We evaluated the use of multivariate analysis in the prediction of shoulder dystocia (SD). One hundred consecutive cases with SD were matched with 100 controls without dystocia. All patients had term, vaginal delivery. Multivariate analysis was used to identify independent variables significantly related to shoulder dystocia. The regression coefficients for the identified factors were used to calculate a composite score from which receiver operating characteristics (ROC) curves were derived. Birthweight (BW), 1-hour Glucola (GLU), operative vaginal delivery (OVD), and height of fundus (HOF) were related independently to SD. The sensitivity and specificity reached 84 and 80%, respectively, with BW + GLU + OVD. Significant associations persisted when HOF and carbohydrate intolerance were substituted for BW and GLU, respectively. SD is independently associated with BW, GLU, and OVD, and may be predicted with clinically acceptable accuracy using multiple variables. This model may be useful in the design of prospective studies for managing suspected macrosomia.

Dystocia, difficult labour, is a common but also complex problem during childbirth. It can be attributed to either weak contractions of the uterus, a large infant, reduced capacity of the pelvis or combinations of these. Previous studies have indicated that there is a genetic component in the susceptibility of experiencing dystocia. The purpose of this study was to identify susceptibility genes in dystocia.

At Counties Manukau Health in Auckland, New Zealand, axillary traction is being used when an internal manoeuvre is required for resolution of shoulder dystocia.

Objectives  The purpose of this study was to evaluate the metabolic pathways activated in the serum of African-American women during late pregnancy that predicted term labor dystocia. Study Design  Matched case-control study ( n  = 97; 48 cases of term labor dystocia and 49 normal labor progression controls) with selection based on body mass index (BMI) at hospital admission and maternal age. Late pregnancy serum samples were analyzed using ultra-high-resolution metabolomics. Differentially expressed metabolic features and pathways between cases experiencing term labor dystocia and normal labor controls were evaluated in the total sample, among women who were obese at the time of labor (BMI ≥ 30 kg/m2), and among women who were not obese. Results  Labor dystocia was predicted by different metabolic pathways in late pregnancy serum among obese (androgen/estrogen biosynthesis) versus nonobese African-American women (fatty acid activation, steroid hormone biosynthesis, bile acid biosynthesis, glycosphingolipid metabolism). After adjusting for maternal BMI and age in the total sample, labor dystocia was predicted by tryptophan metabolic pathways in addition to C21 steroid hormone, glycosphingolipid, and androgen/estrogen metabolism. Conclusion  Metabolic pathways consistent with lipotoxicity, steroid hormone production, and tryptophan metabolism in late pregnancy serum were significantly associated with term labor dystocia in African-American women.

For more than 50 years, the methylation of mammalian actin at histidine 73 has been known to occur1. Despite the pervasiveness of His73 methylation, which we find is conserved in several model animals and plants, its function remains unclear and the enzyme that generates this modification is unknown. Here we identify SET domain protein 3 (SETD3) as the physiological actin His73 methyltransferase. Structural studies reveal that an extensive network of interactions clamps the actin peptide onto the surface of SETD3 to orient His73 correctly within the catalytic pocket and to facilitate methyl transfer. His73 methylation reduces the nucleotide-exchange rate on actin monomers and modestly accelerates the assembly of actin filaments. Mice that lack SETD3 show complete loss of actin His73 methylation in several tissues, and quantitative proteomics analysis shows that actin His73 methylation is the only detectable physiological substrate of SETD3. SETD3-deficient female mice have severely decreased litter sizes owing to primary maternal dystocia that is refractory to ecbolic induction agents. Furthermore, depletion of SETD3 impairs signal-induced contraction in primary human uterine smooth muscle cells. Together, our results identify a mammalian histidine methyltransferase and uncover a pivotal role for SETD3 and actin His73 methylation in the regulation of smooth muscle contractility. Our data also support the broader hypothesis that protein histidine methylation acts as a common regulatory mechanism.

