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The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.
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PMID:Risk factors for shoulder dystocia. 406 77

Our study of 390 patients enrolled in a birthing suite program revealed that antepartum or intrapartum problems allowed only 160 (41%) to actually give birth in the birthing suite. Antepartum complications included premature labor in ten (2.5%), premature ruptured membranes in 31 (8%), postdatism in 50 (13%), preeclampsia in 27 (7%), and diabetes mellitus in five (1.3%). Intrapartum complications included meconium in 62 (16%), arrest of labor in 64 (16%), oxytocin use in 85 (22%), and fetal heart rate decelerations in 28 (7%). Two hundred ninety-seven births (76%) were spontaneous. Forty-two low-forceps deliveries (10%), 12 mid-forceps deliveries (3%), and 39 cesarean sections (10%) were done in the traditional labor and delivery suite. Puerperal complications included one uterine inversion, two cases of placenta accreta, one rectovaginal fistula, and two requirements of blood transfusion. Neonatal morbidity included 22 low Apgar scores (7%), two shoulder dystocia, three cytomegalovirus infestations, and one lethal anomaly. Six infants had meconium aspiration, two with severe hypoxia. Any of these complications would overwhelm the patient in home birth. Intense prenatal screening may decrease some risk factors, but the intrapartum period was found to pose unacceptable risks for home birth in this population.
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PMID:Home birth: negative implications derived from a hospital-based birthing suite. 682 92

Perinatal morbidity and mortality are known to be higher for the macrosomic neonate whose birth weight is 4500 g or more, compared with that of appropriate-weight term-size neonates. In a retrospective study comparing 287 macrosomic neonates with 284 appropriate-weight term-size neonates, we found that macrosomia occurred in 1.3% of our annual deliveries, with a male-to-female ratio of 2.3:1. Factors that occurred significantly more frequently in the mothers of macrosomic infants were maternal obesity, multiparity, diabetes mellitus, and previous delivery of an infant heavier than 4000 g. During the intrapartum period the incidence of labor augmentation by oxytocin, shoulder dystocia, and cesarean section was significantly greater in fetal macrosomia. Most significantly, this study revealed that macrosomia. Most significantly, this study revealed that macrosomic fetuses do not experience greater fetal distress in biophysically monitored labor than appropriate-weight term-size fetuses. Twenty-nine (10%) of the macrosomic infants required admission to the neonatal intensive care unit (NICU) compared to 9 (3%) of the control patients (P less than 0.01). This excess neonatal morbidity in the macrosomic neonates was predominantly caused by the delivery process.
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PMID:Macrosomia--maternal, fetal, and neonatal implications. 736 96

Zinc is present in and indispensable to all forms of life. Zinc is essential for the normal growth of human beings, and zinc proteins have been shown to be involved in the transcription and translation of the genetic material. Zinc deficiency has been incriminated in infertility, abortions, malformations, fetal intrauterine growth retardation, premature and postmature births, perinatal death, and abnormal deliveries with dystocia and placental ablation. Risk groups for developing zinc deficiency, which in turn might modify the expression of the underlying disease, are found among those with insufficient food intake, especially in protein malnutrition; abnormal mucosal uptake, as in celiac disease; abnormal intestinal losses, as in steatorrhea and inflammatory bowel disease; abnormal renal excretion, as in diabetes with insufficient metabolic control; alcoholism; and treatment with diuretic drugs. Zinc deficiency could be identified by means of fasting serum or plasma samples or the more laborious estimation of zinc in leucocytes or monocytes if sampling and handling is carefully performed and if stressful situations and acute-phase reactions as fever, delivery, or abortion are avoided. Zinc therapy in identified low-zinc groups has given favorable results and has reduced the frequencies of premature birth, placental ablation, perinatal death, and postmaturity. It is suggested, as we did in 1980, that these data are compatible with the presence of a zinc-deficiency syndrome in pregnancy, which includes increased maternal morbidity, abnormal taste sensations, abnormally short or prolonged gestations, inefficient labor, atonic bleeding, and increased risks to the fetus such as malformations, growth retardation, prematurity, postmaturity, and perinatal death.
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PMID:Zinc status in pregnancy: the effect of zinc therapy on perinatal mortality, prematurity, and placental ablation. 849 61

