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Grand Rounds

Meta-Analysis: Do Interventional Exercises for Shoulder Dystocia Impact Outcomes?

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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

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Related ObG Topics:

Meta-analysis Results: Do Shoulder Dystocia Simulations Reduce the Prevalence of Neonatal Brachial Plexus Palsy?
New Technique: Shoulder Shrug Maneuver for Delivery During Shoulder Dystocia
How Often are Brachial Plexus Injuries Associated with Shoulder Dystocia?

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