Dystocia is a serious problem for pregnant women, and it increases the cesarean section rate. Although uterine dysfunction has an unknown etiology, it is responsible for cesarean delivery and clinical dystocia, resulting in neonatal morbidity and mortality; thus, there is an urgent need for novel therapeutic agents. Previous studies indicated that statins, which inhibit the mevalonate (MVA) pathway of cholesterol synthesis, can reduce the incidence of preterm birth, but the safety of statins for pregnant women has not been thoroughly evaluated. Therefore, to unambiguously examine the function of the MVA pathway in pregnancy and delivery, we employed a genetic approach by using myometrial cell-specific deletion of geranylgeranyl pyrophosphate synthase (Ggps1) mice. We found that Ggps1 deficiency in myometrial cells caused impaired uterine contractions, resulting in disrupted embryonic placing and dystocia. Studies of the underlying mechanism suggested that Ggps1 is required for uterine contractions to ensure successful parturition by regulating RhoA prenylation to activate the RhoA/Rock2/p-MLC pathway. Our work indicates that perturbing the MVA pathway might result in problems during delivery for pregnant females, but modifying protein prenylation with supplementary farnesyl pyrophosphate or geranylgeranyl pyrophosphate might be a strategy to avoid side effects.

Cesarean birth rates are rising. Uterine dysfunction, the exact mechanism of which is unknown, is a common indication for Cesarean delivery. Biglycan and decorin are two small leucine-rich proteoglycans expressed in the extracellular matrix of reproductive tissues and muscle. Mice deficient in biglycan display a mild muscular dystrophy, and, along with mice deficient in decorin, are models of Ehlers-Danlos Syndrome, a connective tissue anomaly associated with uterine rupture. As a variant of Ehlers-Danlos Syndrome is caused by a genetic mutation resulting in abnormal biglycan and decorin secretion, we hypothesized that biglycan and decorin play a role in uterine function. Thus, we assessed wild-type, biglycan, decorin and double knockout pregnancies for timing of birth and uterine function. Uteri were harvested at embryonic days 12, 15 and 18. Nonpregnant uterine samples of the same genotypes were assessed for tissue failure rate and spontaneous and oxytocin-induced contractility. We discovered that biglycan/decorin mixed double-knockout dams displayed dystocia, were at increased risk of delayed labor onset, and showed increased tissue failure in a predominantly decorin-dependent manner. In vitro spontaneous uterine contractile amplitude and oxytocin-induced contractile force were decreased in all biglycan and decorin knockout genotypes compared to wild-type. Notably, we found no significant compensation between biglycan and decorin using quantitative real time PCR or immunohistochemistry. We conclude that the biglycan/decorin mixed double knockout mouse is a model of dystocia and delayed labor onset. Moreover, decorin is necessary for uterine function in a dose-dependent manner, while biglycan exhibits partial compensatory mechanisms in vivo. Thus, this model is poised for use as a model for testing novel targets for preventive or therapeutic manipulation of uterine dysfunction.

Our aim was to identify factors associated with shoulder dystocia following an attempted operative vaginal delivery (aOVD) in a prospective cohort study and to evaluate whether these factors can be used to accurately predict shoulder dystocia by building a score of shoulder dystocia risk. This was a planned secondary analysis of a prospective cohort study of deliveries with aOVD at term from 2008-2013. Cases were defined as women with shoulder dystocia following an aOVD defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Multivariate logistic regression analyses were performed to determine risk factors for shoulder dystocia. Shoulder dystocia occurred in 57 (2.7%) of the 2118 women included. In the whole cohort, women with shoulder dystocia more often had a history of shoulder dystocia (3.5% vs. 0.2%, p = 0.01), and there was a significant interaction between aOVD and gestational age and the duration of the second stage of labor: women with shoulder dystocia more often had a gestational age > 40 weeks and a second stage of labor longer than 3 h specifically for midpelvic aOVD. In multivariable analysis, a history of shoulder dystocia was the only factor independently associated with shoulder dystocia following aOVD (aOR 27.00, 95% CI 4.10-178.00). The AUC for the receiver operating characteristic curve generated using a multivariate model with term interaction with head station was 0.70 (95% CI 0.62-0.77). The model failed to accurately predict shoulder dystocia.

to identify potentially modifiable risk factors associated with the persistency of macrosomia and/or shoulder dystocia in infants born to women treated for gestational diabetes mellitus (GDM).

