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Risk Factors for Recurrent Shoulder Dystocia, Washington State 1987-2004

Risk Factors for Recurrent Shoulder Dystocia, Washington State 1987-2004. Hillary Moore, MD University of Washington School of Public Health and Community Medicine Department of Epidemiology Maternal and Child Health Track Melissa Schiff, Thesis Advisor Susan Reed, Thesis Committee Member.

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Risk Factors for Recurrent Shoulder Dystocia, Washington State 1987-2004

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  1. Risk Factors for Recurrent Shoulder Dystocia,Washington State 1987-2004 Hillary Moore, MD University of Washington School of Public Health and Community Medicine Department of Epidemiology Maternal and Child Health Track Melissa Schiff, Thesis Advisor Susan Reed, Thesis Committee Member

  2. Introduction • Shoulder dystocia is an obstetric emergency in which an infant’s shoulders fail to deliver spontaneously after delivery of the head Recurrent Shoulder Dystocia

  3. Background • Can result in significant infant morbidity and mortality as well as maternal morbidity • Incidence of primary shoulder dystocia is 0.13-1.16% of vaginal deliveries • Four previous studies on recurrent shoulder dystocia • Very small number of cases • No adjustment for confounding • Referral center populations Recurrent Shoulder Dystocia

  4. Specific Aims • What are the incidences of primary and recurrent shoulder dystocia? • What are the risk factors for recurrent shoulder dystocia? Recurrent Shoulder Dystocia

  5. Methods • Data Source: Washington State Longitudinal Birth Records Database linked with birth hospitalization discharge diagnoses, 1987-2004 Recurrent Shoulder Dystocia

  6. Methods • Calculated primary and recurrent shoulder dystocia annual incidences • Described maternal characteristics of women with and without recurrent shoulder dystocia and a subsequent cesarean section • Used logistic regression to calculate Odds Ratios (OR) and 95% Confidence Intervals (CI) for the following risk factors: • Birth weight • Gestational age • Body Mass Index • Maternal weight gain • Gestational Diabetes • Operative assistance • Induction of labor Recurrent Shoulder Dystocia

  7. Methods • Constructed a multivariable logistic regression model including maternal age and parity as confounding factors to obtain adjusted risk estimates for risk factors found to be significantly associated with recurrent shoulder dystocia • Analysis was performed with stratification by diabetes status Recurrent Shoulder Dystocia

  8. Results Recurrent Shoulder Dystocia

  9. Results (continued) Cases Controls Cesarean Section N=1,060 N=4,238 N=1,172 (%) (%) (%) Maternal Age (years) <20 2.0 3.7 1.6 20-24 19.4 23.1 16.1 25-29 33.1 31.1 30.0 30-34 30.3 27.2 32.6 35+ 15.2 14.8 19.6 Parity 1 42.5 63.5 50.6 2 32.6 20.3 28.9 3 12.4 8.1 10.1 4 4.6 3.0 4.8 5+ 4.9 1.9 3.2 Recurrent Shoulder Dystocia

  10. Results (continued) Risk Factor Crude OR Adjusted OR (95% CI) (95% CI) Gestational diabetes in subsequent pregnancy 1.5 (1.2, 2.0) 1.2 (0.9, 1.5) Birth weight in index pregnancy (grams) <2500 - - 2500-2999 0.4 (0.2, 0.7) 0.4 (0.2, 0.7) 3000-3499 Reference Reference 3500-3999 2.0 (1.6, 2.4) 1.9 (1.5, 2.4) 4000-4499 3.7 (3.0, 4.6) 3.5 (2.8, 4.4) 4500-4999 3.8 (2.8, 5.2) 3.3 (2.4, 4.5) 5000+ 6.5 (3.4, 12.6) 4.5 (2.2, 9.3) Recurrent Shoulder Dystocia

  11. Results (continued) Risk Factor Crude OR Adjusted OR (95% CI) (95% CI) Operative delivery in index pregnancy Forceps 0.9 (0.7, 1.2) 1.1 (0.8, 1.4) Vacuum 1.2 (1.0, 1.4) 1.5 (1.3, 1.9) Both - - No operative assistance Reference Reference Induction in subsequent pregnancy 1.2 (1.0, 1.4) 1.1 (0.9, 1.3) Recurrent Shoulder Dystocia

  12. Discussion • Increasing magnitude of risk with increasing birth weight in the index pregnancy • 50% increased risk of recurrence with vacuum assistance in the index pregnancy • No significant association between gestational diabetes and recurrence after adjustment for maternal age and parity • No effect modification by diabetes status • Caesarean sections after primary shoulder dystocia • Limitations Recurrent Shoulder Dystocia

  13. Conclusion • Based on our population-based study, birth weight and vacuum assistance in the index delivery indicate increased risk of recurrence in a subsequent delivery • In the context of an increasing primary shoulder dystocia incidence, identification of risk factors for recurrent shoulder dystocia is needed for clinical decision-making Recurrent Shoulder Dystocia

  14. Thank you Melissa Schiff Susan Reed Bill O’Brien Sara Donahue and my MCH colleagues Supported in part by Project #T76 MC 00011from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services. Recurrent Shoulder Dystocia

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