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Background: Shoulder dystocia is an unpredictable obstetric condition with potential long-term neonatal complications. The risk of neonatal injury might be related to the condition itself as well as to the obstetrics maneuvers used for its release., Objectives: To examine the available evidence to assess current management and possible improvement of outcomes., Search Strategy: A comprehensive search of MEDLINE, EMBASE, EMCARE, and The Cochrane Library database was performed, all studies reporting on neonatal outcomes in cases of shoulder dystocia stratified by obstetric maneuvers used for delivery were included. Data abstraction was performed and checked by two independent reviewers., Results: McRoberts maneuver was the least associated with risk of neonatal injury (odds ratio 0.6, 95% confidence interval 0.4-0.9), followed by delivery of posterior arm., Conclusion: Delivery of posterior arm might be prioritized in cases of shoulder dystocia after failed McRoberts. Neonatal hypoxic injury correlates with the duration of dystocia rather than the maneuver used., (© 2024 International Federation of Gynecology and Obstetrics.)

Background: This study aims to comprehensively examine the academic development of shoulder dystocia (SD) through bibliometric and document analysis and to identify topics that can guide future research., Methods: In this study, performance, co-citation, co-word, and document analyses were used as bibliometric analysis techniques., Results: The study identified 3 main themes in terms of the intellectual structure of Shoulder Dystocia (SD): "Management of SD, Risk Factors and Associated Complications," "Clinical Practices, Birth Abnormalities and Effects of Complications," and "Impact of Education, Clinical Maneuvers and Fetal Health Outcomes." Co-occurrence analysis identified 4 significant themes: "Management and Clinical Practice of SD," "Fetal Macrosomia and Risk Factors," "Obstetric Maneuvers and Brachial Plexus Injury," and "Clinical Trends and Risks in SD." Additionally, ten consolidated themes were identified as a result of thematic coding analysis., Conclusion: Shoulder dystocia remains a critical component of obstetric practice. Themes such as training and simulation, risk factors, and technical and management approaches are consistently emphasized. Technological advances and studies on how machine learning techniques can be used effectively in this field reflect innovative approaches in the scientific literature. This analysis confirms that shoulder dystocia is a complex topic requiring a multidisciplinary approach and that research in this field is constantly evolving., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

A dynamic tracheal collapse caused by multiple rib fractures in a neonatal wagyu calf was diagnosed by radiography, endoscopy and computed tomography. Conservative treatment, consisting of the medical treatment of respiratory inflammation and the reduction of environmental and social stress was initiated. The respiratory signs improved significantly, and the calf was discharged. The condition deteriorated after several weeks without treatment, most likely due to of excessive callus formation of the fractured ribs causing increased reduction in tracheal diameter., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht.Dieser Artikel ist Herrn Prof. Karl Nuss gewidmet, anlässlich seines Ausscheidens aus dem Universitätsdienst., (Thieme. All rights reserved.)

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Shoulder dystocia is a relatively uncommon but serious childbirth-related emergency., Aim: To explore the improvement and retention of skills in shoulder dystocia management through high-fidelity simulation training., Methods: The SAFE (SimulAtion high-FidElity) study was a prospective cohort study that utilised a high-fidelity birth simulator. Registered midwives and final year midwifery students were invited to participate in a one-day workshop at 6-monthly intervals. There was a 30-minute initial assessment, a 30-minute theoretical and hands-on training, and a 30-minute post-training assessment on shoulder dystocia management. Pre-training and post-training values for the predetermined outcomes were compared. In each workshop we assessed the proportion of successful simulated births, the performance of manoeuvres to manage shoulder dystocia, the head-to-body birth time, the fetal head traction force, the quality of communication, the perception of time-to-birth, and the self-reported confidence levels., Findings: The baseline workshop recruited 101 participants that demonstrated a significant increase in the proportion of successful simulated births (8.9% vs 93.1%), and a two-fold to three-fold increase in the score of manoeuvres, communication, and confidence after training. Those with low pre-training levels of competency and confidence improved the most post-training at baseline. There was a retention of manoeuvres, communication skills and confidence at 6 months. There was no reduction in fetal head traction force over time. Those being proficient before initial training retained and performed best at the 6-month follow-up., Conclusion: The SAFE study found a significant improvement in skills and confidence after the initial high-fidelity simulation training that were retained after 6 months., (Copyright © 2024 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Importance: Macrosomia represents the most significant risk factor of shoulder dystocia (SD), which is a severe and emergent complication of vaginal delivery. They are both associated with adverse pregnancy outcomes., Objective: The aim of this study was to review and compare the most recently published influential guidelines on the diagnosis and management of fetal macrosomia and SD., Evidence Acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and the Department for Health and Wellbeing of the Government of South Australia on macrosomia and SD was conducted., Results: The ACOG and RANZCOG agree that macrosomia should be defined as birthweight above 4000-4500 g regardless of the gestational age, whereas the National Institute for Health and Care Excellence defines macrosomia as an estimated fetal weight above the 95th percentile. According to ACOG and RANZCOG, ultrasound scans and clinical estimates can be used to rule out fetal macrosomia, although lacking accuracy. Routine induction of labor before 39 weeks of gestation with the sole indication of suspected fetal macrosomia is unanimously not recommended, but an individualized counseling should be provided. Exercise, appropriate diet, and prepregnancy bariatric surgery are mentioned as preventive measures. There is also consensus among the reviewed guidelines regarding the definition and the diagnosis of SD, with the "turtle sign" being the most common sign for its recognition as well as the poor predictability of the reported risk factors. Moreover, there is an overall agreement on the algorithm of SD management with McRoberts technique suggested as first-line maneuver. In addition, appropriate staff training, thorough documentation, and time keeping are crucial aspects of SD management according to all medical societies. Elective delivery for the prevention of SD is discouraged by all the reviewed guidelines., Conclusions: Macrosomia is associated not only with SD but also with maternal and neonatal complications. Similarly, SD can lead to permanent neurologic sequalae, as well as perinatal death if managed in a suboptimal way. Therefore, it is crucial to develop consistent international practice protocols for their prompt diagnosis and effective management in order to safely guide clinical practice and improve pregnancy outcomes.

