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Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis: a reply

Published:January 19, 2022DOI:https://doi.org/10.1016/j.ajog.2022.01.013
      To the Editors:
      We congratulate Wagner et al
      • Wagner S.M.
      • Bell C.S.
      • Gupta M.
      • et al.
      Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis.
      for performing a systematic review and meta-analysis of 16 reports on shoulder dystocia (SD) training and clinical outcomes, but we disagree with the interpretation of their results. The article’s key finding that brachial plexus injury (BPI) incidence decreases after simulation training, is true. Moreover, the increase in SD incidence after training is attributable to improved provider awareness of the condition. SD incidence is varied in large part because the diagnosis is subjective. We have found that training with force measurement directly affects the participants’ perception of impeded delivery.
      Most of the included studies compared clinical outcomes after training for many years, often ≥8 years. There has been an increase in cesarean delivery rates over time: 22.3% in 1990 to 32.3% in 2014 in North America.
      • Betrán A.P.
      • Ye J.
      • Moller A.B.
      • Zhang J.
      • Gülmezoglu A.M.
      • Torloni M.R.
      The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014.
      Certainly, there can be no causative conclusion that simulation training explains this rise over time.
      The authors compared 2 studies with opposing results to question whether simulation training can reduce the incidence of permanent BPI. It was established more than 50 years ago that permanent injuries decreased by 400% after the introduction of fetal maneuvers in the 1940s.
      • Adler J.B.
      • Patterson R.L.
      Erb’s palsy. Long-term results of treatment in eighty-eight cases.
      This was during an era when the cesarean delivery rate was <5%. Figure 3 demonstrates multiple other studies that have demonstrated that the incidence of permanent injuries can be reduced with proper training.
      The authors raise a valid point that the cost of simulation may be prohibitive and impractical to train 44,000 providers in the United States who deliver neonates. However, focusing simulations on incoming obstetrical trainees and on those who have already experienced a permanent injury is a good place to start. Training incoming interns for 12 years demonstrated a 6-fold decrease in BPIs and a concomitant decrease in permanent BPI claims.
      • Gurewitsch Allen E.D.
      • Will S.E.B.
      • Allen R.H.
      • Satin A.J.
      Improving shoulder dystocia management and outcomes with a targeted quality assurance program.

      References

        • Wagner S.M.
        • Bell C.S.
        • Gupta M.
        • et al.
        Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis.
        Am J Obstet Gynecol. 2021; 225: 484.e1-484.e33
        • Betrán A.P.
        • Ye J.
        • Moller A.B.
        • Zhang J.
        • Gülmezoglu A.M.
        • Torloni M.R.
        The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014.
        PLoS One. 2016; 11e0148343
        • Adler J.B.
        • Patterson R.L.
        Erb’s palsy. Long-term results of treatment in eighty-eight cases.
        J Bone Joint Surg Am. 1967; 49: 1052-1064
        • Gurewitsch Allen E.D.
        • Will S.E.B.
        • Allen R.H.
        • Satin A.J.
        Improving shoulder dystocia management and outcomes with a targeted quality assurance program.
        Am J Perinatol. 2017; 34: 1088-1096

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