increase the risk of cesarean section. It even increases the likelihood of spontaneous vaginal delivery., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Shoulder dystocia (SD) is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. It complicates 0.5-1% of vaginal deliveries. Risks of brachial plexus birth injury (level of evidence [LE]3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) increase with SD. Its main risk factors are previous SD and macrosomia, but both are poorly predictive; 50-70% of SD cases occur in their absence, and most deliveries when they are present do not result in SD. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of SD. Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for SD (Grade C). In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (Grade A). Women with gestational diabetes require diabetes care (diabetic diet, glucose monitoring, insulin if needed) (Grade A) because it reduces the risk of macrosomia and SD (LE1). Only two measures are proposed for avoiding SD and its complications. First, induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more (professional consensus). Second, cesarean delivery is recommended before labor in three situations and during labor in one: (i) estimated fetal weight (EFW) >4500g if associated with maternal diabetes (Grade C), (ii) EFW >5000g in women without diabetes (Grade C), (iii) history of SD associated with severe neonatal or maternal complications (professional consensus), and finally during labor, (iv) in case of fetal macrosomia and failure to progress in the second stage, when the fetal head station is above +2 (Grade C). In cases of SD, it is recommended to avoid the following actions: excessive traction on the fetal head (Grade C), fundal pressure (Grade C), and inverse rotation of the fetal head (professional consensus). The McRoberts maneuver, with or without suprapubic pressure, is recommended first (Grade C). If it fails and the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, it is preferable to attempt to deliver the posterior arm next (professional consensus). It appears necessary to know at least two maneuvers to perform should the McRoberts maneuver fail (professional consensus). A pediatrician should be immediately informed of SD. The initial clinical examination should check for complications, such as brachial plexus injury or clavicle fracture (professional consensus). If no complications are observed, neonatal monitoring need not be modified (professional consensus). The implementation of practical training with simulation for all care providers in the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury. SD remains an unpredictable obstetric emergency. All physicians and midwives should know and perform obstetric maneuvers if needed, quickly but calmly., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Dystocia is an inevitable challenge in the livestock industries, particularly with primiparous female animals. Prevention and appropriate management will decrease cow and calf morbidity and mortality, which will improve the economic status of the beef or dairy operation. Early identification and proper intervention improves outcomes, and the use of selection tools to decrease the potential for dystocia will have positive returns. Assisted reproductive technologies present a unique set of challenges to the calving process that both the producer and practitioner should be prepared to address., (Published by Elsevier Inc.)

Editorial Note: It has been brought to the authors' attention that there may be an error in the data (Analysis 1.9). This is currently under investigation, and a correction will be made if the data are found to be incorrect. Details can be found in the comments., Background: Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section., Objectives: To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies., Selection Criteria: Randomised trials of induction of labour for suspected fetal macrosomia., Data Collection and Analysis: Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach., Main Results: We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias.Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I(2) = 89%). In one study with data for 818 women, third- and fourth-degree perineal tears were increased in the induction group (RR 3.70, 95% CI 1.04 to 13.17).For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates., Authors' Conclusions: Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents.Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.