Objective: To compare maternal and fetal outcomes of dystocia managed surgically and nonsurgically at referral hospitals (RHs) versus community medicine clinics (CMCs), determine the rate of C-section, and evaluate the incidence of hypoglycemia and hypocalcemia in bitches presented with dystocia., Animals: Bitches presented with dystocia at 2 RHs and 2 CMCs., Methods: Information on signalment, presence of hypoglycemia and/or hypocalcemia, diagnostic imaging performed, nonsurgical and surgical interventions performed, maternal and fetal outcomes, and total cost of care was obtained from the electronic medical records of bitches presenting for dystocia between October 2015 and October 2020. Descriptive statistics were performed and outcome compared between RHs and CMCs using a Fisher exact test, with a P < .05 considered significant., Results: 230 bitches were evaluated with 243 separate episodes of dystocia, with 183 (75%) episodes treated at an RH and 60 (25%) at a CMC. There was a low incidence of hypoglycemia (5% [9/178]) and ionized hypocalcemia (1% [2/164]). Seventy-three percent (177/243) of bitches underwent surgical intervention, 25% (61/243) received nonsurgical management, and 2% (5/243) transferred to their primary veterinarian. There was no difference in survival for bitches operated at an RH compared with a CMC. However, bitches operated at an RH were more likely (P = .04) to be discharged with at least 1 live neonate., Clinical Relevance: In bitches diagnosed with dystocia, hypoglycemia and hypocalcemia were rare. The majority of bitches underwent a C-section. The setting where the C-section was performed did not impact maternal survival.

In the management of shoulder dystocia, it is often recommended to start with external maneuvers, such as the McRoberts maneuver and suprapubic pressure, followed by internal maneuvers including rotation and posterior arm delivery. However, this sequence is not based on scientific evidence of its success rates, the technical simplicity, or the related complication rates. Hence, this review critically evaluates the success rate, technique, and safety of different maneuvers. Retrospective reviews showed that posterior arm delivery has consistently higher success rates (86.1%) than rotational methods (62.4%) and external maneuvers (56.0%). McRoberts maneuver was thought to be a simple method, however, its mechanism is not clear. Furthermore, McRoberts position still requires subsequent traction on the fetal neck, which presents a risk for brachial plexus injury. The 2 internal maneuvers have anatomic rationales with the aim of rotating the shoulders to the wider oblique pelvic dimension or reducing the shoulder width. The techniques are not more sophisticated and requires the accoucher to insert the correct hand (according to fetal face direction) through the more spacious sacro-posterior region and deep enough to reach the fetal chest or posterior forearm. The performance of rotation and posterior arm delivery can also be integrated and performed using the same hand. Retrospective studies may give a biased view that the internal maneuvers are riskier. First, a less severely impacted shoulder dystocia is more likely to have been managed by external maneuvers, subjecting more difficult cases to internal maneuvers. Second, neonatal injuries were not necessarily caused by the internal maneuvers that led to delivery but could have been caused by the preceding unsuccessful external maneuvers. The procedural safety is not primarily related to the nature of the maneuvers, but to how properly these maneuvers are performed. When all these maneuvers have failed, it is important to consider the reasons for failure otherwise repetition of the maneuver cycle is just a random trial and error. If the posterior axilla is just above the pelvic outlet and reachable, posterior axilla traction using either the accoucher fingers or a sling is a feasible alternative. Its mechanism is not just outward traction but also rotation of the shoulders to the wider oblique pelvic dimension. If the posterior axilla is at a higher sacral level, a sling may be formed with the assistance of a long right-angle forceps, otherwise, more invasive methods such as Zavanelli maneuver, abdominal rescue, or symphysiotomy are the last resorts., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This tutorial of the intrapartum management of shoulder dystocia uses drawings and videos of simulated and actual deliveries to illustrate the biomechanical principles of specialized delivery maneuvers and examine missteps associated with brachial plexus injury. It is intended to complement haptic, mannequin-based simulation training. Demonstrative explication of each maneuver is accompanied by specific examples of what not to do. Positive (prescriptive) instruction prioritizes early use of direct fetal manipulation and stresses the importance of determining the alignment of the fetal shoulders by direct palpation, and that the biacromial width should be manually adjusted to an oblique orientation within the pelvis-before application of traction to the fetal head, the biacromial width is manually adjusted to an oblique orientation within the pelvis. Negative (proscriptive) instructions includes the following: to avoid more than usual and/or laterally directed traction, to use episiotomy only as a means to gain access to the posterior shoulder and arm, and to use a 2-step procedure in which a 60-second hands-off period ("do not do anything") is inserted between the emergence of the head and any initial attempts at downward traction to allow for spontaneous rotation of the fetal shoulders. The tutorial presents a stepwise approach focused on the delivering clinician's tasks while including the role of assistive techniques, including McRoberts, Gaskin, and Sims positioning, suprapubic pressure, and episiotomy. Video footage of actual deliveries involving shoulder dystocia and permanent brachial plexus injury demonstrates ambiguities in making the diagnosis of shoulder dystocia, risks of improper traction and torsion of the head, and overreliance on repeating maneuvers that prove initially unsuccessful., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Mare and foal survival are increased with prompt dystocia management. Data regarding mortality outcomes in mares and foals, when mares are recumbent at admission for dystocia resolution, are scarce., Objectives: To evaluate recumbency at hospital admission as a risk factor for survival of mares and foals following dystocia management. Subsequent mare fertility was also evaluated., Study Design: Retrospective cohort., Methods: Data were obtained from medical records at Rood and Riddle Equine Hospital of mares with dystocia between 1995 and 2018. Mare signalment, ambulation status, survival data and foaling records were collected. The proportion of mare survival and mare fertility were analysed using chi-squared tests. Foal survival was analysed using Fisher's exact test. Odds ratios were calculated using multivariable logistic regression., Results: There were 1038 ambulatory mares and 41 recumbent mares included in the analysis. Survival rates after dystocia resolution were 90.5% (977/1079) in mares and 37.3% (402/1079) in foals. Ambulatory mares had higher odds of survival (OR 6.93, 95% CI: 3.25-14.78, p < 0.001) than recumbent mares. Foals delivered from ambulatory mares had higher odds of survival (OR 22.7, 95% CI: 3.11-165.44, p = 0.002) compared with foals delivered from recumbent mares. Fertility was not statistically different for surviving Thoroughbred mares within 3 years following dystocia resolution between ambulatory and recumbent mares., Main Limitations: Retrospective study design and small case number of recumbent mares., Conclusions: Mare and foal survival was significantly decreased when mares with dystocia were recumbent at hospital admission. Subsequent fertility, as defined for this study, of surviving mares was not affected by ambulation status at the time of dystocia resolution., (© 2023 EVJ Ltd.)

