Newborn brachial plexus palsy.

Understanding the causation of newborn brachial plexus injuries and why they are not decreasing in frequency.

Catastrophic shoulder dystocia.

OBJECTIVE: The objective of this paper is to outline in a stepwise fashion a life-saving management sequence for catastrophic shoulder dystocia. METHOD: Five cases of catastrophic shoulder dystocia are analyzed to determine optimal management when confronted with this terrifying obstetric complication. RESULT: The management of these five cases reveals the importance of the early use of uterine relaxing agents and general anesthesia. A second physician is also ideal. The absence of a nuchal cord may result in more favorable outcomes. CONCLUSION: The key to achieving improved outcomes when confronted with catastrophic shoulder dystocia include (1) immediate availability of an operating room and anesthesia personnel, (2) the willingness to use uterine relaxing agents, (3) the availability of a second physician, (4) an understanding of the best sequence of remedial measures to follow, (5) total delivery within 12-13 min of the delivery of the head (almost impossible when the delivery process begins in a birthing room) and (6) a cesarean room should be considered for delivery of all massively obese women.

Erb's palsy without shoulder dystocia.

OBJECTIVES: The purpose of this commentary is to review certain articles which have provided evidence that Erb's palsy can occur without associated shoulder dystocia. The mechanism of the specific cause of the injury will be described. METHODS: Prior to the last 10-12 years it was assumed that Erb's palsy occurred exclusively with and was the result of shoulder dystocia. Gonik et al. [Am J Perinat 1991;8:31-34], reported on a research study based on the premise that when Erb's palsies occurred there must have been shoulder dystocia present but it went undetected by the delivering physician. Subsequently Gherman [Am J Obstet Gynecol 1998;178:423-427], published a detailed study which carefully looked at multiple aspects of shoulder dystocia including those similar injuries occurring with and without associated shoulder dystocia. RESULTS: Both Gonik's and Gherman's research revealed distinct maternal and newborn differences when comparing Erb's palsy occurring with and without associated shoulder dystocia. These differences, which have nothing to do with the ability to recognize shoulder dystocia, provide conclusive evidence that Erb's palsy does occur without associated shoulder dystocia. CONCLUSIONS: Therefore, Gonik's original premise, that shoulder dystocia must have been present if Erb's palsy occurred, is not supported. This brings into question the cause of Erb's palsy in those cases without shoulder dystocia. The maternal forces are the most likely cause both with and without shoulder dystocia.

Erb's palsy: concepts of causation.

In the past, obstetric textbooks have stated (without evidence) that Erb's palsy is caused by the birth attendant. The mechanism cited is stated to be the application of excessive lateral traction placed on the fetal head and neck. Recent research findings refute this unproven theory. Findings include (1) only 50% of cases are associated with shoulder dystocia; (2) the 4.7-fold increase in the condition was associated with a precipitate second stage compared with one of normal length; and (3) the same injury rate with direct manipulation techniques (for resolving shoulder dystocia) was comparable to that of McRobert's position and/or suprapubic pressure. The overwhelming evidence indicts the propulsive nature of the stretching of the involved nerves over which the birth attendant has no control.

The Green Bay cesarean section study. IV. The physician factor as a determinant of cesarean birth rates for the large fetus.

OBJECTIVES: Our purpose was to determine those factors affecting the route of delivery decisions and the effect of delivery route on maternal and newborn outcomes with the macrosomic fetus. Do higher cesarean rates result in improved newborn outcomes? STUDY DESIGN: A 10-year (1985 to 1994) retrospective data set was used to analyze patients with newborns weighing > or = 4536 and 4000 to 4535 gm at two Green Bay hospitals. Patients with newborns weighing 2500 to 3999 gm were similarly analyzed for comparison purposes. Individual and obstetrician group cesarean rates and newborn and maternal outcomes were identified. RESULTS: Cesarean birth rates for the fetus weighing > 4000 gm were low and varied from 12.8% in the low obstetrician cesarean rate group to 24.0% in the high group. Higher obstetrician group cesarean rates did not result in improved newborn outcomes. Newborn morbidity and mortality were very low but significantly higher for cesarean birth newborns. Maternal complications were fairly low with cesarean birth and rare after vaginal delivery. CONCLUSION: Patients with a suspected macrosomic fetus should be given the same opportunity to achieve a vaginal delivery as patients with smaller fetuses.

Auscultation of the fetal heart presents advantages over electronic monitoring.

