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Savas Menticoglou Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada Abstract: Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts’ position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier’s maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord. Keywords: shoulder dystocia, brachial plexus injury, symphysiotomy, neonatal resuscitation, Jacquemier’s maneuver

Objective: It was our goal to determine the false-negative rate of the biophysical profile, characterize an 18-year variation in the false-negative rate, examine the relationship between the last normal biophysical profile score and death, and compare the false-negative rate of 2 disparate populations.Study Design: Biophysical profile scores of 86,955 patients at 2 medical centers were collected and recorded prospectively. All perinatal deaths occurring within 1 week of a normal score were similarly recorded. The annual false-negative rate, the cumulative false-negative rate, and the ratio of false-negative results in cases of subsequent fetal death to the perinatal mortality rate were calculated.Results: There were 65 fetal deaths among 86,955 fetuses. Over an 18-year study period at one institution, the false-negative rate varied but not significantly. The cumulative false-negative rate was 0.708 per 1000 at one medical center studied and 2.289 per 1000 at the other center. The average interval between last normal score and fetal death was 3.62 days and did not vary significantly between the medical centers.Conclusions: False-negative results in cases of subsequent fetal death reflect events that are subsequent to the last normal test result. Fetomaternal hemorrhage was the single most identifiable fetal cause of false-negative results in cases of subsequent fetal death. The ratio of the false-negative rate in cases of subsequent fetal death to the perinatal mortality rate should be used as a more objective approach to reporting this value, because the false-negative rate likely reflects the underlying perinatal mortality. [ABSTRACT FROM AUTHOR]

Objective: The intent of this comparative clinical study was fourfold: (1) to determine the incidence of cerebral palsy in a large obstetric population, (2) to compare the incidence of cerebral palsy in patients at high risk referred for and managed according to the fetal biophysical profile score result with the incidence among unreferred and untested patients, (3) to determine the relationship, if any, between the last fetal biophysical profile score and the incidence of cerebral palsy, and (4) to categorize cases of cerebral palsy according to the clinical parameters and the probable time and nature of the damaging insult.Study Design: In this retrospective 5-year comparative study (1987 to 1991) the incidence of cerebral palsy was determined by analysis of International Classification of Diseases, Ninth Revision, -coded related medical services. The clinical records were then sought and reviewed in index cases and obstetric, neonatal, and postnatal clinical data were abstracted. Cross-correlation with partial registries was done to confirm completeness of capture of index cases. The population of referred high-risk patients who received serial fetal biophysical profile scoring and were managed according to test results was determined by review of a prospective computer-stored database and by review of patient log books. The population of untested patients was calculated as the residual of total cases minus tested cases. The rate of cerebral palsy for all patients and for the tested and untested population was calculated and compared. The tested and untested perinates were compared for birth age, weight, and assigned timing or etiology of cerebral palsy. In the tested population the distribution of test results by last recorded biophysical profile score was determined and the relationship between the last test result and cerebral palsy and predictive accuracy parameters of the fetal biophysical profile score were calculated.Results: The incidence of cerebral palsy among the 84,947 live births was 3.68 per 1000 live births (313 cases). The rate of cerebral palsy in the 26,290 referred high-risk tested patients was 1.33 per 1000 (35 cases) compared with a rate of 4.74 per 1000 live births in the 58,657 untested mixed low-risk/high-risk patients (278 cases). These differences were highly significant. A significant declining trend in the annual incidence of cerebral palsy was observed in the total population and the untested population, whereas the rate in the tested population remained relatively constant over the 5-year study interval. The differences in the cerebral palsy rate between the tested and untested population were not related to differences in gestational age, birth weight, or assigned timing or etiology category. In the tested population the relationship between the incidence of cerebral palsy and the last test fetal biophysical profile score was inverse, exponential, and highly significant.Conclusions: Antepartum assessment by fetal biophysical profile scoring is associated with a significant reduction in the incidence of cerebral palsy compared with untested patients. The relationship between the last test score and the incidence of cerebral palsy is inverse and exponential, suggesting that antenatal asphyxia is an important and potentially avoidable cause of cerebral palsy. [ABSTRACT FROM AUTHOR]

Objectifs: Déterminer les risques et les avantages de l'accouchement du siège par voie vaginale planifié par rapport à la césarienne planifiée et recommander des critères de sélection, des paramètres de prise en charge intrapartum et des techniques d'accouchement du siège par voie vaginale., Options: Accouchement du siège par voie vaginale planifié ou césarienne planifiée en cas de grossesse monofœtale à terme., Issues: Mortalité périnatale, morbidité néonatale et infantile à court et à long terme, mortalité maternelle et morbidité maternelle à court et à long terme. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline jusqu'à avril 2018 pour trouver des essais randomisés et des études de cohortes qui comparent les issues après l'accouchement du siège par voie vaginale planifié et la césarienne planifiée, ainsi que des études de cohortes qui comparent les techniques d'accouchement du siège par voie vaginale. Des articles supplémentaires ont été repérés dans les bibliographies., Validation: L'évaluation par les pairs de la présente directive clinique a été réalisée par des cliniciens internationaux experts en accouchement du siège par voie vaginale; la directive a également été comparée à la ligne directrice du Royal College of Obstetricians and Gynecologists, Green-top Guideline N o  20b : Management of Breech Presentation. Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes utilisées dans le présent document a été évaluée au moyen des critères du cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)., Promoteurs: Société des obstétriciens et gynécologues du Canada. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS: Critères de sélection du travailPrise en charge du travailTechnique d'accouchementSituation et consentement., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: To discern the risks and benefits of planned vaginal breech birth versus planned Caesarean section and to recommend selection criteria, intrapartum management parameters, and delivery techniques for vaginal breech birth., Options: Planned vaginal breech birth or planned Caesarean section for women with a singleton breech fetus at term., Outcomes: Perinatal mortality, short- and long-term neonatal/infant morbidity, maternal mortality, and short- and long-term maternal morbidity., Evidence: Medline was searched up to April, 2018 for randomized trials and cohort studies comparing outcomes after planned vaginal breech birth and planned Caesarean section and for cohort studies comparing vaginal breech birth techniques. Additional articles were identified through bibliography tracing., Validation: This guideline was peer reviewed by international clinicians with expertise in vaginal breech birth and compared with the 2017 Royal College of Obstetricians and Gynaecologists Green Top Guideline 20b: Management of Breech Presentation. The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework., Sponsors: The Society of Obstetricians and Gynaecologists of Canada., Summary Statements: RECOMMENDATIONS: Labour Selection Criteria Labour Management Delivery Technique Setting and Consent., (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.)

The human (h) placental lactogenic hormone chorionic somatomammotropin (CS) is highly produced during pregnancy and acts as a metabolic adaptor in response to maternal insulin resistance. Maternal obesity can exacerbate this "resistance", and a >75% decrease in CS RNA levels was observed in term placentas from obese vs. lean women. The genes coding for hCS ( hCS-A and hCS-B) and placental growth hormone ( hGH-V) as well as the hCS-L pseudogene and pituitary growth hormone (GH) gene ( hGH-N) are located at a single locus on chromosome 17. Three remote hypersensitive sites (HS III-V) located >28 kb upstream of hGH-N as well as local hCS gene promoter and enhancer regions are implicated in hCS gene expression. A placenta-specific chromosomal architecture, including interaction between HS III-V and hCS but not hGH gene promoters, was detected in placentas from lean women (BMI <25 kg/m 2 ) by using the chromosome conformation capture assay. This architecture was disrupted by pre-pregnancy maternal obesity (BMI >35 kg/m 2 ), resulting in a predominant interaction between HS III and the hGH-N promoter, which was also observed in nonplacental tissues. This was accompanied by a decrease in hCS levels, which was consistent with reduced RNA polymerase II and CCAAT/enhancer-binding protein-β association with individual hCS promoter and enhancer sequences, respectively. Thus, pre-pregnancy maternal obesity disrupts the placental hGH/CS gene locus chromosomal architecture. However, based on data from obese women who develop GDM, insulin treatment partially recapitulates the chromosomal architecture seen in lean women and positively affects hCS production, presumably facilitating prolactin receptor-related signaling by hCS.

