Obstetric Brachial Plexus Palsy Health And Social Care Essay

The estimated incidence of OBPP in the UK and the Republic of Ireland is 0.42 [ 1 ] , in the US 1.5 [ 23 ] and in other western states 1-3 per 1000 unrecorded births [ 3,5,9,22,24-30 ] . Variations in the estimated incidence may be explained by differences in populations and in the antenatal and intrapartum direction [ 31,32 ] .
A population-based survey from western Sweden estimated that between 1999-2001 the incidence of OBPP was 2.9 per 1000 unrecorded births, and of prevailing OBPP was 0.46 per 1000 births ( REF Lagerkvist ) . . In another survey from Sweden Bager [ 13 ] had antecedently found an addition in the incidence of brachial rete paralysis ( BPP ) from 1.3 per 1000 vaginal bringings in 1980 to 2.2 per 1000 vaginal bringings in 1994.
Chauhan et Al. [ 3 ] compared two clip periods ( 1980-1991 1991-2002 ) and found that the incidence of OBPP has non changed significantly ( 0.9 per 1000 and 1.0 per 1000 severally ) .

Gurewitsch et Al. [ 10 ] estimated an incidence of 5.8 per 1000 between the old ages 1993 and 2004 and noted that this remained changeless during the period of their survey.
Many writers have admitted that an addition in the cesarean subdivision rates over the past few decennaries may hold been counteracted by an increased birthweight. Furthermore, despite the debut of systematic preparation in the direction of shoulder dystocia with usage of standard manoeuvres, manikins and simulators no important decrease of the incidence of OBPP has been noted.
Hazard Factors
The hazard factors for OBPP are foetal, maternal, and obstetric, [ 37 ] the most important being foetal macrosomia [ 3,18,20,22,26-28 ] which is a hazard factor for shoulder dystocia [ 27,38-42 ] . Nesbitt et al conducted a big population based survey and reported the undermentioned rates of shoulder dystocia for single-handed births of nondiabetic female parents: 5.2 % for birthweight 4000-4250g, 9.1 % for 4250-4500g, 14.3 % for 4500-4750g, and 21.1 % for 4750-5000g ( Nesbitt et al. 1998 ) .
OBPP after rear of barrel bringings can besides happen, normally in low birthweight foetuss [ 43,44 ] . The upper roots are often affected in these instances and the hurts tend to be more terrible [ 45 ] .
Diabetess mellitus [ 22 ] , fleshiness [ 46,47 ] or inordinate weight addition [ 47 ] , maternal age ( & gt ; 35years ) [ 48 ] , maternal pelvic anatomy ( platypelloid, level pelvic girdle ) [ 3,22,27,39,40,49 ] and primiparity [ 50 ] are common maternal hazard factors. Diabetess mellitus is a important hazard factor for OBPP, as it frequently causes foetal macrosomia [ 51 ] . Nesbitt et Al found that the hazard of shoulder dystocia for single-handed births to diabetic adult females was 8.4 % , 12.3 % , 19.9 % , and 23.5 % when the birth weight was 4000-4250g, 4250-4500g, 4500-4750g, or & gt ; 4750g, severally. ( Nesbitt et al. 1998 ) . Mild glucose intolerance in adult females without diabetes is besides associated with hazards of OBPP, proposing that there is a continuum of glucose-insulin impact on foetal growing that is correlated to the hazard of OBPP [ 52 ] .
Shoulder dystocia is a major hazard factor for OBPP [ 9,22,24,40,54-57 ] . The reported incidence of OBPP in bringings complicated by shoulder dystocia varies widely from 4 % to 40 % [ 14,57,58 ] and the incidence of lasting brachial rete hurt after shoulder dystocia is 1.6 % [ 59 ] . Although foetal macrosomia is the most important hazard factor for shoulder dystocia and is associated with most of the other hazard factors ( maternal diabetes, multiparity, old macrosomic baby, drawn-out gestation, maternal fleshiness or inordinate weight addition ) , about half of the instances of shoulder dystocia occur in babies & lt ; 4000g ( Acker et al. 1985 ) .
