- Email: [email protected]
495 Recurrence of Shoulder Dystocia in a Subsequent Delivery
spa Abstracts
Volume 168 Number I, Pa rt 2
495
RECURRENCE OF SHOULDER DYSTOCIA IN A SUBSEQUENT DELIVERY. HM Wolfe. U Dierker, TL Gross, MC Treadwell and RJ Sokol. Dept. of OB/GYN, WSU/Hutzel Hospital, Detroit, MI, Metro Health Medieal Ctr., Cleveland, OH and Univ. of Illinois at Peoria, IL.
497
OBJECTIVE: Counseling patients following a shoulder dystocia (ShD) is difficult since its occurrence is rare. Our goal was to define the recurrence risk for ShD and to determine if any factors in the index ShD delivery predict recurrence. STUDY DESIGN: Deliveries complicated by ShD in 1984-5 were identified. The study group consisted of patients with a subsequent vaginal delivery. Maternal characteristics, 6 major dysfunctional labor paUerns (DLP), birth weight (bwl) and the occurrence of birth trauma in the index (ShD) delivery as well as bwl in the subsequent pregnancy were analyzed for prediction of ShD in the next delivery. RESULTS: The baseline risk for ShD was 0.7% (5317138). Of the 53 patients identified, 17 underwent a second delivery. 6117 (35%) experienced a recurrence of ShO for a 73 fold increase in risk. Maternal height, race, parity, occurrence of ShD related birth trauma and bwl in either delivery did not predict recurrent ShD. DLP's, analyzed individually and additively, were common in the index ShD delivery and only a history of a prolonged deceleration phase in the index ShD was related to recurrence (33% sensitivity, 100% specificity). Recurrence No Recurrence p (n = 6) (D - 11) Bwt (grams) 3948 3645 NS Injury 60% 45% NS Abnormal Labor 83% 64% NS Prolonged Deceleration 33% 0% 0.04 CONCLUSIONS: A previous ShD is a massive (73 fold) risk for ShD in a subsequent delivery, with only prolonged deceleration phase in the index ShD delivery related to recurrence. Infonnation from an index ShD delivery offers liule help in distinguishing women destined for recurrence. Variable
496
NEOIIATAL CLAV~QJlAR fRACT.lIRE: AN ~EDICTABLE EVENT. S. Roberts,'
C. Hernandez, M. Adams, M. Maberry, K. leveno, G. Wendel. Dept. Obstetrics & Gynecology, U. of Texas Southwestern Medical Center, Parkland Memorial Hospital, Dallas lX. OBJECTIVES: The purpose of the study was to examine risk factors for obstetric clavicular fracture to determine whether high risk gravidas or neonates could be identified antepartun. STWY DESIGN: 215 cases of clavicular fracture after vaginal del ivery occurring between 1983 and 1988 at Parkland Memorial Hospital were pair-matched with controls for date of delivery, and maternal race and age. Antenatal risk factors examined included length 0'· second stage of labor, use of oxytocin, epiwral anesthesia, prenatal care, use of forceps, gestational diabetes, maternal obesity (>200 lbs), use and type of episiotomy, parity, hlstory of macrosomic infant, and shoulder dystocia. Postnatal risk factors included neonatal gestational age >40 weeks birthweight >4000 grams, and large for gestational age (lGA). Odd~ ratios (OR) with confidence intervals (el) were first determined univariately for each risk factor, and then logistic regression was used to control for confounding. RESULTS:
Risk Factor Cases Controls OR 95% CI mi d force s 2.0% 5.6% 3.00 0.95'9.49 gest. diabetes 1.4% 3.7% 2.72 0.71·10.43 >40 wks. gestation 23.9% 10.6% 1.54'4.64" 2.67 should. dystocia 0.5% 8.42'456.20" 22.8% 61.99 >4000 grams 28.4% 8.9% 4.04 2.31·7.07" LGA 11.5% 3.33'9.31" 42.0% 5.57 " p<.001 Model ing supported these findings when confounding was control led with the exception of gestational diabetes where interaction was present (OR 0.82,95): CI 0.14-4.89). CONCLUSION: ~o cl inical risk factor that might have been accurately identified antepartun or intrapartUTI was conclusively associated with obstetric clavicular fracture except shoulder dystocia. \.Ie speculate that obstetric clavicular fractures are not preventable in our population . \.Ie suggest that matching on birthweight may iqlrove efficiency in future observational studies on obstetric clavicular fracture.
498
THE OUTCOME OF MACROSOMIC DELIVERIES ~4500 GRAMS): LAC+USC EXPERIENCE. K. Lipscomb', K. Gregory, K. Shaw. Dept. Ob/Gyn, University Southern California School of Medicine, LA, CA OBJECTIVE: To describe the marernal and neonatal outcome in macrosomic deliveries 2. 4500 grams. STUDY DESIGN: We reviewed maternal and neonatal records of infants with birthweighlB L 4500gms identified from birth records at Women·s Hospital during the calendar year 1991 . Outcome variables were mode of delivery. incidence of neonatal complications (shoulder dystocia (SD), birth trauma, perinatal death) and maternal complications (laceration requiring repair. hemorrhage, infection, length of hospita.l stay). RESULTS: Total births during the study period was 14,560. The study sample consisted of 227 maternal and infant pairs. Mean birthweight was 4706gms (±2l9). 185 women sllempted a trial of labor . 84% (157) delivered vaginally (VD), representing 69% of the study population. The incidence of primary and repeal cesarean seetion (CIS) was 2l % (48) and 9.6% (22) respectively. SO occurred 29 times for an incidence rate of 18.5% of macrosomic deliveries. There were seven cases each of Erb's Pwsy and clavicular fracture, and one humeral fracture. By two months of age, all affected infants were without permanent sequelae. There were no cases of birth asphyxia or perinatal mortality related to macrosomic delivery. Maternal complications included increased risk of lacerations requiring repair when VO was complicated by SO. especially 3rd and 4th degrees (RR 5.4, 95% CI 3.1·9 .4) . There was no difference with regard to hemorrhage or hospital stay in women who had YO with or without SO as compared to women who had CIS. Infectious morbidity. however. increased significantly in those patients who underwent a CIS after a trial of labor when compared with VD (RR 7.1,95% CI3.9-l3.I)or elective CIS (RR 5.4, 95% CI3.1· 9.4). 90% of patients undergoing elective CIS had no complications at alt. CONCLUSION: Although elective CIS appears to be safe, this data suggests vaginal delivery can be a reasonable alternative and supports offering a trial of lahor to patients with macrosomia.
A
PROSPECTIVE
!£M!RANES AT
RANIXJ1IZED
TERM:
EARLY
STIJIlY OF PREMA1\JRE RUPTURE OF INOUCTION OF l.A8OR VS. EXPECTNIT
HANAGDtONT • M. Alealay-. G. Barka1 B. Reicnnan' S. lipitz B. Chayen, S. Mashiach-. IJep. Ob/Gyn and A. Hourv1tz"', Chaim Sheba Medical Center, Tel Hashomer, Neonatology' , Israel. OBJECTIVE: The purpose of this study was to compare expectant management and early induction of labor in patients with premature rupture of membranes at term. SruDY DESIGN: This was a prospective randomized study and involved 154 low risk parturients. of which 80 were a110cated to expectant management (EXP) and 74 to oxytocin induction (IND) with minimum vaginal interventions. Outcome data were subjected to chi square and student-t test, when appropriate. RESULTS: Length of labor was significantly shorter in the EXP group (5.75 vs 7.45 hr, p
,
.M,
M
,
433
Volume 168 Number I, Pa rt 2
495
RECURRENCE OF SHOULDER DYSTOCIA IN A SUBSEQUENT DELIVERY. HM Wolfe. U Dierker, TL Gross, MC Treadwell and RJ Sokol. Dept. of OB/GYN, WSU/Hutzel Hospital, Detroit, MI, Metro Health Medieal Ctr., Cleveland, OH and Univ. of Illinois at Peoria, IL.
497
OBJECTIVE: Counseling patients following a shoulder dystocia (ShD) is difficult since its occurrence is rare. Our goal was to define the recurrence risk for ShD and to determine if any factors in the index ShD delivery predict recurrence. STUDY DESIGN: Deliveries complicated by ShD in 1984-5 were identified. The study group consisted of patients with a subsequent vaginal delivery. Maternal characteristics, 6 major dysfunctional labor paUerns (DLP), birth weight (bwl) and the occurrence of birth trauma in the index (ShD) delivery as well as bwl in the subsequent pregnancy were analyzed for prediction of ShD in the next delivery. RESULTS: The baseline risk for ShD was 0.7% (5317138). Of the 53 patients identified, 17 underwent a second delivery. 6117 (35%) experienced a recurrence of ShO for a 73 fold increase in risk. Maternal height, race, parity, occurrence of ShD related birth trauma and bwl in either delivery did not predict recurrent ShD. DLP's, analyzed individually and additively, were common in the index ShD delivery and only a history of a prolonged deceleration phase in the index ShD was related to recurrence (33% sensitivity, 100% specificity). Recurrence No Recurrence p (n = 6) (D - 11) Bwt (grams) 3948 3645 NS Injury 60% 45% NS Abnormal Labor 83% 64% NS Prolonged Deceleration 33% 0% 0.04 CONCLUSIONS: A previous ShD is a massive (73 fold) risk for ShD in a subsequent delivery, with only prolonged deceleration phase in the index ShD delivery related to recurrence. Infonnation from an index ShD delivery offers liule help in distinguishing women destined for recurrence. Variable
496
NEOIIATAL CLAV~QJlAR fRACT.lIRE: AN ~EDICTABLE EVENT. S. Roberts,'
C. Hernandez, M. Adams, M. Maberry, K. leveno, G. Wendel. Dept. Obstetrics & Gynecology, U. of Texas Southwestern Medical Center, Parkland Memorial Hospital, Dallas lX. OBJECTIVES: The purpose of the study was to examine risk factors for obstetric clavicular fracture to determine whether high risk gravidas or neonates could be identified antepartun. STWY DESIGN: 215 cases of clavicular fracture after vaginal del ivery occurring between 1983 and 1988 at Parkland Memorial Hospital were pair-matched with controls for date of delivery, and maternal race and age. Antenatal risk factors examined included length 0'· second stage of labor, use of oxytocin, epiwral anesthesia, prenatal care, use of forceps, gestational diabetes, maternal obesity (>200 lbs), use and type of episiotomy, parity, hlstory of macrosomic infant, and shoulder dystocia. Postnatal risk factors included neonatal gestational age >40 weeks birthweight >4000 grams, and large for gestational age (lGA). Odd~ ratios (OR) with confidence intervals (el) were first determined univariately for each risk factor, and then logistic regression was used to control for confounding. RESULTS:
Risk Factor Cases Controls OR 95% CI mi d force s 2.0% 5.6% 3.00 0.95'9.49 gest. diabetes 1.4% 3.7% 2.72 0.71·10.43 >40 wks. gestation 23.9% 10.6% 1.54'4.64" 2.67 should. dystocia 0.5% 8.42'456.20" 22.8% 61.99 >4000 grams 28.4% 8.9% 4.04 2.31·7.07" LGA 11.5% 3.33'9.31" 42.0% 5.57 " p<.001 Model ing supported these findings when confounding was control led with the exception of gestational diabetes where interaction was present (OR 0.82,95): CI 0.14-4.89). CONCLUSION: ~o cl inical risk factor that might have been accurately identified antepartun or intrapartUTI was conclusively associated with obstetric clavicular fracture except shoulder dystocia. \.Ie speculate that obstetric clavicular fractures are not preventable in our population . \.Ie suggest that matching on birthweight may iqlrove efficiency in future observational studies on obstetric clavicular fracture.
498
THE OUTCOME OF MACROSOMIC DELIVERIES ~4500 GRAMS): LAC+USC EXPERIENCE. K. Lipscomb', K. Gregory, K. Shaw. Dept. Ob/Gyn, University Southern California School of Medicine, LA, CA OBJECTIVE: To describe the marernal and neonatal outcome in macrosomic deliveries 2. 4500 grams. STUDY DESIGN: We reviewed maternal and neonatal records of infants with birthweighlB L 4500gms identified from birth records at Women·s Hospital during the calendar year 1991 . Outcome variables were mode of delivery. incidence of neonatal complications (shoulder dystocia (SD), birth trauma, perinatal death) and maternal complications (laceration requiring repair. hemorrhage, infection, length of hospita.l stay). RESULTS: Total births during the study period was 14,560. The study sample consisted of 227 maternal and infant pairs. Mean birthweight was 4706gms (±2l9). 185 women sllempted a trial of labor . 84% (157) delivered vaginally (VD), representing 69% of the study population. The incidence of primary and repeal cesarean seetion (CIS) was 2l % (48) and 9.6% (22) respectively. SO occurred 29 times for an incidence rate of 18.5% of macrosomic deliveries. There were seven cases each of Erb's Pwsy and clavicular fracture, and one humeral fracture. By two months of age, all affected infants were without permanent sequelae. There were no cases of birth asphyxia or perinatal mortality related to macrosomic delivery. Maternal complications included increased risk of lacerations requiring repair when VO was complicated by SO. especially 3rd and 4th degrees (RR 5.4, 95% CI 3.1·9 .4) . There was no difference with regard to hemorrhage or hospital stay in women who had YO with or without SO as compared to women who had CIS. Infectious morbidity. however. increased significantly in those patients who underwent a CIS after a trial of labor when compared with VD (RR 7.1,95% CI3.9-l3.I)or elective CIS (RR 5.4, 95% CI3.1· 9.4). 90% of patients undergoing elective CIS had no complications at alt. CONCLUSION: Although elective CIS appears to be safe, this data suggests vaginal delivery can be a reasonable alternative and supports offering a trial of lahor to patients with macrosomia.
A
PROSPECTIVE
!£M!RANES AT
RANIXJ1IZED
TERM:
EARLY
STIJIlY OF PREMA1\JRE RUPTURE OF INOUCTION OF l.A8OR VS. EXPECTNIT
HANAGDtONT • M. Alealay-. G. Barka1 B. Reicnnan' S. lipitz B. Chayen, S. Mashiach-. IJep. Ob/Gyn and A. Hourv1tz"', Chaim Sheba Medical Center, Tel Hashomer, Neonatology' , Israel. OBJECTIVE: The purpose of this study was to compare expectant management and early induction of labor in patients with premature rupture of membranes at term. SruDY DESIGN: This was a prospective randomized study and involved 154 low risk parturients. of which 80 were a110cated to expectant management (EXP) and 74 to oxytocin induction (IND) with minimum vaginal interventions. Outcome data were subjected to chi square and student-t test, when appropriate. RESULTS: Length of labor was significantly shorter in the EXP group (5.75 vs 7.45 hr, p
,
.M,
M
,
433