Dear Editor,
We read with interest the recent publication by Galbiatti and colleagues: “Obstetric Paralysis: Who is to blame? A systematic literature review.” The title is incorrect, since the review described in the publication is a narrative literature review, which is limited to review articles, and not a systematic review (SR). A SR should only include original research and not review articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (27-item checklist), with a flow diagram, should be used, and it is advisable to register a SR with a protocol registry (Campbell or Cochrane Collaboration, International Prospective Register of Systematic Reviews [PROSPERO]). Randomized controlled trials provide the highest validity and the least bias, followed by prospective cohort studies, case-control/retrospective cohort studies, and case series with increasing bias. There are multiple tools available to assess the quality of the evidence used for SRs, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which rates the certainty of evidence, and the Quality in Prognosis Studies (QUIPS) tool, which assesses the risk of bias.
Galbiatti et al.[1] stated that the literature is changing its direction and that, with their study, they helped to break the paradigm that obstetric palsy (OP) is compulsorily associated with shoulder dystocia and that its occurrence necessarily implies negligence, malpractice, or recklessness of the team involved. We are not aware that such a paradigm exists or has existed in the medical literature for over 20 years, with the direction having been changed already a long time ago. Jennett et al.[2] reported, in 1992, that only 43% of their OP cases were associated with shoulder dystocia and that the data were strongly suggestive that intrauterine maladaption may play a role in OP and should not be taken as prima facie evidence of a birth-process injury.
Gilbert et al.[3] reported, in 1999, on 1,611 OP cases born in California in 1994 and 1995, identifying large birth weight (> 4.5 kg), malpresentation, maternal diabetes, and operative vaginal deliveries, in addition to shoulder dystocia, as risk factors without indicating an association to training, experience, or malpractice of the team.
Galbiatti et al.[1] indicated that the incidence of OB does not differ if the baby is delivered by young obstetricians or surgeons with extensive experience. This is contradicted by Murphy et al.,[4] who reported on 393 operative deliveries of term singletons with 59 cases of head trauma and brachial plexus palsy. Ninety-eight percent of deliveries were performed by a trainee, and 2% by a consultant obstetrician. The six most severe cases of neonatal morbidity were initiated by a trainee. The authors concluded: “Operator experience clearly played a role in the frequency of excessive pulls and the use of multiple instruments.”
Inglis et al.[5] reported, in 2011, that training of maternity staff resulted in a decrease of the OP rate in vaginal deliveries from 0.4 to 0.14%, and after shoulder dystocia from 30 to 10.67%. Ameh et al.[6] reported, in 2019, that staff training, adherence to protocols, communication, team working, and resuscitation technique reduce trauma after shoulder dystocia and neonatal hypothermia and hypoxia.
The change that has taken place is the acknowledgement that communication and training on how to manage complex deliveries with shoulder dystocia can reduce the risk of OP.