Objective: The success of internal manual or digital rotation of the head in mechanical dystocia due to malpresentation, malposition or malrotation is presented in this paper on our own clinical material with reference of today's research and clinical recommendations., Study Design: Through a retrospective bicentric clinical study, we investigated the success of internal head rotation in two University Clinics for gynecology and obstetrics from year 2017 to 2023. In 152 singleton term (37-42 weeks) in cases of persistens intrapartum arrest of the fetal head. After palpatory and ultrasonographically verified arrest of fetal head engagement, a therapeutic manual (Liepmann) or digital rotation was performed., Results: In 152 cases, manual rotation was performed in 108 (71.05 %) and digital rotation in 44 (28.94 %) cases in 73 (48.02 %) primiparous and 79 (51.97 %) multiparous. Intrapartum identification by digital palpation was done in all cases, and the following are: persistent occipital posterior position in 68 (44.73%), persistent deep transverse head presentation in 12 (7.89%), persistent high (longitudinal) occipital presentation in 64 (42.10 %) and persistent anterior asynclitism in 8 (5.26 %) cases. Episiotomy was used in 36 (23.68%) cases. Vacuum extraction was completed in 14 (9.21 %) deliveries, and cesarean section due to unsuccessful internal rotation in 15 (9.8 %) cases (%) without other indication. We did not record any intrapartum complications or cardiotocographic abnormalities. Cervical lacerations were treated with sutures in 4 cases (2.63 %). Successful correction of internal rotation procedure with spontaneous vaginal delivery was found in 80.92 % of cases. If we exclude delivery assisted by vacuum extraction whose indications were fetal hypoxia or dystocia after successful internal head rotation procedure, then the success rate of this method was 90.13 %., Conclusion: Internal head rotation is a simple, safe and successful obstetric manual intervention that directly increases the rate of vaginal deliveries after correction of the birth mechanism anomaly and directly reduces the percentage of cesarean section. Manual or digital head rotation is an established midwifery/obstetric skill in several centers which, based on numerous clinical researches and experience, should become protocolized and included in the guidelines of professional associations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this document is to define labor and labor arrest and provide recommendations for the management of dystocia in the first and second stage of labor and labor arrest., Target Population: Pregnant individuals in the first or second stage of labor., Methods: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements., Recommendations: This Clinical Practice Guideline includes definitions of labor and labor arrest, along with recommendations for the management of dystocia in the first and second stages of labor and labor arrest. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019., Methods: This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods., Results: The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045)., Conclusion: More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019., Competing Interests: The corresponding author is the programme director for the Safe Obstetric Practice for High risk and Emergency (SOPHIE) course. Other authors have disclosed no conflicts of interest.

