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

Published:January 19, 2022DOI:https://doi.org/10.1016/j.ajog.2022.01.011
      We appreciate Dr Robert Allen’s and Dr Edith Allen’s interest in our systematic review and Bayesian meta-analysis of pre- and postinterventions trials to decrease the complications associated with shoulder dystocia.
      • Wagner S.M.
      • Bell C.S.
      • Gupta M.
      • et al.
      Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis.
      We disagree with several statements in their letter.
      The increase in the diagnosis of shoulder dystocia, without a convincing overall reduction in brachial plexus injury, is not without ill consequences. Aside from being traumatic to both the mother and clinicians,
      • Beck C.T.
      The obstetric nightmare of shoulder dystocia: a tale from two perspectives.
      a history of shoulder dystocia may lead to cesarean deliveries in subsequent pregnancies, with associated morbidity and mortality.
      • Chauhan R.S.
      • Chauhan S.P.
      Montgomery v Lanarkshire Health Board: a paradigm shift.
      Regarding the noted increase in the rate of cesarean delivery before and after the implementation of the intervention, we wrote that “[f]rom the analysis, however, we cannot establish a causal relationship between the intervention and the change in the route of delivery.” Nonetheless, clinicians and policymakers who advocate for shoulder dystocia training ought to be cognizant of the possibility that the intervention may unintentionally and unexpectedly increase the rate of cesarean delivery.
      Please note that Figure 3 in our article, does not report on the “incidence of permanent injury” before and after the training. The written description for Figure 3 is “[p]roportion of NBPP [neonatal brachial plexus palsy] per shoulder dystocia case during pre- and postintervention.” The word permanent was intentionally not in the descriptor. Subsequently, we summarized the results of the 2 publications, which followed children for at least 12 months, and rightly concluded that “[i]n 2 studies, the persistence of neonatal brachial palsy at 12 months was reported with contradicting conclusions.”
      We appreciate Dr Robert Allen’s and Dr Edith Allen’s acknowledgment that we have a “valid point” that training all clinicians in the country may be prohibitive and impractical. However, we are doubtful that their suggestion to focus training on incoming trainees suffices. The only cluster randomized trial on the topic
      • Fransen A.F.
      • van de Ven J.
      • Schuit E.
      • van Tetering A.
      • Mol B.W.
      • Oei S.G.
      Simulation-based team training for multi-professional obstetric care teams to improve patient outcome: a multicentre, cluster randomised controlled trial.
      noted no reduction when all faculty and trainees participated in the simulation.
      We do agree with Dr Robert Allen and Dr Edith Allen that currently there is insufficient evidence for policymakers—be it at an institution or at a national organization committee—to recommend simulation and shoulder dystocia protocols to decrease persistent neonatal brachial plexus palsy.

      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
        • Beck C.T.
        The obstetric nightmare of shoulder dystocia: a tale from two perspectives.
        MCN Am J Matern Child Nurs. 2013; 38: 34-40
        • Chauhan R.S.
        • Chauhan S.P.
        Montgomery v Lanarkshire Health Board: a paradigm shift.
        BJOG. 2017; 124: 1152
        • Fransen A.F.
        • van de Ven J.
        • Schuit E.
        • van Tetering A.
        • Mol B.W.
        • Oei S.G.
        Simulation-based team training for multi-professional obstetric care teams to improve patient outcome: a multicentre, cluster randomised controlled trial.
        BJOG. 2017; 124: 641-650

      Linked Article

      • Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis: a reply
        American Journal of Obstetrics & GynecologyVol. 226Issue 6
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          We congratulate Wagner et al1 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.
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