A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders

Gentamicin (GM) has been shown to reversibly reduce the ability of contralateral noise to suppress ipsilateral cochlear activity, in a dose-dependent manner. However, during chronic administration of lower doses (60 mg/kg) the involvement of medial efferents could not be demonstrated. The purposes of the present study were to determine whether other aminoglycosides would display the same acute effects as GM and whether there was any correlation between their specificity and degree of cochlear and vestibular toxicity and their potency of blockade of the medial efferent system. Thus, we observed changes in ipsilateral ensemble background activity (EBA) of the VIIIth nerve without and with contralateral low level (55 dB SPL) broadband noise stimulation, in awake guinea pigs (GPs), before and after one single high-dose intramuscular injection of different aminoglycoside antibiotics (AAs) (gentamicin, amikacin, neomycin, netilmicin, streptomycin, tobramycin). For comparison, the effects of strychnine, a known antagonist of the efferent transmission and of cisplatin, an antineoplastic agent with cochleotoxic properties were also studied. Netilmicin displayed blocking properties similar to GM, although less pronounced, while amikacin and neomycin had no effect on medial efferent function. With tobramycin and streptomycin a decrease in suppression was usually associated with a reduction of the EBA measured without acoustic stimulation. However, with cisplatin, suppression was still effective when EBA was severely decreased. We could not observe specific effects of strychnine on medial efferent function. In conclusion, no correlation was found between specificity and degree of AA ototoxicity and their action on the medial efferent system.     

Difficulties in delivery, including shoulder dystocia and malpresentations of the fetus

Shoulder dystocia is a true obsteric emergency. It may be suspected in large multiparous women, women who have previously delivered large babies, prolonged pregnancy, women who make poor progress in labor, and when the fetus seems very large to palpation. Women with abnormal pelves should be suspect. More liberal use of cesarean section in these situations will reduce the incidence of shoulder dystocia. It is important to have a carefully considered plan of action if shoulder dystocia does occur. The most helpful and definitive maneuver is extration of the posterior arm. Malpresentations cause acute emergencies mainly because of the associated increased incidence of prolapse of the cord. This possibility should be evaluated immediately when rupture of the membranes occurs. Prompt delivery by cesarean section is the treatment of choice with this complications.     

A case report: cephalic replacement and emergency caesarean section for the resolution of shoulder dystocia

Shoulder dystocia is a serious complication of delivery. Various manoeuvres had been described, all aim at achieving shoulder descent and vaginal delivery. We report a case whereby shoulder dystocia was managed by a rather unique technique--the foetal head was replaced in the vagina and baby delivered by emergency Caesarean Section.     

Elective delivery of infants with macrosomia in diabetic women: reduced shoulder dystocia versus increased cesarean deliveries

OBJECTIVE: We sought to test the hypothesis that elective delivery of infants diagnosed with macrosomia by ultrasonographic studies in diabetic women will significantly reduce the rate of shoulder dystocia without significantly increasing cesarean section rate. STUDY DESIGN: In a prospective study diabetic women with ultrasonographic estimated fetal weight > or = 4250 gm underwent elective cesarean section; women with estimated fetal weight > or = 90th percentile but < 4250 gm underwent induction of labor. Maternal and neonatal outcomes were analyzed and compared for the periods before and after initiation of the protocol. RESULTS: A total of 2604 diabetic patients were included in this study. The rate of shoulder dystocia was significantly lower after instituting the protocol (2.4% vs 1.1%, odds ratio 2.2). The cesarean section rate increased significantly between the two periods (21.7% vs 25.1%, p < 0.04). Ultrasonography correctly identified the presence or absence of macrosomia in 87% of patients. Only 10.6% of diabetic patients at term required intervention under the protocol (6.8% labor induction, 3.8% elective cesarean section). The rate of shoulder dystocia was 7.4% in macrosomic infants delivered vaginally. CONCLUSION: An ultrasonographically estimated weight threshold as an indication for elective delivery in diabetic women reduces the rate of shoulder dystocia without a clinically meaningful increase in cesarean section rate. This practice, in conjunction with an intensified management approach to diabetes, improves the outcome of these high-risk women and their infants.     

Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy

BACKGROUND: Helicobacter pylori may interfere with gastroduodenal protective mechanisms. Such effects could be due to a direct interaction with gastric epithelial cells but also to the action of a wide range of secreted and membrane-bound virulence factors. Our aim was to study the acute effects of water extracts produced from H. pylori on gastric mucosal blood flow and acid secretion and to relate them to VacA and CagA activity. METHOD: Extracts were produced from strains 88-23 and A5, both wild type; A5VacA, an isogenic mutant lacking expression of the vacuolating cytotoxin (VacA) and the immunodominant antigen (CagA); and Escherichia coli strain ATCC-25922. Bacterial extracts were applied on the exteriorized gastric corporal mucosa in inactin-anaesthetized rats after removal of as much as possible of the mucus layer, during intravital microscopy. Blood flow was measured by means of laser-Doppler flowmetry. RESULTS: All H. pylori extracts, including the extract from 88-23 heated to 100 degrees C for 30 min, significantly reduced blood flow by 15%-19%, whereas E. coli had no significant effect on blood flow. CONCLUSION: A factor or a combination of factors, other than VacA and CagA released from H. pylori, might compromise the natural defence of the gastric corporal mucosa by reducing mucosal blood flow. The factor is heat-stable and lacking or less potent in E. coli.     

Shoulder dystocia

Shoulder dystocia is an unpredictable and potentially serious obstetric emergency. By applying a recognized and rehearsed series of manoeuvres, maternal and neonatal morbidity can be minimized.     

Shoulder dystocia and symphysiotomy: a case report

Six patients were examined by CT following head trauma, with bleeding from the ear and trismus. The mandibular condyles were normal and MRI in two patients demonstrated a normally located meniscus. An unilateral comminuted temporal bone fracture (TBF) with multiple fracture lines and one or more fragments detached from the petrous bone was demonstrated by CT in every patient. On physical examination there was trismus, inability to chew and local pain in the temporomandibular joint (TMJ) without tenderness and swelling. Measurements of vertical and horizontal mandibular movement unequivocally demonstrated TMJ malfunction in comparison with 10 controls. The malfunction was presumably due to instability of the fractured petrous bone, base of the TMJ. Immobilising one TMJ results in blocking of both joints. Clinical improvement in 6-8 months and absence of symptoms of joint derangement on repeated physical examination were thought to be explained by restored petrous bone stability following healing of the fractures. The phenomenon of trismus following TBF with normal TMJ is rare and not yet reported.     

Shoulder dystocia: fifteen years'' experience in Ramathibodi Hospital

Although shoulder dystocia does not occur frequently the adverse effect to the patient and especially to infants can be catastrophic. The purpose of this study was to evaluate the incidence, the factors which may be related to or predispose to this condition and the consequence to the patients and their infants. All cases of shoulder dystocia which occurred during the fifteen year period from January 1982 to December 1996 were scrutinized. There were 17 cases of shoulder dystocia from a total of 109,923 deliveries giving the incidence of 1.6 per 10,000 deliveries. Of these 17 patients, 11 (65%) were delivered by vacuum extraction. Two patients had postpartum hemorrhage requiring blood transfusion. Infants' birthweights ranged between 3350 to 5160 grams. Erb's palsy occurred in 6 infants and all made full recovery subsequently.     

Welfare reform: a commentary

Aid to the Families of Dependent Children (AFDC) has been successful in most cases. Welfare reform should focus on aiding children by identifying and helping dysfunctional, welfare dependent parents when possible and relieving them of parenting responsibilities with adoption of their children when they neglect and abuse their children and are unable or unwilling to become competent parents. AFDC is illsuited to be an employment or an antipoverty program.