Currently available data support the conclusion that within specified intervals, intermittent auscultation of fetal heart sounds is equivalent to continuous electronic fetal monitoring (EFM) for detecting intrapartum fetal compromise. One of the disadvantages of EFM is its associated increase in cesarean delivery rates. Patients should receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment. Presently, EFM is routinely used with the majority of laboring patients in the United States. This is likely due to confusion regarding the proper technique used for intermittent auscultation as well as insufficient information about appropriate interventions in the event fetal bradycardia occurs. We have developed a protocol for the performance of intermittent auscultation, including recommended responses to different levels of bradycardia. Intermittent auscultation is simple, provides objective information, and appeals to many well-informed patients. In addition, when the collection of information not relevant to management decisions is eliminated, intermittent auscultation nursing requirements are not greater than with EFM. Laboring patients should receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment.

The Green Bay cesarean section study. III. Falling cesarean birth rates without a formal curtailment program.

OBJECTIVES: We observed decreases in cesarean birth rates at two Green Bay hospitals after the 1990 publication of our first cesarean section study. The purpose of this study was to determine the causes of those decreases and to see whether any outcome changes occurred with lower rates. An additional objective was to determine the perceptions of the 10 physicians regarding the determinants of cesarean birth rates. STUDY DESIGN: We compared recent cesarean birth rates (1990 to 1992) to former rates (1986 to 1988) for 10 of the 11 physicians analyzed in our previous studies. Newborn outcomes were analyzed to determine whether variations occur in comparing low to high cesarean rate physician groups. RESULTS: The total, primary, and repeat cesarean birth rates declined from 13.3% to 10.2%, 8.6% to 6.8%, and 4.7% to 3.4%, respectively, between 1986 to 1988 and 1990 to 1992. Variations in cesarean rates occurred among physicians and groups of physicians. Higher cesarean rates did not result in better perinatal outcome. Literature reports, residency training, continuing medical education attendance, and liability risks were the major determinants of cesarean birth as perceived by the 10 physicians in the study. The least important determinant, rated fifteenth of 15, was the national cesarean birth rate.

Whither ultrasonic prediction of fetal macrosomia?

During the past 15-20 years, ultrasonic estimation of fetal weight (EFW) has been used increasingly to make management decisions regarding the induction of labor or delivery route. The propriety of this approach depends on proof that its use improves newborn or maternal outcome without disproportionate increases in morbidity and mortality. A barrier to achieving this goal is the inaccuracy associated with ultrasonic EFW. The current ultrasonic EFW procedures are not accurate enough for detecting macrosomia defined by weight criteria. Even if clinicians could determine fetal weight accurately, the frequency of persistent fetal injuries associated with vaginal birth of the macrosomic fetus is so low that induction of labor or cesarean birth is not justified on that basis. Furthermore, the inaccurate ultrasonic determination of fetal weight leads to inappropriate obstetric interventions. Evidence-based decision-making should be an important goal for all obstetric care givers. Delivery decisions based on inaccurate EFW should be avoided.

The Green Bay cesarean section study. II. The physician factor as a determinant of cesarean birth rates for failed labor.

OBJECTIVE: Our study was designed to develop a profile of specific labor management characteristics generally used by physicians with low versus those with high rates of cesarean sections in the care of nonprogressive labor in nulliparous patients. STUDY DESIGN: A 4-year retrospective data set was used to analyze all patients with nonprogressive labor cared for by 11 board-certified obstetricians and gynecologists practicing full-time at two Green Bay hospitals. Variations in labor management are analyzed and tested for their effect on the rate of cesarean section for failure of labor to progress. RESULTS: Cesarean section in nulliparous women for nonprogressive labor varied from 4.3% of all deliveries in the low group to 12.3% in the high group. Through multivariate analysis we developed a profile of specific labor management characteristics used by physicians with low versus those with high rates of cesarean section. CONCLUSION: These techniques can be used to definitively identify management strategies that result in a decrease in cesarean rates for nonprogressive labor.

Whither electronic fetal monitoring?

Largely based on promising animal studies, continuous electronic fetal monitoring (EFM) was introduced into clinical practice in the early 1970s. After almost 20 years of experience, it is now apparent that the anticipated benefits of this technology have not materialized. Undesirable side effects of EFM include inappropriate operative intervention for some patients and increased liability for physicians and hospitals, resulting in an increase in the costs of obstetric services. After reviewing several research studies, The American College of Obstetricians and Gynecologists concluded that EFM and intermittent auscultation are equivalent methods for intrapartum assessment. We have developed a protocol for the performance of intermittent auscultation, including indicated responses to different levels of bradycardia. This protocol has allowed us to substitute auscultation for EFM in a high percentage of patients using existing nursing personnel. Laboring patients should, at a minimum, receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment.