What is the appropriate mode of delivery after a previous shoulder dystocia?

 

  • The rate of SD in women who have had a previous SD has been reported to be 10 times higher than the rate in the general population.There is a reported recurrence rate of SD of between 1% and 25%.May be an underestimate due to selection bias,as CS may have been advocated for pregnancies after severe SD esp with a poor neonatal outcome.(Level 3 evid).
  • Either CS or vaginal delivery can be appropriate.(Recommendation Level D).There is no requirement to recommend elective CS routinely,but factors such as severity of any previous neonatal or maternal injury,predicted fetal size and maternal choice should all be considered and discussed with the woman and her family,in planning the next delivery.(Level 4 evid)

Does induction of labour prevent shoulder dystocia?

  •  Early IOL for women with suspected fetal macrosomia,who do not have gestational diabetes,does not improve either maternal or fetal outcome.(Evid level 4)
  • In women with gestational diabetes, the incidence of SD is reduced with early IOL.(Evid level 2+)
  • The NICE diabetes guideline recommends that pregnant women with diabetes who have a normally grown fetus should be offered elective birth through IOL,or by elective CS if indicated, after 38 completed weeks
  • Infants of diabetic mothers have a 2-4 fold increased risk of SD compared with infants of the same birth weight born to non diabetic mothers.
  • IOL does not prevent SD in non-diabetic women with a suspected macrosomic fetus.(Recommendation Level D)
  • IOL at term can reduce the incidence of SD in women with GDM.(Recommendation Level B)

References

  • Baskott TF,AllenAC.Perinatal implications of SD.Obstet Gynecol 1995;86:14-7
  • SmithRB,LaneC,PearsonJF.SD:what happens at the next delivery?Br J Obs Gynae 1994;101:713-15
  • AskerDB,SachsBP,FriedmanEA.Risk Factors for SD.Obs Gynae 1985;66:762-8
  • NesbittTS,GilbertWM,HerrchenB.SD and assoc RFs with macrosomic infants born in California.Am J O&G 1998:179:476-80
  • BaherAM.RFs and fetal outcome in cases of SD compared with normal deliveries of a similar birthweight.Br J Obst Gynae 1996:103:868-72
  • Centre for Reviews and Dissemination,NHS National Institute for Health Research.Expectant Mx vs IOL for suspected fetal macrosomia:a systematic review.Database of Abstracts of reviews of effectiveness 2004:2:2
  • IrionO,BoulvainM.IOL for suspected fetal macrosomia.Cochrane Database Systematic Rev 2002:2:CD 000938
  • UstaIM,HayekS,YahyaF,Abu-MusaA.SD:what is the risk of recurrence?Acta Obst Gynae Scand 2008:87:992-7

Should we be giving our women steroids prior to elective caesarean section?

Image result for pregnancyDelivery by elective caesarean section at less than 39+0 weeks of gestation can lead to respiratory morbidity in neonates, requiring admission to the neonatal intensive care unit

A recent retrospective cohort study showed that, compared with elective caesarean section births at 39+0 weeks of gestation, births at 37+0 weeks of gestation and at 38+0 weeks of gestation were associated with an increased risk of a composite outcome of neonatal death and/or respiratory complications, treated hypoglycaemia, newborn sepsis and admission to the NICU (adjusted OR for births at 37 weeks of gestation 2.1, 95% CI 1.7–2.5; adjusted OR for births at 38 weeks of gestation 1.5; 95% CI 1.3–1.7; P for trend <0.001).

The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycaemia, admission to the NICU and hospitalisation for 5 days or more were increased by a factor of 1.8–4.2 for births at 37 weeks of gestation and 1.3–2.1 for births at 38 weeks of gestation.A further study in Denmark23 showed the risk of respiratory morbidity for infants delivered by elective caesarean section decreased by gestation compared with vaginal birth (37 weeks of gestation OR 3.9, 95% CI 2.4–6.5; 38 weeks of gestation OR 3.0, 95% CI 2.1–4.3; and 39 weeks of gestation OR 1.9, 95% CI 1.2–3.0).

Treatment with antenatal corticosteroids prior to delivery by elective caesarean section has been shown to reduce the need for admission to the NICU up to 38+6 weeks of gestation compared with controls.

A. Corticosteroids should be given to reduce the risk of respiratory morbidity in all babies delivered by elective caesarean section prior to 38+6 weeks of gestation.

  • 1. Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ,Varner MW, et al.; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360:111–20.
  • 2. Yee W,Amin H,Wood S. Elective cesarean delivery, neonatal intensive care unit admission, and neonatal respiratory distress. Obstet Gynecol 2008;111:823–8.
  • 3. Hansen AK,Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008;336:85–7.
  • 4. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbid- ity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynecol 1995;102:101–6.