American Journal of Obstetrics and Gynecology
Systematic ReviewsInterventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis
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.