Objective: We reviewed cases of group B Streptococcus (GBS) sepsis in term infants at our institution to identify areas for potential prevention., Methods: We identified cases by searching our institution's microbiology databases for all positive GBS blood and cerebrospinal fluid cultures taken from infants between 2008 and 2013. Patients were included if the timing of the positive culture met the criteria for early-onset GBS disease (age 7 days or under). Charts that met inclusion criteria were abstracted for details related to antepartum screening, intrapartum care, and postpartum outcome., Results: There are an average of 10 000 deliveries per year in our institution. During the five-year period (2008-2013), we identified 13 cases representing early-onset GBS disease in term infants. Of the 13 cases, nine mothers screened negative for GBS, two screened positive, and two were screened unknown. Four cases qualified for intrapartum prophylaxis; of these, two did not receive appropriate prophylaxis, one because of parental refusal and one for unspecified reasons after the membranes had been ruptured for > 18 hours. All 13 infants had confirmed GBS bacteremia, and four had concurrent GBS meningitis. One infant died and one infant had neurologic sequelae., Conclusion: Early-onset GBS disease in term infants continues to occur at our institution, and consequences for the infant can be severe. The majority of cases identified were screened and managed in accordance with current guidelines. Most cases were GBS negative when screened in the antepartum period, raising the question of whether a more sensitive test or a test closer to delivery could prevent further cases of early-onset GBS disease., (Copyright © 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background. To propose hypovolemic shock as a possible explanation for the failure to resuscitate some babies after shoulder dystocia and to suggest a change in clinical practice. Case Presentation. Two cases are presented in which severe shoulder dystocia was resolved within five minutes. Both babies were born without a heartbeat. Despite standard resuscitation by expert neonatologists, no heartbeat was obtained until volume resuscitation was started, at 25 minutes in the first case and 11 minutes in the second. After volume resuscitation circulation was restored, there was profound brain damage and the babies died. Conclusion. Unsuspected hypovolemic shock may explain some cases of failed resuscitation after shoulder dystocia. This may require a change in clinical practice. Rather than immediately clamping the cord after the baby is delivered, it is proposed that (1) the obstetrician delay cord clamping to allow autotransfusion of the baby from the placenta and (2) the neonatal resuscitators give volume much sooner.

Objective: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient., Outcomes: Significant health and economic outcomes considered in comparing alternative practices., Evidence: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1)., Benefits, Harms, and Costs: This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Objective: The purpose of this study was to evaluate pregnancy outcomes in a cohort of women with a placental edge between 11 and 20 mm from the internal cervical os, and to determine the likelihood of a successful vaginal delivery when trial of labour is attempted in these women., Methods: We carried out a prospective observational study of women with singleton pregnancies and a placental edge between 11 and 20 mm from the internal cervical os (identified by transvaginal sonography) who underwent a trial of labour., Results: Fourteen women with the above characteristics underwent a trial of labour during the study period. The mean interval (± SD) from ultrasound to delivery was 17.2 ± 9.6 days. Thirteen women (92.9%) delivered vaginally with no complications, and only one woman (7.1%) required an emergency Caesarean section for intrapartum bleeding. The risks of antepartum and postpartum hemorrhage were 21.4% and 14.3%, respectively., Conclusion: Having a placental edge more than 10 mm from the internal os, measured by transvaginal sonography near term, justifies allowing a trial of labour and carries a low risk of subsequent obstetrical hemorrhage.