To find the maternal-fetal outcome 98 pregnancies with fetal weight over 4000 g have been observed. For the period 1993-1994 the rate of large fetus was 2.76%, 0.84% of which were over 4500 g. The second period of delivery was prolonged in 9.7% of all primigravidas. The registered shoulder dystocia and perineal lacerations of the mother were related to increasing birthweight. Difficult deliveries resulting in clavicle fracture or brachial plexus injuries and facial trauma. Fetal distress was observed in 7.14%. Congenital anomalies were not increased in the group of the large fetus. No maternal death was registered. The strict observation of the pregnant for latent diabetes mellitus and anticipation of the potential complications associated with delivery of a large infant may reduce maternal and neonatal morbidity rates and maintain low mortality rates.
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PMID:[The large fetus--its obstetrical management and the results]. 865 37

This paper is a univariate analysis of the demographic, antepartum and intrapartum risk factors in a series of 16,471 consecutive deliveries in a tertiary obstetric and gynaecological unit in Singapore. In total, 12,229 term vaginal cephalic deliveries with 77 cases of shoulder dystocia were entered into the study for analysis. The incidence of shoulder dystocia was found to be 0.63% of all term vaginal cephalic deliveries. There is a direct relationship between increasing infant birthweight and incidence of shoulder dystocia. The critical birthweight for the prediction of shoulder dystocia is 3600 g. In order of decreasing relative risks, the factors which appear to be predictive of shoulder dystocia are a birthweight in excess of 3600 g, diabetes in pregnancy, lower social class, of Indian origin, maternal weight in excess of 70 kg, parity more than 4, and the use of oxytocics during labour. The local birthweight distribution is very different from the West. A policy for elective caesarean section for birthweights in excess of 4000 g (97% tile) would prevent 44% of shoulder dystocias, increase the caesarean section rate by 2% and half the perinatal mortality among births with shoulder dystocia.
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PMID:An analysis of risk factors for the prediction of shoulder dystocia in 16,471 consecutive births. 883 91

Our objective was to determine the factors involved in the development of shoulder dystocia in association with operative vaginal delivery. In this prospective study, patients who were candidates for operative vaginal delivery were randomized either to forceps (N = 315) or vacuum with M-cup (N = 322) and timed from initial placement of instrument to final delivery. Data were gathered prior to and after instrumental delivery. Statistics used were Pearson chi square, Fisher's exact, analysis of variance, and multiple logistic regression. There were a total of 21 patients with shoulder dystocia in both groups (3.3% incidence). Discriminant factors that did nor meet significance included use of epidural analgesia (P = .12), station (P = .99), previous vaginal delivery (P = .99), fetal gender (P = .54), indication for operative vaginal delivery (P = .63), > 45 degrees rotation (P = .68), use of episiotomy (P = .62), maternal weight (P = .26), and maternal diabetes (P = .08). Nearly attaining significance in univariate analysis was randomization to vacuum (P = .052). Significant factors included gestational age (P = .03), time required to effect delivery (P = .007), and birthweight (P = .0001). When these factors were subjected to stepwise multiple logistic regression, three factors remained as significant associations with shoulder dystocia: randomization to vacuum (P = .04), time for delivery (P = .03), and birthweight (P = .0001). In this operative vaginal delivery trial, shoulder dystocia was strongly associated with large fetal size, longer time to delivery, and the use of vacuum for delivery.
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PMID:Shoulder dystocia and operative vaginal delivery. 926 Jan 20