Introduction: In the Netherlands, low-risk pregnancies are managed by midwives in primary care. Despite strict definitions of low risk, obstetric complications can occur. Midwives seldom encounter uncommon labour complications, but are sufficiently trained to manage these. We assessed neonatal and maternal outcome after management of shoulder dystocia in primary midwifery care., Materials and Methods: In this 2-year prospective cohort study from April 2008 to April 2010, primary-care midwives, who participated in an obstetric emergency course, reported all obstetric complications. Main outcome was neonatal and maternal outcome., Results: In sixty-four cases of shoulder dystocia McRoberts was the first maneuver in 42/64 (65.6%) cases with a success rate of 23.8%. All-fours maneuver was most frequently used as the second maneuver (24/45; 53.3%). No neonatal mortality occurred, none of the infants suffered from hypoxic ischemic injury, two (3.1%) had transient brachial plexus injuries, two (3.1%) had fractured clavicles and one (1.6%) had a fractured humerus. Eight (12.5%) neonates were successfully resuscitated because of birth asphyxia. All infants fully recovered. In neonates with immediate adverse outcome significantly more maneuvers were used compared with those without adverse neonatal outcome (p = 0.02). Postpartum hemorrhage occurred in 2/64 (3.1%) women, deep vaginal lacerations in 2/64 (3.1%), perineal tears in 23/64 (35.9%). No anal sphincter injuries occurred., Conclusions: McRoberts and all-fours maneuvers are widely used by primary-care midwives in the management of shoulder dystocia. Low rates of adverse neonatal and maternal outcomes were observed in cases of shoulder dystocia up to 6 weeks postpartum., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme., Design: Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99), (ii) Early training (2001-04), and (iii) Late training (2009-12)., Setting: Southmead Hospital, Bristol, UK, with approximately 6000 births per annum., Population: Infants and their mothers who experienced shoulder dystocia., Method: A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000., Main Outcomes: Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval)., Results: Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training., Conclusions: There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: To determine the impact of (i) computed tomographic (CT) pelvimetry for the choice of the mode of delivery, (ii) cesarean, (iii) induction of labor, and of (iv) various delivery managements on the risk of shoulder dystocia in case of fetal macrosomia, with or without maternal diabetes, and in women with previous history of shoulder dystocia., Methods: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted., Results: In case of clinically suspected macrosomia, a sonography should be performed to increase diagnostic performances and to assist in decision-making (Professional consensus). Because CT pelvimetry is associated with high false positive rates and increases cesarean deliveries, its use is not recommended to prevent shoulder dystocia in case of fetal macrosomia (Professional consensus). To avoid the neonatal complications of shoulder dystocia, mainly permanent brachial plexus palsy, cesarean delivery is recommended in case of estimated fetal weight (EFW) greater than 4500 g if associated with maternal diabetes (grade C), and greater than 5000 g in the absence of maternal diabetes (grade C). The published data do not provide definitive evidences to recommend systematic labor induction in case of impending fetal macrosomia (Professional consensus). In case of favourable cervix and gestational age greater than 39 weeks of gestation, labor induction should be promoted (Professional consensus). Prophylactic McRoberts maneuver is not recommended to prevent shoulder dystocia in case of fetal macrosomia (grade C). Because data are lacking, no recommendation is possible regarding the use of episiotomy. In case of fetal macrosomia and failure to progress in the second stage of labor, midpelvic and higher instrumental deliveries are not recommended and a cesarean delivery should be preferred (grade C), if the fetal head is at or lower than a +2 station, cesarean delivery is not recommended and an instrumental delivery should be preferred (grade C). Finally, cesarean delivery should be discussed when history of shoulder dystocia has been associated with severe neonatal or maternal complications (Professional consensus)., Conclusion: To avoid shoulder dystocia and its complications, only two measures are proposed. Induction of labor is recommended in case of impending macrosomia if the cervix is favourable and gestational age greater than 39 weeks of gestation (Professional consensus). Cesarean delivery is recommended before labor in case of (i) EFW greater than 4500 g if associated with maternal diabetes (grade C), (ii) EFW greater than 5000 g in the absence of maternal diabetes (grade C), and finally (iii) during labor, in case of fetal macrosomia and failure to progress in the second stage, when the fetal head is above a +2 station (grade C). Finally, cesarean delivery should be discussed when history of shoulder dystocia has been associated with severe neonatal or maternal complications (Professional consensus)., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To determine whether it is possible to prevent the occurrence of risk factors for shoulder dystocia before or during pregnancy., Methods: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. Studied measures were exercise before or during pregnancy, dietary management, and gestational diabetes management in obese and non-obese patients., Results: No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of shoulder dystocia. In the general population, physical exercise is recommended either before or during pregnancy to reduce the risk of gestational diabetes (physical activity before pregnancy) (grade B), fetal macrosomia (grade C) or maternal weight gain during pregnancy (grade C). No dietary regimen is recommended to reduce these issues (grade B). In overweight or obese (body mass index [BMI]>25), physical activity coupled with dietary management is recommended (grade A) because it reduces fetal macrosomia (EL1). In addition, it allows a modest reduction in maternal weight gain during pregnancy (EL2), but did have an effect on the occurrence of gestational diabetes (EL1). In case of gestational diabetes, diabetes care is recommended (diabetic diet, glucose monitoring, insulin if needed) (grade A) as it reduces the risk of macrosomia and shoulder dystocia (EL1). The recommended weight gain during pregnancy is 11.5 kg to 16 kg for normal BMI patients (grade B). Obese patients should be aware of the importance of controlling their weight gain during pregnancy (professional consensus). It is recommended that patients regain their pre-conception weight, and ideally a BMI between 18 and 25 kg/m(2), 6 months postpartum (grade B) to reduce the risk of gestational diabetes and macrosomia in a subsequent pregnancy (EL2)., Conclusion: Physical activity is recommended before and during pregnancy to reduce the occurrence of risk factors for shoulder dystocia. In obese patients, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia., Methods: We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37(+0) weeks and 38(+6) weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320., Findings: We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15-0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01-1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups., Interpretation: Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour., Funding: Assistance Publique-Hôpitaux de Paris and the University of Geneva., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Importance: Shoulder dystocia is an obstetric emergency with potential catastrophic outcomes., Objective: To perform a systematic literature review examining the effectiveness of episiotomy in the prevention and management of shoulder dystocia during vaginal birth., Evidence Acquisition: Search was conducted by a research librarian in MEDLINE, Web of Science, Cochrane Library, and SCOPUS databases using the terms "episiotomy" and "shoulder dystocia," with no language or time restrictions. Two investigators independently selected original researches examining the effects of episiotomy on shoulder dystocia and its neonatal andmaternal outcomes. Relevant articles were accessed in full text, including manual search of the references. We contacted authors of studies with insufficient or unclear data. Because of clinical and methodological diversity of the studies, meta-analysis was not performed., Results: Fourteen articles met the inclusion criteria, encompassing a total of 9769 shoulder dystocia cases. Only 1 study effectively evaluated the role of episiotomy in shoulder dystocia prevention, yielding a nonsignificant result. Three articles assessed neonatal consequences of shoulder dystocia, one of them linking episiotomy to higher risk of neonatal injury. Two of the 3 studies evaluating maternal outcomes showed that episiotomy is related to increased risk of advanced perineal tears. Overall quality of evidence was rated as very low., Conclusions and Relevance: Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue.