Human chorionic somatomammotropin (CS) and placental growth hormone variant (GH-V) act as metabolic adaptors in response to maternal insulin resistance, which occurs in "normal" pregnancy. Maternal obesity can exacerbate this "resistance," suggesting that CS, GH-V, or transcription factors that regulate their production might be targets. The human CS genes, hCS-A and hCS-B, flank the GH-V gene. A significant decrease in pre-term placental CS/GH-V RNA levels was observed in transgenic mice containing the CS/GH-V genes in a model of high fat diet (HFD)-induced maternal obesity. Similarly, a decrease in CS/GH-V RNA levels was detected in term placentas from obese (body mass index (BMI) ≥ 35 kg/m(2)) versus lean (BMI 20-25 kg/m(2)) women. A specific decrease in transcription factor CCAAT-enhancer-binding protein β (C/EBPβ) RNA levels was also seen with obesity; C/EBPβ is required for mouse placenta development and is expressed, like CS and GH-V, in syncytiotrophoblasts. Binding of C/EBPβ to the CS gene downstream enhancer regions, which by virtue of their position distally flank the GH-V gene, was reduced in placenta chromatin from mice on a HFD and in obese women; a corresponding decrease in RNA polymerase II associated with CS/GH-V promoters was also observed. Detection of decreased endogenous CS/GH-V RNA levels in human placental tumor cells treated with C/EBPβ siRNA is consistent with a direct effect. These data provide evidence for CS/GH-V dysregulation in acute HFD-induced obesity in mouse pregnancy and chronic obesity in human pregnancy and implicate C/EBPβ, a factor associated with CS regulation and placental development.

Background: Uterine incarceration occurs when the gravid uterus remains trapped within the sacral hollow and cannot ascend out of the pelvis as it enlarges. Predisposing factors include uterine fibroids. Optimal management of uterine incarceration involves manual reduction of the uterus because of the significant maternal and fetal risks associated with persistent incarceration., Case: A nulliparous woman with known uterine incarceration secondary to a large anterior uterine fibroid was managed conservatively throughout her pregnancy after attempts at manual reduction were unsuccessful., Conclusion: Conservative management of the incarcerated uterus is a reasonable option if attempts at manual reduction are unsuccessful. Magnetic resonance imaging can be helpful in delineating anatomy and planning for delivery.

Background: Urgent delivery of the fetus is often considered as the treatment of choice for mothers in their second or third trimester with hepatitis unique to pregnancy (HUP)., Objective: To determine whether standard liver function tests (serum bilirubin and international normalized ratio levels) help to identify mothers and their newborns who might benefit from early delivery., Methods: A total of 149 patients with HUP were retrospectively classified as those with normal (stable-HUP, n=118) or abnormal (progressive-HUP, n=31) liver function tests. Clinical outcomes consisted of maternal lengths of hospital stay after delivery and neonatal appearance, pulse, grimace, activity, respiration score ratings at 0 and 5 min., Results: Patients with stable-HUP had similar lengths of hospital stay after delivery whether delivered early (4.8±3.4 days) or at term (4.8±3.6 days). Appearance, pulse, grimace, activity, respiration score ratings at birth were similar in neonates from patients with stable-HUP delivered prematurely (5.8±2.7) and at term (7.8±1.7, P=0.48) but significantly higher at 5 min in those delivered at term (7.5±2.0 vs. 8.9±0.3, P=0.003). Too few patients with progressive-HUP were delivered at term (N=4) to allow similar comparisons in this cohort., Conclusion: The results of this study indicate that mothers with HUP and normal liver function tests (bilirubin and international normalized ratio) can be safely followed to term without jeopardizing the health of either mother or neonates. Additional studies are required to determine whether abnormal liver function tests represent an indication for immediate delivery of the fetus in mothers with HUP.