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

https://doi.org/10.1016/j.ajog.2021.05.008Get rights and content

Objective

This study aimed to evaluate the outcomes associated with the implementation of simulation exercises to reduce the sequela of shoulder dystocia.

Data Sources

Electronic databases (Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and Scopus) were initially queried in June 2020 and updated in November 2020. The following 3 concepts were introduced and refined using the controlled vocabulary of the database: vaginal birth, shoulder dystocia, and simulation training. There were no limitations to the year of publication as part of the search strategy.

Study Eligibility Criteria

We included all studies that reported on the frequency of shoulder dystocia and the associated complications before and after the implementation of interventional exercises to improve outcomes.

Methods

Two authors independently assessed the abstracts and full-text articles of all studies for eligibility and evaluated the quality of the included studies using the Newcastle-Ottawa Scale. Any inconsistencies related to study evaluation or data extraction were resolved by a third author. The coprimary outcomes of this systematic review and meta-analysis were neonatal brachial plexus palsy diagnosed following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the frequency of shoulder dystocia and cesarean delivery. Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs).

Results

Of the 372 articles reviewed, 16 publications, which included 428,552 deliveries with 217,713 (50.8%) deliveries during the preintervention and 210,839 (49.2%) deliveries during the postinterventional period, were included in the meta-analysis. The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from 12.1% to 5.7% (risk ratio, 0.37; 95% Cr, 0.26–0.57; probability of reduction 100%). The overall proportion of neonatal brachial plexus palsy decreased, but with less precision, from 0.3% to 0.1% (risk ratio, 0.53; 95% Cr, 0.21–1.26; probability of reduction 94%). Two studies followed newborns with brachial plexus palsy for at least 12 months. One study that reported on persistent neonatal brachial plexus palsy at 12 months among 1148 shoulder dystocia cases noted a reduction in persistent neonatal brachial plexus palsy from 1.9% to 0.2% of shoulder dystocia cases (risk ratio, 0.13; 95% confidence interval, 0.04–0.49). In contrast, the study that reported on persistent neonatal brachial plexus palsy at 12 months for all deliveries noted that it did not change significantly, namely from 0.3 to 0.2 per 1000 births (risk ratio, 0.77; 95% confidence interval, 0.31–1.90). Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly from 1.2% to 1.7% of vaginal deliveries (risk ratio, 1.39; 95% Cr, 1.19–1.65; probability of increase 100%). Compared with the preimplementation period, the cesarean delivery rate increased postimplementation from 21.2% to 25.9% (risk ratio, 1.22; 95% Cr, 0.93–1.59; probability of increase 93%). We created an online tool (https://ccrebm-bell.shinyapps.io/sdmeta/) that permits calculation of the absolute risk reduction and absolute risk increase attributable to the intervention vis-à-vis the incidence of shoulder dystocia, neonatal brachial plexus palsy, and cesarean deliveries.

Conclusion

Introduction of shoulder dystocia interventional exercises decreased the rate of neonatal brachial plexus palsy per shoulder dystocia case; the data on persistence of neonatal brachial plexus palsy beyond 12 months is limited and contradictory. Implementation of the interventions was associated with an increase in the diagnosis of shoulder dystocia and rate of cesarean deliveries.

Introduction

Shoulder dystocia occurs in about 1% to 3% of all deliveries and, by definition, requires additional maneuvers other than gentle traction to effectuate birth. Deliveries complicated by shoulder dystocia are associated with maternal (eg, obstetrical anal sphincter injuries) and neonatal complications (eg, fracture).1 Among the various complications linked to shoulder dystocia, neonatal brachial plexus palsy (NBPP), defined as weakness or paralysis of the upper extremity, is associated with long-term sequelae like contractures and subluxations, need for microreconstruction and muscle transfers with residual muscle imbalance, and glenohumeral abnormalities.2, 3, 4, 5, 6, 7 In addition, children with NBPP are at risk for obesity and for developing psychological and behavioral problems.8,9

To reduce the risk of NBPP, 3 national guidelines on shoulder dystocia recommend interventional exercises (ie, consisting variably of didactics, communication skills, simulation exercises with mannequins, reviewing the maneuvers to use, debriefing, and documentation) for all staff in the labor and delivery unit because it improves communication skills and reduces the incidence of NBPP associated with shoulder dystocia.1,10,11 Some reports on the topic of simulated exercise suggest a reduction in the frequency of NBPP after the implementation of training.12,13 A universal recommendation for simulated training, however, is problematic for at least 4 reasons. First, some reports suggest that the rate of brachial plexus palsy does not change or may paradoxically increase after training.14, 15, 16 Second, the decrease in the likelihood of palsy at the time of shoulder dystocia may be caused by an increased rate of cesarean delivery or a tendency to overdiagnose shoulder dystocia. Third, about 40% of palsy cases is not associated with shoulder dystocia and a smaller proportion is diagnosed subsequent to cesarean delivery.2,17,18 Fourth, in the absence of a systematic review and meta-analysis, the unintended consequences of interventions are insufficiently explored.

The coprimary outcomes of this systematic review and meta-analysis were a diagnosis of NBPP following deliveries complicated by shoulder dystocia and persistence of brachial palsy at 12 months or later. The secondary outcomes were the impact of the intervention on the frequency of shoulder dystocia and cesarean delivery.

Section snippets

Sources

This systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews database (CRD42020166467) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.19 A comprehensive literature search was conducted by a trained Medical Librarian (L.O.) to locate material on the effect of interventional exercises on the clinical outcomes of vaginal births complicated by shoulder dystocia. Using Ovid MEDLINE

Study Selection

We included randomized and nonrandomized studies published in English that reported on the outcomes of brachial plexus injury after the implementation of shoulder dystocia interventional exercises in labor and delivery units. We excluded studies that did not examine the rates of neonatal brachial plexus injury after the implementation of interventional exercises to reduce sequelae of shoulder dystocia or those that did not assess the outcomes of a shoulder dystocia simulation program. Data from

Results

Of the 1298 articles identified, 751 nonduplicated articles were screened and 379 of these were excluded. A total of 372 full-text articles were assessed of which 16 met the inclusion criteria (Figure 1); 14 of these were peer-reviewed publications and 2 were abstracts.12,13,15,16,21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 The 16 included studies encompassed 428,552 deliveries, with 217,713 (50.8%) deliveries in labor and delivery units not exposed to interventional exercises and 210,839

Principal findings of the study

Our systematic review and meta-analysis of intervention studies indicate that the 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, albeit with significant heterogeneity in the findings across studies. The overall

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    The authors report no conflict of interest.

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