Objective: To investigate the composite prevention strategy for shoulder dystocia., Methods: The published articles of randomized controlled trial (RCT) of comparison about the prevention of shoulder dystocia were searched in PubMed, EMBASE, EBSCO databases and Cochrane Library, and these studies were screened under inclusion and exclusion criteria. The quality of included studies were evaluated. And the Meta-analysis using statistic software RevMan 5.1 was completed., Results: Totally 16 articles, all English published with no one Chinese article being searched out, were included in this analysis, published from 1993 to 2009. ( 1)To the gestational diabetes mellitus (GDM) patients, reviewed from 2 articles, it was found that the incidence of shoulder dystocia was reduced significantly by prenatal intervention versus usual care (OR = 0.40, 95% CI:0.21- 0.75, P = 0.004). (2)To the GDM patients with intensive prenatal intervention, reviewed form 5 articles, it was found that the incidence of shoulder dystocia was reduced significantly by intensive intervention(diet control combined with insulin if necessary)versus less intensive intervention (only diet control), OR = 0.29 (95%CI:0.11-0.73, P = 0.009). (3) To the non-GDM patients with suspected macrosomia, reviewed from 4 articles, it was found that the incidence of shoulder dystocia was not reduced by early artificial induction of parturition (OR = 0.85, 95%CI:0.41-1.75, P = 0.660). (4)To the GDM patients, reviewed form 2 articles, it was found that the incidence of shoulder dystocia was reduced marginal significantly by artificial induction of parturition in 38-39 gestational weeks compared with all spontaneous parturition patients (OR = 0.18, 95%CI:0.03-0.97, P = 0.050) and significantly reduced when compared with those spontaneous parturition patients after 40 gestational weeks (OR = 0.13, 95%CI: 0.02-0.75, P = 0.020). (5)To the GDM patients with suspected macrosomia, reviewed from only one article, it was found that the incidence of shoulder dystocia was reduced marginal significantly by early artificial induction of parturition (OR = 0.34, 95%CI:0.12-0.99, P = 0.050). (6)Reviewed from 2 articles, it was found that the incidence of shoulder dystocia was not significantly reduced by the intrapartum prophylactic maneuvers (OR = 0.44, 95% CI:0.16-1.18, P = 0.100)., Conclusion: Some varieties of intervention for the high risk patients could reduced the occurrence of shoulder dystocia.

A belief that prolonged head-to-body delivery interval endangers the newborn underpins the common obstetrical practice of delivering the baby's trunk immediately after the head is born. Without intervention, however, birth typically occurs in two steps: once the fetal head is delivered there is usually a pause, and the rest of the infant is born with the next contraction. Allowing a two-step delivery does not increase the risk of fetal harm, and may lower the incidence of shoulder dystocia. A two-step approach to delivery should be considered physiologically normal. This has implications for the definition of shoulder dystocia.

