Neonatal and Maternal Outcomes following Shoulder Dystocia Resolution Utilizing ≥ versus < 3 Maneuvers

Objective Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with ≥3 maneuvers, compared with fewer, is associated with a higher likelihood of adverse outcomes. The secondary objective was to examine if postpartum hemorrhage is associated with SD managed with ≥3 maneuvers versus fewer. Study Design This was a secondary analysis of the assessment of perinatal excellence (APEX) study, an observational cohort of over 115,000 deliveries in 25 U.S. hospitals from 2008 to 2011. We included individuals with singleton, vertex, and nonanomalous fetuses at ≥34 weeks who had SD requiring at least one maneuver. We stratified participants according to if ≥3 maneuvers, versus fewer, were utilized to resolve the SD. The primary outcome was the incidence of a neonatal composite adverse outcome including APGAR &lt;5 at 5 minutes, fetal fractures, intracranial hemorrhage, brachial plexus palsy, facial nerve palsy, hypotension treated, hypoxic-ischemic encephalopathy, or neonatal death. Using modified-Poisson-regression, we calculated adjusted incidence relative risk (aIRR) with 95% confidence intervals (CI). Results The rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 cases of SD, 96% met the inclusion criteria. ≥3 maneuvers were utilized in 18.9% (391/2,062) of SD cases. The composite neonatal adverse outcome occurred in 8.1% (168/2,062) of cases, and in adjusted models, the risk for the composite outcome was significantly higher with SD requiring ≥3 maneuvers (15.1%) versus &lt;3 maneuvers (6.5%; aIRR: 2.08; 95% CI: 1.50-2.89). Additionally, APGAR &lt;5 at 5 minutes (aIRR: 4.10; 95% CI: 1.18-14.25), neonatal brachial plexus palsy (aIRR: 2.58; 95% CI: 1.45-4.60), and hypoxic-ischemic encephalopathy (aIRR: 2.83; 95% CI: 1.36 and 5.89) were significantly more likely when ≥3 were used. No significant difference was noted for postpartum hemorrhage (PPH) by number of maneuvers (aIRR: 0.74; 95% CI: 0.44 and 1.21). Conclusion SD relieved by ≥3 maneuvers, compared with &lt;3, was associated with a 2-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for PPH.