Neonatal and Maternal Outcomes Following Shoulder Dystocia Resolution Utilizing > versus < 3 Maneuvers

Introduction: Most shoulder dystocia (SD) cases do not have associated adverse outcomes. The objective was to assess whether SD relieved with >3 maneuvers, compared to 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 vs fewer. Methods: This was a secondary analysis of the Assessment-of Perinatal-Excellence(APEX) study, a observational-cohort of over 115,000 deliveries in 25-U.S. hospitals from 2008-2011. We included individuals with singleton, vertex, non-anomalous 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 <5 at 5 min, 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, risk for the composite outcome was significantly higher with SD requiring ≥ 3 maneuvers(15.1%) versus < 3 maneuvers(6.5%; aIRR 2.08; 95% CI 1.50-2.89). Additionally, Apgar <5 at 5 minutes(aIRR 4.10 95% CI 1.18-14.25), NBPP(aRR 2.58; 95%CI 1.45-4.60) and HIE(aIRR 2.83; 95% CI 1,36, 5.89) were significantly more likely when > 3 were used. No significant difference was noted for postpartum hemorrhage by number of maneuvers (aIRR 0.74; 95%-CI 0.44, 1.21). Conclusions: Shoulder dystocia relieved by > 3 maneuvers, compared to <3, was associated with two-fold-increased risk for the composite neonatal adverse outcome, with no difference in risk for postpartum hemorrhage.

Publication History

Received: 27 February 2025

Accepted after revision: 15 April 2025

Accepted Manuscript online:
16 April 2025