Veterinary care of breeding dogs begins before a breeding takes place, during prebreeding consultations, through matings, gestation, and delivery of newborns., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: This study aimed to compare the use of hand-powered vacuum pumps and the suspension by the hind legs within the scope of resuscitating newborn dystocial calves., Material and Methods: For this study, data were collected from 60 dystocial calves of different breeds. Various reanimation methods were employed to these calves immediately after birth. In group I (n=20), the hand-powered vacuum pump from HK-Rheintechnik (Neuwied, Deutschland) was used to remove mucus and amniotic fluid from the respiratory tract. In group II (n=20), the McCulloch Medical (Elmwood, England) hand-powered vacuum pump was used to remove mucus and amniotic fluid from the respiratory tract. In group III (n=20) 10 to 12 liters of cold water were poured over the neck of 20 calves immediately after birth. In addition, the calves were suspended by the hind legs via a gate or a pole, so that the head hung downwards vertically. The calves' Time to Sternal Recumbency (T-SR) of the calves was measured following the different resuscitation procedures in order to assess their vitality. In addition, the calves were examined segmentally at one-hour post natum. Furthermore, the calves were examined clinically on the seventh day of life. In addition, we investigated whether confounding variables such as calf sex, dam parity, obstetric intervention, and the season affected T-SR., Results: T-SR ranged from 1.5 to 10.5 minutes. There was no difference between the three initial treatment procedures (p=0.07). However, the T-SR of calves treated with a hand-powered vacuum pump tended to be shorter. No statistically significant difference between the pulse rates (p=0.73), respiratory rates (p=0.13), and rectal temperature (p=0.65) of the animals in the three groups on the first and seventh day of life was evident. There was no statistically significant difference in the incidence of the diseases up to the seventh day of life between the individual study groups., Conclusion and Clinical Relevance: The present study was able to show that the use of hand-powered vacuum pumps is at least equivalent to suspending calves. When using hand-powered vacuum pumps, the girth of the muzzle must be taken into account, as this can limit their utility., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: We estimated the association between diabetes and shoulder dystocia by infant birth weight subgroups (<4,000, 4,000-4,500, and >4,500 g) in an era of prophylactic cesarean delivery for suspected macrosomia., Study Design: A secondary analysis from the National Institute of Child Health and Human Development U.S. Consortium for Safe Labor of deliveries at ≥24 weeks with a nonanomalous, singleton fetus with vertex presentation undergoing a trial of labor. The exposure was either pregestational or gestational diabetes compared with no diabetes. The primary outcome was shoulder dystocia and secondarily, birth trauma with a shoulder dystocia. We calculated adjusted risk ratios (aRRs) with modified Poison's regression between diabetes and shoulder dystocia and the number needed to treat (NNT) to prevent a shoulder dystocia with cesarean delivery., Results: Among 167,589 assessed deliveries (6% with diabetes), pregnant individuals with diabetes had a higher risk of shoulder dystocia at birth weight <4,000 g (aRR: 1.95; 95% confidence interval [CI]: 1.66-2.31) and 4,000 to 4,500 g (aRR: 1.57; 95% CI: 1.24-1.99), albeit not significantly at birth weight >4,500 g (aRR: 1.26; 95% CI: 0.87-1.82) versus those without diabetes. The risk of birth trauma with shoulder dystocia was higher with diabetes (aRR: 2.29; 95% CI: 1.54-3.45). The NNT to prevent a shoulder dystocia with diabetes was 11 and 6 at ≥4,000 and >4,500 g, versus without diabetes, 17 and 8 at ≥4,000 and >4,500 g, respectively., Conclusion: Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered. Guidelines providing the option of cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights., Key Points: · >Diabetes increased the risk of shoulder dystocia, even at lower birth weight thresholds than at which cesarean delivery is currently offered.. · Cesarean delivery for suspected macrosomia may have decreased the risk of shoulder dystocia at higher birth weights.. · These findings can inform delivery planning for providers and pregnant individuals with diabetes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to significantly poor perinatal outcome, especially permanent disability or perinatal death., Content: To better objectify the graduation and to include other important clinical parameters, we believe it is appropriate to present a proposal for a complete perinatal weighted graduation of shoulder dystocia, based on several years of numerous other and our own clinical and forensic studies and thematic biobibliography. Obstetric maneuvers, neonatal outcome, and maternal outcome are three components, which are evaluated according to the severity of 0-4 proposed components. Thus, the gradation is ultimately in four degrees according to the total score: I. degreee, score 0-3: slightly shoulder dystocia with simple obstetric interventions, but without birth injuries; II. degree, score 4-7: mild shoulder dystocia resolved by external, secondary interventions and minor injuries; III. degree, score 8-10: severe shoulder dystocia with severe peripartum injuries; IV. degree, score 11-12: extremely difficult, severe shoulder dystocia with ultima ratio interventions applied and resulting extremely severe injuries with chronic disability, including perinatal death., Summary: As a clinically evaluated graduation, it certainly has an applicable long-term anamnestic and prognostic component for subsequent pregnancies and access to subsequent births, as it includes all relevant components of clinical forensic objectification., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Background: The paucity of published veterinary clinical audits suggests that clinical audit is an under-used tool for quality improvement (QI) in the veterinary profession. Therefore, a continuous QI process was designed and implemented at a UK multisite small animal emergency practice, focusing on audit of clinical management of canine dystocia., Methods: Data collection phases were undertaken in 2014, 2019 and 2021, with intervening knowledge dissemination activities. Nine variables relating to clinical management of canine dystocia were selected as audit criteria in the initial dataset, and 21 variables were measured in each subsequent phase., Results: Between 2014 and 2021, statistically significant increases (p < 0.05) were demonstrated in recording of bodyweight, use of diagnostic imaging, use of ultrasonography, recording of fetal heart rates, use of calcium gluconate, and use during caesarean section of intravenous fluid therapy, multimodal analgesia, full agonist opioids, paracetamol and local anaesthesia. Statistically significant decreases were demonstrated in median first quantity and median first dose of oxytocin, and in the use of NSAIDs during caesarean section. A clinical audit planning template was created for future audits., Limitations: Typical case presentation and management of canine dystocia cases may vary between dedicated emergency and non-emergency primary-care settings., Conclusion: This study demonstrates the feasibility of large-scale veterinary clinical audit and suggests that the application of the clinical audit process promotes learning within the veterinary team and improved clinical outcomes., (© 2023 The Authors. Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association.)