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Dystocia is a stressful and traumatic event for both the cow and calf. As the prevalence of dystocia has increased over time, attention has been focused on maintaining the health and longevity of the cow. Lack of vitality in the newborn calf may go unnoticed and result in short or long-term implications for calf health and performance. A prolonged or assisted delivery may increase birth stress in calves causing a variety of effects including injury, inflammation, hypoxia, acidosis, pain and an inability to maintain homeostasis. Each of these effects can further contribute to a reduced state of vitality in the newborn calf. Newborn vitality is essential to the health, survival and welfare of the calf. If the calf is not vital at birth, it may be unwilling or unable to get up and suckle colostrum in a timely manner. Early colostrum intake improves passive transfer of immunoglobulins, energy uptake and thermoregulation. Intervention may be required to assist these calves such as respiratory and thermal support, manual feeding of colostrum or the administration of non-steroidal anti-inflammatory drugs to aid health and long-term survival. However, more research is needed to determine ways in which newborn calf vitality can be assessed and improved in order to reduce the increased risk of morbidity and mortality and long-term effects on performance., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

A study was undertaken to investigate the performance of breeding ewes fed a range of forage and concentrate-based diets in late pregnancy, balanced for supply of metabolizable protein (MP). For the final 6 weeks before lambing, 104 twin-bearing multiparous ewes were offered one of four diets: ad libitum precision-chop grass silage + 0.55 kg/day concentrates (GS); ad libitum maize silage + 0.55 kg/day concentrates (MS); a 1 : 1 mixture (on a dry matter (DM) basis) of grass silage and maize silage fed ad libitum + 0.55 kg/day (GSMS); or 1.55 kg/day concentrates + 50 g/day chopped barley straw (C). The CP content of the concentrates was varied between treatments (157 to 296 g/kg DM) with the aim of achieving a daily intake of 130 g/day MP across all treatments. Compared with ewes fed GS, forage DM intake was higher (P < 0.05) in ewes fed MS (+0.21 kg/day) and GSMS (+0.16 kg/day), resulting in higher (P < 0.001) total DM intakes with these treatments. C ewes had the lowest total DM intake of all the treatments examined (P < 0.001). C ewes lost more live weight (LW; P < 0.001) and body condition score (BCS; P < 0.05) during the first 3 weeks of the study but there were no dietary effects on ewe LW or BCS thereafter. The incidence of dystocia was lower (P < 0.01) in C ewes compared with those offered silage-based diets (7.5% v. 37.4% ewes), and was higher (P < 0.01) in ewes fed MS compared with GS or GSMS (50.7%, 34.7% and 26.9%, respectively). There were no significant dietary effects on the plasma metabolite concentrations of ewes in late pregnancy, pre-weaning lamb mortality, weaned lamb output per ewe or on lamb growth rate. The results of this study demonstrate that both maize silage and all-concentrate diets can replace grass silage in pregnant ewe rations without impacting on performance, provided the supply of MP is non-limiting. The higher incidence of dystocia in ewes fed maize silage as the sole forage is a concern.

As a way to prevent maternal mortality and stillbirth, the dystocia risk score includes three components: a left column provides a list of eight characteristics to check for in the woman; an upper horizontal section provides a checklist of possible outcomes of the pregnancy itself: and a rectangular grid indicates the prognosis in three zones: a large red (dangerous), a medium-sized grey (doubtful) and a small blue (hopeful). The DRS is positive if there is at least one cross in the dangerous zone and/or two crosses in the doubtful zone (it indicates that the woman should be referred to a center specialized in obstetric emergency care); elsewhere, the DRS is negative. The validation test gives good results (sensitivity=83.61%, specificity=90.05%, positive predictive value=72.34%, and negative predictive value=94.04%). Its large-scale use would accelerate the identification of pregnant women with a high risk of dystocia. Their timely referral to specialized emergency obstetrics centers would increase the efficacy of care and reduce the levels of maternal mortality and stillbirth., (Copyright © 2013 Académie des sciences. Published by Elsevier SAS. All rights reserved.)

Birth injuries are devastating to parents and carers alike. They carry the possibility of residual loss of function to the infant and thus the potential for litigation. The aim of this study was to determine the incidence of Erb-Duchenne's palsy and the identification of any contributing factors. A retrospective review over a five-year period, 2005-2009, was performed and an incidence of 0.94 per 1000 live births was noted. An association between both macrosomia and shoulder dystocia and the development of Erb-Duchenne palsy in the newborn was noted. The authors recommended the use of partograms and improved note documentation in the management of labour.