Objective  The main purpose of this article is to describe the technique and mechanism of action of a novel intervention for the relief of shoulder dystocia we are labeling Carit maneuver. Methods  We report a cohort study of eight cases of shoulder dystocia not relieved by the combination of McRobert's maneuver and suprapubic pressure treated with the Carit maneuver. This intervention involves the use of the fetal head and neck as the grasping point of the fetus to exert a ventral rotation of the fetal trunk, reduce the bi-acromial diameter, and deliver the posterior shoulder by passive displacement. In all these cases, the direction of the original head restitution, direction of exerted rotation, and side and location of delivery of the first shoulder were recorded. Maternal and neonatal outcomes were reviewed and reported. Results  In all cases, the Carit rotational maneuver resulted in the delivery of the posterior shoulder in the transverse (4), oblique anterior (2), or direct anterior (2) diameters. No instances of neonatal depression or fetal acidemia were noted in this cohort. Conclusion  The Carit maneuver is an original and successful intervention in the management of shoulder dystocia unresponsive to McRobert's maneuver and suprapubic pressure.

Shoulder dystocia is defined as vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has been delivered and gentle traction has failed. A bigger difference between the transverse abdominal diameter (TAD) (abdominal circumference [AC]/π) and biparietal diameter (BPD) (TAD-BPD) has been reported as a risk factor for shoulder dystocia in different countries; however, it remains unclear if this relationship is relevant in Japan. This study aimed to clarify the association between TAD-BPD and shoulder dystocia after adjusting for potential confounding factors in a Japanese cohort. We retrospectively examined 1,866 Japanese women who delivered vaginally between 37+0 and 41+6 weeks of gestation at the University of Yamanashi Hospital between June 2012 and November 2018. The cutoff value of TAD-BPD associated with shoulder dystocia and the association between TAD-BPD and shoulder dystocia were evaluated. The mean maternal age was 32.5±5.3 years; the patients included 1,053 nulliparous women (57.5%), 915 male infants (49.0%), 154 women with gestational diabetes mellitus (GDM) (8.3%), and 5 infants with macrosomia (0.3%). The mean TAD-BPD was 9.03±4.7 mm. The overall incidence of shoulder dystocia was 2.4% (44/1866). The cutoff value to predict shoulder dystocia was 12.0 mm (sensitivity, 61.4%; specificity, 73.8%; likelihood ratio, 2.34; positive predictive value, 5.4%; negative predictive value, 98.8%). We then used a multivariable logistic regression analysis to examine the association between TAD-BPD and shoulder dystocia while controlling for the potential confounding factors. In multivariate analyses, TAD-BPD ≥12.0 mm (adjusted odds ratio [OR], 4.39; 95% confidence interval [CI], 2.35-8.18) and GDM (adjusted OR, 3.59; 95% CI, 1.71-7.52) were associated with shoulder dystocia. Although TAD-BPD appears to be a relevant risk factor for shoulder dystocia, sonographic fetal anthropometric measures do not appear to be useful in screening for shoulder dystocia due to a low positive predictive value.