Background: Due to the rarity of shoulder dystocia, an obstetric emergency, it is difficult even for experts to develop the appropriate routine in this emergency. Regular further training is therefore recommended for obstetricians and midwives. Evidence is lacking on the extent to which e-learning as a teaching method can be successfully used to acquire these skills and put them into practice. The purpose of this study is to demonstrate how the learning objectives for shoulder dystocia, listed in the National Competence Based Learning Objectives Catalog for Medicine (NKLM, Germany) can be successfully taught in medical studies using a blended learning concept (e-learning and practical application on a birth simulator)., Methods: After completing an e-learning course, final year medical students and midwife trainees demonstrated their action competence for shoulder dystocia procedure on a birth simulator. This transfer of the theoretical knowledge to the case study was assessed using an evaluation form oriented to the recommendations for action., Results: One hundred sixty medical students and 14 midwifery trainees participated in the study from April to July 2019. Overall, 95.9% of the study participants met the required standards, i.e. achieved very good to adequate performance (Ø good) in simulation training., Conclusions: E-learning with annotated high-quality learning videos is an excellent way to transfer theoretical knowledge about shoulder dystocia procedures into medical practice on a birth simulator. The learning objectives required by the NKLM for shoulder dystocia can be successfully conveyed to students via the applied blended learning concept., (© 2023. The Author(s).)

The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The standard maneuvers taught to obstetric practitioners are not always successful in relieving shoulder dystocia. The "inverse shoehorn" is a manual technique not previously described in the literature.

Purpose: There are few data on maternal and neonatal morbidities associated with shoulder dystocia (SD), depending on the use of fetal manipulation (FM). A prior 5-year study was conducted in our center in 2012 for this purpose. Our objective was to compare severe maternal and neonatal morbidities according to FM execution in a larger cohort., Methods: We conducted a retrospective study between 2007 and 2020. SD was considered when additional maneuvers were required to complete a delivery. Severe maternal morbidity was defined as the occurrence of obstetric anal sphincter injury (OASI). Severe neonatal morbidity was defined as Apgar < 7 at 5 min and/or cord arterial pH < 7.1 and/or or a permanent brachial plexus palsy. We studied these data in the FM group compared to the non- FM group., Results: FM was associated with increased OASI rates (21.1% vs. 3.8%, OR = 6.72 [2.7-15.8]). We found no significant difference in severe neonatal morbidity. Maternal age > 35 and FM appear to be associated with the occurrence of OASI, with ORa = 13.3 [1.5-121.8] and ORa = 5.3 [2.2-12.8], respectively. FM was the only factor associated with the occurrence of severe neonatal morbidity (ORa = 2.3 [1.1-4.8]. The rate of episiotomy was significantly decreased (20% versus 5% p < 0.05) and there was an increase in the rate of SD managed with FM in our center., Conclusion: FM is the only factor associated with an increased risk of OASI. In case of failure of non-FM maneuvers, the rapid implementation of FM maneuvers resulted in no difference regarding severe neonatal morbidity., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI)., Design: Retrospective observational study., Setting: Helsinki University Women's Hospital, Finland., Sample: Deliveries with SD., Methods: Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period., Main Outcome Measures: The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed., Results: During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm., Conclusions: Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI., (© 2022 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Purpose of This Review: Even today, hundreds of thousands of women die or suffer high levels of morbidity associated with childbirth. One of the most common causes is halted labor progress, or labor dystocia. There have been no developments in the diagnosis or treatment of dystocic deliveries since Friedman designed the Partogram in the 1950s. Oxytocin is the only treatment for dystocic labor. Sometimes, oxytocin is a lifesaver for the woman, especially in severe postpartum hemorrhages. At the same time, it is also one of the most overused drugs in obstetric care. This review article is meant to provide a short overview of the current knowledge of uterine metabolism during labor, uterine lactate production, and its association with labor dystocia. The article also intends to reflect new ways of thinking regarding practical recommendations for treating labor dystocia and offer a look at the future of dystocic labor management.