Anthropometric and skinfold measurements in 51 newborns of mothers with gestational diabetes were compared to reference ranges obtained from measurements of 501 newborns of nondiabetic mothers. In newborns of diabetic mothers, the means of fetal birth weight, biceps, subscapular, suprailiac skinfolds, and total fat index measurements (the sum of all measurements) were significantly greater than those of the nondiabetic group. While the means of fetal crown-heel length and head circumference did not significantly differ between the two groups, these findings suggest a disproportionate pattern of growth in fetuses of diabetic mothers, with increased tendency for deposition of subcutaneous fat. The studied population were then stratified into six categories according to birth weight percentiles. Within each category, the skinfold measurements in newborns of diabetic mothers were greater--though the difference was not statistically significant than that of nondiabetic mothers. It is possible, however, that in severe cases of maternal diabetes, the risks of complications, such as shoulder dystocia, increase with disproportionate deposition of subcutaneous fat. These risks appear greater than in fetuses of nondiabetic mothers at a comparable birthweight.
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PMID:Anthropometric measurement of newborns of gestational diabetic mothers: does it indicate disproportionate fetal growth? 936 Jan 89

The purpose was to identify risk factors and document the incidence and prognosis for brachial plexus palsy (BPP) and clavicular fracture (CF) among consecutive hospital liveborn (LB) infants in the United Arab Emirates. During a 2-year period, all hospital-born infants were examined twice by paediatricians before discharge and those found to have BPP or CF were evaluated and followed up by an orthopaedic surgeon. Each clavicular fracture was confirmed radiologically. For the assessment of risk factors, three controls were selected for each case of BPP or CF. Of the 9231 LB, 27 (2.9/1000) had BPP while 24 (2.6/1000) sustained CF. After controlling for potential confounding variables, shoulder dystocia (SD), fetal macrosomia (birthweight > 4000 g), instrumental vaginal delivery and diabetes remained risk factors for BPP while only fetal macrosomia and instrumental delivery increased the risk of CF. The frequency of these risk factors was higher than that reported from the West. Infants with BPP had a higher incidence of SD (p = 0.0001) and tended to be heavier (p = 0.052) than those with CF. All infants with CF recovered while 20% of those with BPP had moderate to severe residual disabilities. This study highlights geographic differences in risk factors for BPP and CF and the possible contribution of BPP to morbidity in infancy. Early recognition of fetal macrosomia and improved management of SD and maternal diabetes are necessary to reduce the incidence of BPP and CF as well as morbidity from BPP in this community.
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PMID:Risk factors and prognosis for brachial plexus injury and clavicular fracture in neonates: a prospective analysis from the United Arab Emirates. 942 73

The objective of this paper is to evaluate the influence of maternal and neonatal factors on the recurrence of gestational diabetes mellitus (GDM). A study was conducted on 164 predominantly Hispanic patients whose index pregnancy was complicated by GDM and whose subsequent consecutive pregnancy was managed at our institution between January 1988 and December 1992. The diagnosis of GDM was based on the criteria recommended by the National Diabetes Data Group using a 100-g oral glucose tolerance test. One-hundred and eleven (68%) of the 164 women had recurrence of GDM. Fifty-three (32%) did not demonstrate recurrence in their subsequent pregnancy. Patients with recurrence had GDM diagnosed earlier (30.3 vs 32.5 weeks, p = 0.03), frequently required insulin (25 vs. 8%, p <0.05) and had more hospital admissions (32 vs. 10% p <0.05) in their index pregnancy compared to women who did not have recurrence of GDM. Women who had recurrence had elevated mean third-trimester plasma glucose values: fasting 87.6 vs. 83 mg/dL, (p = 0.009) and 2-hr postprandial 109.7 vs. 102.2 mg/dL, (p = 0.008). Neonates of patients with recurrence were heavier (3656 vs. 3373 g, p = 0.004) and had an increased incidence of macrosomia (26 vs. 10%, p <0.05). No significant differences were observed in maternal age, prepregnancy body mass index, HbgA1C values, second-trimester blood glucose levels, method of delivery, incidence of shoulder dystocia and Apgar scores between the two groups of women. Hispanic patients with history of GDM have significant risk of recurrence in their subsequent pregnancy. The risk for recurrence in women is increased if GDM is diagnosed earlier, they require insulin, have elevated third-trimester plasma glucose level, and deliver macrosomic infants in their index pregnancy. It appears that obesity does not increase the risk of recurrence of gestational diabetes in Hispanics.
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PMID:Recurrence of gestational diabetes mellitus: identification of risk factors. 947 84


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