(1032) Shoulder Dystocia Resolution Utilizing < vs. > 3 Maneuvers and Associated Adverse Outcomes

This was a secondary analysis of the Assessment of Perinatal EXcellence (APEX) study, a observational cohort of over 115,000 deliveries within 25 U.S. hospitals. We included women with singleton, vertex, non-anomalous gestations at > 34 weeks who had SD, relieved with at least 1 maneuver. We excluded SD if no maneuvers were documented. We stratified the groups according to the number of maneuvers used to resolve the shoulder dystocia. The primary outcome was a neonatal composite outcome encompassing Apgar < 5 at 5’, fetal fractures, intracranial hemorrhage, brachial plexus injury, facial nerve palsy, hypotension and neonatal death. Statistical analysis included Chi-square, Kruskal-Wallis, logistic and Poisson regressions with robust error variance for adjusted Incidence Rate Ratios, adjusting for BMI and maternal age.

Results:

The overall rate of SD in APEX was 1.9% (2,138/118,422). Of 2,138 SD, 96% met the inclusion criteria for analysis. Three or more maneuvers were utilized in 19% (391/2,062) of SD.  The composite outcome was higher with > 3 maneuver (14.6%) vs < than 3 (5.7%; Fig 1). After adjustement the aIRR was 2.28 (95%CI 1.62, 3.20). Additionally, Apgar < 5 at 5` (aIRR 4.10 95% CI 1.18-14.25), fetal fractures (aIRR 2.58 95% CI 1,66-4.00), intracranial hemorrhage (aIRR 4.28 95%CI 1.06-17.19), brachial plexus injury (aIRR 2.58 95%CI 1.45-4.60) were significantly more likely when > 3 vs < 3 maneuvers were used. No statistically significant differences were noted for rates of facial nerve palsy, hypotension requiring treatment and neonatal death and postpartum hemorrhage (Table 1).

Conclusion: Shoulder dystocia relieved by 3 or more maneuvers, compared to fewer, was associated with a 2.5-fold increased risk of composite neonatal adverse outcomes, albeit not postpartum hemorrhage.