A deeper understanding of the risk factors for dystocia and stillbirth could help farmers make decisions about dairy cow management. The objectives of this study were to investigate cow-level risk factors associated with dystocia and stillbirth in a relatively large sample of dairy cows using multivariable linear regression models. The data consisted of 51,405 calving records of 14,546 Holstein cows from 3 dairy herds in Isfahan Province, Iran, collected between April 2011 and September 2017. To investigate the association between selected blood macro-minerals and the incidence of dystocia and stillbirth, blood samples were collected at the time of parturition from a random subset of these cows, which included 1311 animals. The incidence of dystocia and stillbirths averaged 14.7% and 4.3%, respectively. Results showed that calving year, calving season, dry period length, BCS, parity, calf sex, calf birth weight, twin status, and stillbirth were significantly associated with the incidence of dystocia. According to the Random Forest (RF) classifier, we found that dry period length, calf birth weight, and parity were the most important cow-level risk factors for the incidence of dystocia. Calving year, calving season, parity, twin status, dry period length, calf birth weight, calf sex, and dystocia were significantly associated with the incidence of stillbirths. The most important risk factors identified by the RF classifier for stillbirths were twin status, parity, dry period length, and calf birth weight. Also, interactions between the cow-level risk factors associated with dystocia and stillbirth were identified. The incidence of dystocia was associated with the interactions of twin status × calf birth weight and twin status × stillbirth. According to our analysis, the incidence of stillbirth is caused by interactions among several factors, such as twin status × length of dry period, twin status × calving season, and twin status × parity. The highest incidence of dystocia (21.3%) and stillbirths (5.4%) was observed in hypo-calcemic cows. In conclusion, twin status seems to be a determining factor for the incidence of stillbirths but not for dystocia. Finally, the results of this study may help the dairy industry make management decisions aimed at reducing dystocia and stillbirth rates.

To investigate whether fetuses with accelerated third trimester growth velocity are at increased risk of shoulder dystocia, even when they are not large-for-gestational-age (LGA; estimated fetal weight (EFW) >95th centile).

The Norwegian Board of Health Supervision inspects healthcare institutions to ensure safety and quality of health and welfare services. A planned inspection of 12 maternity units aimed to investigate the practice of obstetric care in the case of birth asphyxia, shoulder dystocia and severe postpartum hemorrhage.

Human chorionic gonadotropin (hCG) is implicated in the maintenance of uterine quiescence by down-regulating myometrial gap junctions during pregnancy, and it was considered as a strategy to prevent preterm birth after the occurrence of preterm labor. However, the effect of hCG on innate and adaptive immune cells implicated in parturition is poorly understood. Herein, we investigated the immune effects of hCG at the maternal-fetal interface during late gestation, and whether this hormone can safely prevent endotoxin-induced preterm birth. Using immunophenotyping, we demonstrated that hCG has immune effects at the maternal-fetal interface (decidual tissues) by: 1) increasing the proportion of regulatory T cells; 2) reducing the proportion of macrophages and neutrophils; 3) inducing an M1 → M2 macrophage polarization; and 4) increasing the proportion of T helper 17 cells. Next, ELISAs were used to determine whether the local immune changes were associated with systemic concentrations of progesterone, estradiol, and/or cytokines (IFNgamma, IL1beta, IL2, IL4, IL5, IL6, IL10, IL12p70, KC/GRO, and TNFalpha). Plasma concentrations of IL1beta, but not progesterone, estradiol, or any other cytokine, were increased following hCG administration. Pretreatment with hCG prevented endotoxin-induced preterm birth by 44%, proving the effectiveness of this hormone as an anti-inflammatory agent. However, hCG administration alone caused dystocia and fetal compromise, as proven by Doppler ultrasound. These results provide insight into the mechanisms whereby hCG induces an anti-inflammatory microenvironment at the maternal-fetal interface during late gestation, and demonstrate its effectiveness in preventing preterm labor/birth. However, the deleterious effects of this hormone on mothers and fetuses warrant caution.

The objective of the present study was to assess the effectiveness of an intravaginal thermometer in the field prediction of the second stage of labor and to determine its impact on the health of dams and newborn calves. Holstein cows (n = 241) were randomly selected about 5 (mean ± SD: 4.7 ± 2.0) days before the expected date of calving and the thermometer was inserted into the vagina. Another 113 cattle served as controls. There was no false alarm during the experiment. The risk of dystocia (Score >1) was 1.9 times higher, the prevalence of stillbirth was 19.8 times higher, the risk of retained fetal membranes (RFM) was 2.8 times higher and the risk of clinical metritis was 10.5 times higher in the control group than in the experimental group. The prevalence of stillbirth was 7 times higher in cows with dystocia compared to cows with eutocia. The presence of dystocia and stillbirth increased the risk of RFM 4 and 5 times, respectively. The occurrence of RFM increased the risk of development of clinical metritis with a 22 times higher odds. The results indicate that the use of calving alert systems not only facilitates controlling the time of parturition and providing prompt and appropriate calving assistance but also decreases the number of dystocia cases and improves reproductive efficiency, postpartum health of the dam and newborn calf survival.

Calving difficulty or dystocia has a great economic impact in the US dairy industry. Reported risk factors associated with calving difficulty are feto-pelvic disproportion, gestation length and conformation. Different dairy cattle breeds have different incidence of calving difficulty, with Holstein having the highest dystocia rates and Jersey the lowest. Genomic selection becomes important especially for complex traits with low heritability, where the accuracy of conventional selection is lower. However, for complex traits where a large number of genes influence the phenotype, genome-wide association studies showed limitations. Biological networks could overcome some of these limitations and better capture the genetic architecture of complex traits. In this paper, we characterize Holstein, Brown Swiss and Jersey breed-specific dystocia networks and employ them in genomic predictions.

Obstetric palsy is classically defined as the brachial plexus injury due to shoulder dystocia or to maneuvers performed on difficult childbirths. In the last 2 decades, several studies have shown that half of the cases of Obstetric palsy are not associated with shoulder dystocia and have raised other possible etiologies for Obstetric palsy. The purpose of the present study is to collect data from literature reviews, classic articles, sentries, and evidence-based medicine to better understand the events involved in the occurrence of Obstetric palsy. A literature review was conducted in the search engine PubMed (MeSH - Medical Subject Headings) with the following keywords: shoulder dystocia and obstetric palsy , completely open, boundless regarding language or date. Later, the inclusion criterion was defined as revisions. A total of 21 review articles associated with the themes described were found until March 8, 2018. Faced with the best available evidence to date, it is well-demonstrated that Obstetric palsy occurs in uncomplicated deliveries and in cesarean deliveries, and there are multiple factors that can cause it, relativizing the responsibility of obstetricians, nurses, and midwives. The present study aims to break the paradigms that associate Obstetric palsy compulsorily with shoulder dystocia, and that its occurrence necessarily implies negligence, malpractice or recklessness of the team involved.

Dystocia is a major problem for the dairy cattle industry, and the observed high rates of this condition stem from genetic selection to increase subsequent milk production of the calving female. Because smaller birth size does not adversely affect subsequent milk production, selecting for cows with a smaller birth size would reduce dystocia rates and be beneficial for both the cattle and the farmers. To identify genes that regulate birth weight, we conducted a genome-wide association study using 1151 microsatellite markers and identified a single nucleotide polymorphism (SNP) associated with birth weight: A-326G in the 5' untranslated region (UTR) of solute carrier family 44, member 5 (SLC44A5). Cows with higher birth weights carried the A polymorphism in the SLC44A5 5' UTR, and the presence of the A polymorphism correlated with a high rate of dystocia. Luciferase assays and quantitative polymerase chain reaction (QPCR) assays revealed that SLC44A5 transcripts with the A polymorphism are expressed at lower levels than those carrying the G polymorphism. SLC44A5 encodes a choline transporter-like protein, and choline is a component of the major phospholipids of cell membranes. Uptake studies in HeLa cells demonstrated that SLC44A5 knockdown reduces choline efflux, whereas SLC44A5 overexpression resulted in the opposite effect. Furthermore, cell viability assays indicated that SLC44A5 knockdown increased cell proliferation, whereas SLC44A5 overexpression repressed proliferation. Taken together, our results suggest that calves with reduced SLC44A5 expression are larger due to enhanced cell proliferation. This study provides novel insights into the molecular mechanisms that control birth weight in Holsteins and suggests that SLC44A5 may serve as a potential target for preventing dystocia.

The use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety.