Abstract
The risk for shoulder dystocia is increased in women with diabetes and macrosomic fetuses; however, estimation of fetal weight is imperfect. Women with estimated fetal weights above certain thresholds may be offered elective cesarean delivery. Those not offered this option may have unsuspected macrosomia and develop an indication during labor for urgent delivery. To avoid shoulder dystocia, the question arises as to whether laboring diabetic women should preferentially undergo cesarean section rather than operative vaginal delivery. There are no randomized clinical trials addressing this issue. In other areas of medicine, observational studies that used randomized clinical trial-like inclusion criteria and controlled confounding generated results similar to those in randomized clinical trials. We used these design features in a retrospective cohort study among 28,484 deliveries of which 1089 had shoulder dystocia. When an immediate delivery was deemed necessary and inclusion criteria were met (nonreassuring fetal status or slow progress in labor, n = 4844), shoulder dystocia occurred in 245 deliveries. Operative vaginal delivery occurred in 241 (98.4%) of these shoulder dystocia cases and diabetes was noted in only seven (4.5%) cases. After controlling for other prognostic factors, diabetes was not significantly associated with shoulder dystocia (adjusted odds ratio [OR]: 1.28; 95% confidence interval [CI]: 0.86–3.40; p = 0.585), whereas obesity more than doubled the risk (adjusted OR: 2.53; 95% CI: 1.07–5.99; p = 0.034). These data suggest that diabetes should not be the primary factor upon which the delivery mode decision is made when there is an indication for urgent delivery. The known increased risk of postoperative complications among diabetics, especially if obese, must also be considered.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.