Introduction: Shoulder dystocia is a nonpreventable obstetric emergency that causes severe complications, such as obstetric brachial plexus palsy. The objective of the study was to determine the incidence of obstetric brachial plexus palsy and other neonatal complications associated with shoulder dystocia in deliveries managed in a university hospital after the implementation of a simulation-based training that was offered to all the labour and delivery staff on a voluntary basis., Material and Methods: Retrospective observational study including all cases of shoulder dystocia and associated complications (mainly obstetric brachial plexus palsy) documented between January 2017 and December 2020, after the implementation of the training. In addition, we collected retrospective data on cases of obstetric brachial plexus palsy that developed in the hospital before the training (2008-2016)., Results: In the 2017-2020 period, in the total of 125 cases of shoulder dystocia (amounting to 1.38% of vaginal deliveries), there were 14 cases of obstetric brachial plexus palsy (11.2% of the cases of shoulder dystocia), 7 clavicle fractures and 1 humerus fracture; none of the cases of obstetric brachial plexus palsy was permanent or required treatment or rehabilitation past six months. In the years preceding the training, there were 7 cases of obstetric brachial plexus palsy, 2 permanent and 5 temporary (3 of which required rehabilitation)., Conclusion: These results reflect the importance of knowing the morbidity present in the labour and delivery ward and the potential benefit of simulation-based training programmes in the resolution of these obstetric complications., (Copyright © 2022 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: This study will present our results in management of fetal shoulder dystocia with special consideration of maternal and neonatal outcome., Study Design: A retrospective study was performed at a university tertiary perinatal center. The study included data of singleton vaginal term deliveries in the period of 15 years (2006-2020). Analized informations include: obstetrics maternal and neonatal data and outcomes., Results: This period included 45,687 deliveries with diagnosed shoulder dystocia in 254 (0.7 %) cases in vaginal deliveries. Most of the deliveries were spontaneous births 69.7 %, induced deliveries 30.3 %, 47.2 % primiparas and preexisting or gestational diabetes in 21.7 %. The delivery was managed by vacuum extraction in 13.8 %, mediolateral episiotomy in 48.0 % of births, most of the shoulder dystocia were unilateral anterior, while only two cases were diagnosed as more difficult bilateral and 5 cases were recurrent. 87.4 % cases were resolved by McRobert's maneuver, 7.8 % by Barnum's 3.9 % by Wood's maneuver and one case was managed by Menticoglou and by Bourgoise-Siegemundin maneuver. 4.3 % injuries were classified as OASIS of III/IV degree, early postpartum hemorrhage due in 1.6 %. 54.3 % of newborns were male sex, 61.0 % of newborns had birth weight of above 4000 g (mean 4071 g). Maximal Apgar scores were atributed to 92.5 % in first and to 97.2 % in fifth minute, one case that requaired resuscitation. Clavicle fracture was found in 9.5 %, humerus fracture in 0.4 %, transient form of Duchenne Erb obstetrics brachial palsy was diagnosed in only in 7.5 % newborns, while we have not found any case of permanent brachial palsy., Conclusions: Our results confirmed that strategy of prompt identification of shoulder dystocia accompanied by cessation of axial fetal head traction decrease the risk of brachial plexus strain, injury or tear, while performance of exact obstetrical maneuvers resulted in decanceration of fetal shoulders without permanent obstetrics brachial palsy or cerebral morbidity. We think that our good results corelate with our opinion that the performance of external obstetrical manoeuvres should be done without one minute postpone since efforts should be put in sooner shoulder liberation decreasing the time of fetal hypoxia., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: The Yaari Extractor is intended to wrap around and guide the fetal shoulder to facilitate vaginal delivery in cases of shoulder dystocia., Instrument: The Yaari Extractor is a single-use device for fetal shoulder extraction. The device consists of two curved, rigid plastic-coated metal arms with handles and an elastic engagement element that includes two hollow sleeves that cover the portion of the device that enters the vagina and contacts the fetus., Experience: The device has been used in three cases of shoulder dystocia. In all three cases, the shoulder dystocia was resolved without the need for ancillary obstetric maneuvers, and there was no reported maternal or fetal injury., Conclusion: The Yaari Extractor is a novel technology that can be used to successfully resolve shoulder dystocia., Competing Interests: Financial Disclosure The authors declare in the article that the device is not yet approved by the U.S. Food and Drug Administration. Robert B. Gherman, MD, serves as a strategic advisor to Fetal Ease, LTD. Rajnish Patel, MD, did not report any potential conflicts of interest., (Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Most of our knowledge pertaining to this obstetric emergency has emanated from case reports and retrospective studies that have subsequently resulted in empirical management protocols. This article has identified the existence of large gaps in our clinical knowledge base regarding the prevention and resolution of shoulder dystocia, as well as its long-term sequelae. We have attempted to challenge current recommendations regarding whether prophylactic cesarean delivery should be performed based on estimated fetal weight alone or a prior history of shoulder dystocia, shoulder dystocia management techniques, what defines "excessive" traction, and the role of simulation training for all clinicians., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Competing Interests: None to declare.

Background: Shoulder dystocia is an emergency and risky situation that most likely directly involves midwives., Aim: The aim of this study is to determine the effects of simulation training with a high fidelity mannequin on midwives' shoulder dystocia management., Subjects and Methods: This study utilized a quantitative, quasi-experimental research design. No sample selection was made. The study included all midwives (n:16) working in the maternity unit of Manisa Province Hospital, Turkey. Management of shoulder dystocia was lectured both theoretically and practically, using a high fidelity simulation. Midwives' shoulder dystocia management skills and knowledge were evaluated before and after training using shoulder dystocia knowledge form and management skill checklist., Results: There was a statistically significant increase in their shoulder dystocia management knowledge scores and management skills after simulation-based shoulder dystocia training (P < 0.05). Before the training, the midwives (62.5%) mostly used the McRoberts maneuver and suprapubic pressure as the primary interventions in shoulder dystocia management. After training, all the midwives were able to apply secondary maneuvers (Wood's or Rubin's maneuvres or posterior arm delivery) along with the primary maneuvers, in accordance with the shoulder dystocia management algorithm., Conclusion: Using a high fidelity simulation model in training increased midwives' shoulder dystocia management skills and knowledge., Competing Interests: None

Practical Relevance: Cats are common pets worldwide. Successful breeding of cats starts with the selection of suitable breeding animals, and care should be taken to avoid inbreeding. Keeping cats in smaller groups reduces stress and facilitates management., Clinical Challenges: Breeding cats is challenging in many ways. Group housing is a common scenario, and care should be taken not to have groups that are too large, because of the risk of stress and infectious diseases. Feline pregnancy and parturition both vary in length, which is one reason why it may be challenging to diagnose dystocia. In queens with pyometra, a vaginal discharge may not be evident due to their meticulous cleaning habits., Audience: This review is aimed at clinicians in small animal practice, especially those in contact with cat breeders., Patient Group: Reproductive emergencies occur in both intentionally and unintentionally bred cats, and more often in young or middle-aged queens. Pyometra tends to be a disease of older queens., Evidence Base: Evidence is poor for many conditions in the breeding queen, and information is extrapolated from the dog or based on case reports and case series.

Objective: To investigate the manipulative reduction in abnormal uterine inclination in vaginal delivery., Methods: With the independently developed uterine inclination surveyor, 40 primiparas with abnormal uterine inclination were randomly divided into two groups: treatment group (Group A, 20 cases) and control group (Group B, 20 cases). The general condition of the primipara, the labor stages, the changes in uterine inclination after treatment, postpartum hemorrhage at 2 hours, and the general condition of fetuses were observed to study the therapeutic value of manual reduction in abnormal uterine inclination., Result: In the control group, one uterine inclination was not corrected with the change in labor process, and the pregnancy was terminated due to stagnation of the active phase. In the first stage of labor, the time spent in the treatment group (393.4 ± 31.3 mins) was significantly lower than that in the control group (440.7 ± 34.9 mins) ( P = 0.001). Compared with the control group (49.8 ± 6.5 mins), the treatment group (42.6 ± 7.2 mins) also exhibited a significantly shortened second stage of labor ( P = 0.02). Sixteen cases (16/20) in the treatment group returned to normal after manual reduction, and 9 cases (9/20) in the control group returned to normal with the progression of natural labor. Manual reduction could be used as an option to treat abnormal uterine inclination ( P = 0.01). There was no significant difference in the third stage of labor ( P = 0.2), 2-hour postpartum hemorrhage ( P = 0.35), Apgar score ( P = 0.64), or body weight ( P = 0.76) between the two groups., Conclusion: Manual reduction in the treatment of abnormal uterine inclination has obvious effects, shortens the birth process, and is safe for the fetus., Competing Interests: There is no conflict of interest., (Copyright © 2022 Jia Chen et al.)

Objective: To determine if simulation-based team training improves the management of shoulder dystocia compared to traditionally taught obstetrical emergencies., Methods: The prospective mixed-method study was conducted at the Centre for Innovation in Medical Education at the Aga Khan University, Karachi, from June to August 2018, and comprised doctors and nurses having up to five years of labour and delivery experience. The subjects were divided into two equal groups which were further subdivided into four equal teams. Group 1 was taught to manage shoulder dystocia using traditional lectures and hands-on pelvic models, while group 2 was trained in a simulated environment with a simulated scenario of shoulder dystocia. After two weeks, the performance of both teams were assessed and compared. Data was analysed using SPSS 19. A focus group discussion was subsequently conducted on the quality of the simulation experience., Results: Of the 32 subjects, 16(50%) each were doctors and nurses. They were divided into groups having 16(50%) members each, and each group had 4 teams having 4(25%) subjects. The overall mean age of the sample was 31.9±2.8 years (range: 28-38 years). The mean score for performance on technical and communication task of group 2 was 10.25±1.258 compared to 5.7±2.500 in group 1 (p=0.028). Focus group participants agreed that training in a simulated environment was far superior than being traditionally taught., Conclusions: Simulation-based team training in shoulder dystocia management was associated with better feedback than traditional-style teaching.

The Zavanelli manoeuvre is often the final resort of the clinician facing undeliverable shoulder dystocia and we present retrospective pooled data comprising 110 shoulder dystocia cases, 11 impacted breech and 11 locked twin deliveries assessed from ten case series and 38 individual case reports. Although recommended when other external and internal manipulations have failed, we suspect that many clinicians have not had formal training on how to conduct the manoeuvre and may be unfamiliar with the steps involved, leading to a reluctance and delay in initiating this. We describe original descriptions of the manoeuvre, examine its use in intractable shoulder dystocia and illustrate stepwise the cephalic replacement technique. For this review, we have concentrated mainly on the outcomes of the Zavanelli manoeuvre in shoulder dystocia but have also touched on its role in impacted breech and locked twin deliveries. Lastly, we discuss the cognitive load an obstetrician faces when having to make time critical decisions in severe shoulder dystocia and share how other disciplines train and prepare their personnel to manage similar rare and unexpected scenarios., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: To date, no research has focused on the sonographic quantification of the degree of flexion of the fetal head in relation to the labor outcome in women with protracted active phase of labor., Objective: This study aimed to assess the relationship between the transabdominal sonographic indices of fetal head flexion and the mode of delivery in women with protracted active phase of labor., Study Design: Prospective evaluation of women with protracted active phase of labor recruited across 3 tertiary maternity units. Eligible cases were submitted to transabdominal ultrasound for the evaluation of the fetal head position and flexion, which was measured by means of the occiput-spine angle in fetuses in nonocciput posterior position and by means of the chin-to-chest angle in fetuses in occiput posterior position. The occiput-spine angle and the chin-to-chest angle were compared between women who had vaginal delivery and those who had cesarean delivery. Cases where obstetrical intervention was performed solely based on suspected fetal distress were excluded., Results: A total of 129 women were included, of whom 43 (33.3%) had occiput posterior position. Spontaneous vaginal delivery, instrumental delivery, and cesarean delivery were recorded in 66 (51.2%), 17 (13.1%), and 46 (35.7%) cases, respectively. A wider occiput-spine angle was measured in women who had vaginal delivery compared with those submitted to cesarean delivery owing to labor dystocia (126±14 vs 115±24; P<.01). At the receiver operating characteristic curve, the area under the curve was 0.675 (95% confidence interval, 0.538-0.812; P<.01), and the optimal occiput-spine angle cutoff value discriminating between cases of vaginal delivery and those delivered by cesarean delivery was 109°. A narrower chin-to-chest angle was measured in cases who had vaginal delivery compared with those undergoing cesarean delivery (27±33 vs 56±28 degrees; P<.01). The area under the curve of the chin-to-chest angle in relation to the mode of delivery was 0.758 (95% confidence interval, 0.612-0.904; P<.01), and the optimal cutoff value discriminating between vaginal delivery and cesarean delivery was 33.0°., Conclusion: In women with protracted active phase of labor, the sonographic demonstration of fetal head deflexion in occiput posterior and in nonocciput posterior fetuses is associated with an increased incidence of cesarean delivery owing to labor dystocia. Such findings suggest that intrapartum ultrasound may contribute in the categorization of the etiology of labor dystocia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Selected conditions affecting broodmares are discussed, including arterial rupture, dystocia, foal support with ex utero intrapartum treatment, uterine prolapse, postpartum colic, the metritis/sepsis/systemic inflammatory response syndrome complex, and retained fetal membranes. Postpartum colic beyond third-stage labor contractions should prompt comprehensive evaluation for direct injuries to the reproductive tract or indirect injury of the intestinal tract. Mares with perforation or rupture of the uterus are typically recognized 1 to 3 days after foaling, with depression, fever, and leukopenia; laminitis and progression to founder can be fulminant. The same concerns are relevant in mares with retention of fetal membranes., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

Objective: To examine the effects of position management, manual rotation of the fetal position, and using a U-shaped birth stool in primiparous women with a fetus in a persistent occiput posterior position., Methods: This was a prospective pilot study of women who delivered at Gansu Provincial Maternity and Child-care Hospital between January and June 2018. The women were divided into the position management ([PM] position management, manual rotation of fetal position, use of a U-shaped birth stool at different stages, and routine nursing) and control groups (position selected by women and routine nursing)., Results: There were 196 women in the PM group and 188 in the control group. There were no significant differences in maternal age, gestational weeks, newborn weight, and the neonatal asphyxia rate between the PM and control groups. The duration of labor was shorter in the PM group than in the control group. Pain and blood loss 2 hours after delivery and the episiotomy rate were significantly lower in the PM group than in the control group., Conclusion: Applying position management, manual rotation of the fetal position, and using a U-shaped birth stool should be considered for women with a fetus in a persistent occiput posterior position.

Background: Guidelines and description about the achievement of the McRoberts manoeuvre are discordant, particularly concerning the need for abduction before the beginning of the manoeuvre. We sought to compare the biomechanical efficiency of the McRoberts' manoeuvre, with and without thigh abduction., Methods: In a postural comparative study, twenty-three gravidas > 32 weeks of gestational age and not in labour were assessed during three repetitions of two McRoberts' manoeuvre that differed in terms of starting position. For the (i) McRoberts, the legs were initially placed in stirrups; for the (m) McRoberts, the legs were resting on the bed, with thighs in wide abduction. For each manoeuvre, flexion of the plane of the external conjugate of the pelvis on the spine (ANGce), hip flexion and abduction, were assessed using an optoelectronic motion capture system. Lumbar curve were assessed with Epionics Spine® system. Temporal parameters including movement duration or acceleration of the external conjugate were also computed. All values ​​obtained for the two types of manoeuvres were compared using a Wilcoxon matched-pairs signed-ranks test. The significance level was defined as p < 0.05., Results: The starting position of McRoberts' otherwise had no effect on the maximum ANGce (p = 0.199), the minimal lordosis of the lumbar curve (p = 0.474), or the maximal hip flexion (p = 0.057). The other parameters were not statistically different according to the starting position (p > 0.005)., Conclusion: Regardless of the starting position, the McRoberts' manoeuvre allows ascension of the pubic symphysis and reduction of the lumbar lordosis. This results imply that the McRoberts' manoeuvre could be performed with the legs initially placed in the stirrups.