BACKGROUND AND PURPOSE:

• Guidelines recommend simulation exercises, communication skills, and documentation for labor and delivery staff to reduce risk for adverse outcomes associated with shoulder dystocia
• Wagner et al. (AJOG, 2021) evaluated the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia

METHODS:

• Systematic review and meta-analysis
• Study inclusion criteria
  • Reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes
• Study design
  • Quality of included studies was evaluated
  • Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Cr)
• Primary outcomes
  • neonatal brachial plexus palsy (NBPP) following shoulder dystocia
  • Persistence of brachial palsy ≥12 months
• Secondary outcomes
  • Frequency of shoulder dystocia
  • Frequency of cesarean delivery

RESULTS:

• 16 studies | 428,552 deliveries total
  • Deliveries preintervention: 50.8%
  • Deliveries postintervention: 49.2%
• The incidence of NBPP after shoulder dystocia decreased postintervention
  • Preintervention: 12.1%
  • postintervention: 5.7%
  • RR 0.37 (95% Cr, 0.26 to 0.57); probability of reduction 100%
• The overall proportion of neonatal brachial plexus palsy also decreased
  • Preintervention: 0.3%
  • Postintervention: 0.1%
  • RR 0.53 (95% Cr, 0.21 to 1.26); probability of reduction 94%
• 2 studies followed newborns with NBPP for ≥12 months
  • First study followed shoulder dystocia cases only and found a reduction in persistent NBPP
    • Preintervention: 1.9%
    • Postintervention: 0.2%
    • RR 0.13 (95% CI, 0.04 to 0.49)
  • Second study followed all deliveries and found no significant difference
    • Preintervention: 0.3 per 1000 births
    • Postintervention: 0.2 per 1000 births
    • RR 0.77 (95% CI, 0.31 to 1.90)
• Diagnosis of shoulder dystocia increased significantly following simulation implementation
  • Preintervention: 1.2%
  • Postintervention: 1.7%
  • RR 1.39 (95% Cr, 1.19 to 1.65); probability of increase 100%
• The overall cesarean delivery rate increased postintervention
  • Preintervention: 21.2%
  • Postintervention: 25.9%
  • RR 1.22 (95% Cr, 0.93 to 1.59); probability of increase 93%

CONCLUSION:

• The rate of NBPP per shoulder dystocia cases decreased following implementation of interventional exercises
• Data on persistent NBPP at 12 months are limited and inconsistent
• Postimplementation, the rates of shoulder dystocia diagnoses and cesarean deliveries increased
• The authors created an online tool to calculate absolute change in risk related to interventions (see ‘Learn More – Primary Sources’ below)
• The authors state

…risk for NBPP following shoulder dystocia decreased by 63% postintervention compared with the preintervention period

However, concurrent with the decrease in the risk for NBPP per shoulder dystocia case, the frequency of documented shoulder dystocia cases increased by 39% alongside a 22% increase in the rate of cesarean delivery

Learn More – Primary Sources:

Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis

Tool for calculation of risk decrease and increase attributable to intervention

Related ObG Topics: