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The Cochrane Database of Systematic... Oct 2006The early management of shoulder dystocia involves the administration of various manoeuvres which aim to relieve the dystocia by manipulating the fetal shoulders and... (Review)
Review
BACKGROUND
The early management of shoulder dystocia involves the administration of various manoeuvres which aim to relieve the dystocia by manipulating the fetal shoulders and increasing the functional size of the maternal pelvis.
OBJECTIVES
To assess the effects of prophylactic manoeuvres in preventing shoulder dystocia.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 June 2006).
SELECTION CRITERIA
Randomised controlled trials comparing the prophylactic implementation of manoeuvres and maternal positioning with routine or standard care.
DATA COLLECTION AND ANALYSIS
Two review authors independently applied exclusion criteria, assessed trial quality and extracted data.
MAIN RESULTS
Two trials were included; one comparing the McRobert's manoeuvre and suprapubic pressure with no prophylactic manoeuvres in 185 women likely to give birth to a large baby and one trial comparing the use of the McRobert's manoeuvre versus lithotomy positioning in 40 women. We decided not to pool the results of the two trials. One study reported fifteen cases of shoulder dystocia in the therapeutic (control) group compared to five in the prophylactic group (relative risk (RR) 0.44, 95% confidence interval (CI) 0.17 to 1.14) and the other study reported one episode of shoulder dystocia in both prophylactic and lithotomy groups. In the first study, there were significantly more caesarean sections in the prophylactic group and when these were included in the results, significantly fewer instances of shoulder dystocia were seen in the prophylactic group (RR 0.33, 95% CI 0.12 to 0.86). In this study, thirteen women in the control group required therapeutic manoeuvres after delivery of the fetal head compared to three in the treatment group (RR 0.31, 95% CI 0.09 to 1.02). One study reported no birth injuries or low Apgar scores recorded. In the other study, one infant in the control group had a brachial plexus injury (RR 0.44, 95% CI 0.02 to 10.61), and one infant had a five-minute Apgar score less than seven (RR 0.44, 95% CI 0.02 to 10.61).
AUTHORS' CONCLUSIONS
There are no clear findings to support or refute the use of prophylactic manoeuvres to prevent shoulder dystocia, although one study showed an increased rate of caesareans in the prophylactic group. Both included studies failed to address important maternal outcomes such as maternal injury, psychological outcomes and satisfaction with birth. Due to the low incidence of shoulder dystocia, trials with larger sample sizes investigating the use of such manoeuvres are required.
Topics: Delivery, Obstetric; Dystocia; Female; Humans; Pregnancy; Shoulder
PubMed: 17054263
DOI: 10.1002/14651858.CD005543.pub2 -
The Cochrane Database of Systematic... 2000In pregnancies complicated by diabetes the major concerns during the third trimester are fetal distress and the potential for birth trauma associated with fetal... (Review)
Review
BACKGROUND
In pregnancies complicated by diabetes the major concerns during the third trimester are fetal distress and the potential for birth trauma associated with fetal macrosomia.
OBJECTIVES
The objective of this review was to assess the effect of a policy of elective delivery, as compared to expectant management, in term diabetic pregnant women, on maternal and perinatal mortality and morbidity.
SEARCH STRATEGY
We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (last searched July 1999).
SELECTION CRITERIA
All available randomized controlled trials of elective delivery, either by induction of labour or by elective caesarean section, compared to expectant management in diabetic pregnant women at term.
DATA COLLECTION AND ANALYSIS
The reports of the only available trial were analysed independently by the three co-reviewers to retrieve data on maternal and perinatal outcomes. Results are expressed as relative risks (RR) and 95% confidence intervals (CI).
MAIN RESULTS
The participants in the one trial included in this review were 200 insulin-requiring diabetic women. Most had gestational diabetes, except 13 women with type 2 preexisting diabetes (class B). The trial compared a policy of active induction of labour at 38 completed weeks of pregnancy, to expectant management until 42 weeks. The risk of caesarean section was not statistically different between groups (RR 0.81, 95% CI 0.52 - 1.26). The risk of macrosomia was reduced in the active induction group (RR 0.56, 95%CI 0.32 - 0. 98) and 3 cases of mild shoulder dystocia were reported in the expectant management group. No other perinatal morbidity was reported.
REVIEWER'S CONCLUSIONS
There is very little evidence to support either elective delivery or expectant management at term in pregnant women with insulin-requiring diabetes. Limited data from a single randomized controlled trial suggest that induction of labour in women with gestational diabetes treated with insulin reduces the risk of macrosomia. Although the small sample size does not permit one to draw conclusions, the risk of maternal or neonatal morbidity was not modified. Women's views on elective delivery and on prolonged surveillance and treatment with insulin should be assessed in future trials.
Topics: Cesarean Section; Delivery, Obstetric; Female; Humans; Labor, Induced; Pregnancy; Pregnancy in Diabetics
PubMed: 10796277
DOI: 10.1002/14651858.CD001997