The hazard of OBPP is increased by labour abnormalcies. OBPP occurs more often in induced labours [ 52 ] . Cephalopelvic or fetopelvic disproportion ( the size or place of the foetal caput or the foetus precludes transition into the maternal pelvic recess ) is a hazard factor for shoulder dystocia and OBPP. A relentless occipito- posterior place [ 65 ] has been associated with an increased incidence of OBPP. Lurie et al [ 60 ] found no difference in rates of distension or continuance of the 2nd phase in instances with shoulder dystocia and concluded that protracted labour was non a hazard factor for it. Gross et al [ 66 ] showed that a drawn-out 2nd phase increased the hazard of OBPP, but concluded that shoulder dystocia can non be predicted from labour abnormalcies. Weizsaecker et al support the association of drawn-out 2nd phase in labour with OBPP independent of macrosomia, diabetes, and other factors [ 52 ] . Several other surveies considered a drawn-out 2nd phase as a hazard factor for shoulder dystocia [ 46,62,67-69 ] and for OBPP [ 27,66 ] . In contrast, a high incidence of hasty 2nd phase of labour among babies with OBPP has besides been demonstrated [ 70 ] . However, Poggi et al suggest that although hasty 2nd phase is the most prevailing labour abnormalcy associated with shoulder dystocia, no feature of second-stage of labour predicts lasting brachial rete hurt [ 37 ] . Operative vaginal bringing is another hazard factor for shoulder dystocia and OBPP [ 3,21,22,26,27,68,71,72 ] . In Nesbitt ‘s survey the hazard of shoulder dystocia for operative vaginal bringings to diabetic female parents was 12.2 % for babies 4000-4250g, 16.7 % for those 4250-4500g, 27.3 % for those 4500-4750g, and 34.8 % for those 4750-5000g ( Nesbitt et al. 1998 ) . Cesarean subdivision decreases the hazard, but OBPP may still happen accounting for merely 1-4 % of all instances [ 22 ] [ 73 ] .
When looking at combinations of hazard factors including manner of bringing, maternal diabetes and foetal macrosomia [ 22 ] , the incidence of OBPP appears similar in aided vaginal bringings of nondiabetic adult females and self-generated vaginal bringings in diabetic adult females. The combination of maternal diabetes, foetal macrosomia ( & gt ; 4500g ) and assisted vaginal bringing has the highest OBPP rate ( 7.8 % ) . Gilbert et Als have besides shown stronger associations between shoulder dystocia and brachial rete hurt with increasing birth weights. Twenty two per cent of neonates weighing 2.5-3.5kg with OBPP besides had shoulder dystocia, which increases to 74 % in newborns weighing more than 4.5kg. Overall, 53 % of brachial plexus hurt instances were associated with shoulder dystocia. The frequence of diagnosing of other malpresentation was increased ( OR 73.6, 95 % CI 66, 83 ) in this survey. This determination, harmonizing to the writers, suggests that “ brachial rete hurt has other causes in add-on to shoulder dystocia and might ensue from an abnormalcy during the antepartum or intrapartum period ” [ 22 ] .
A old gestation complicated with OBPP is another hazard factor [ 74 ] . Al-Qattan and al-Kharfy [ 74 ] reported a high return rate in adult females with history of old childbearing with lasting OBPP and advocated elected cesarean bringing in these instances particularly if there is besides foetal macrosomia. However it is non known whether these consequences would use to instances of old impermanent OBPP. Gordon et al [ 6 ] besides found that 14 % of their 59 topics with OBPP were born to female parents who had given birth to babes with OBPP in old gestations.
OBPP has been considered as a effect of inordinate grip and sidelong extension exerted on the foetal cervix during bringing, which consequences in stretching, rupturing or avulsing the cervical nervus roots from the spinal cord [ 75 ] . However, OBPP may happen in the absence of any grip or any identifiable hazard factors. During labour, the brachial rete is exposed to two potentially harmful forces: the endogenous ( intrauterine ) forces and exogenic ( grip ) forces applied by the clinician.
Mathematical theoretical accounts, manikins and computing machine simulations have been used to quantify the forces applied on the brachial rete and the threshold for doing hurt. Although these surveies attempted to objectively quantify the grade of both endogenous and exogenic forces, their consequences should be interpreted with cautiousness due to their experimental nature.
Exogenous ( grip ) forces
If the foetal shoulders remain in a relentless anteroposterior place at the pelvic recess, as observed in instances of foetal macrosomia with an increased bisacromial diameter ( e.g. , with maternal diabetes mellitus ) [ 76,77 ] or precipitate 2nd phase of labour [ 54,70 ] the anterior shoulder may go wedged behind the symphysis pubic bone and farther descent of the foetal caput consequences in stretching of the anterior brachial rete. In shoulder dystocia the applied force and the clip to present the foetal shoulders is frequently significantly increased. Forceful downward grip of the caput when the shoulder is impacted under the symphysis pubic bone can potentially ensue in farther impaction and cause overstretching and hurt of the brachial rete. Downward grip of the foetal caput appears strongly associated with OBPP ( OR: 15.2, 95 % C.I. : 8.4-27.7 ) and the hazard is significantly increased with the grip force applied. Rotation of the shoulders into oblique pelvic diameter is besides associated with hazard of OBPP ( OR: 5.5, C.I. :1.6-18.9 ) [ 30 ] . Gonik et al [ 88 ] , showed that downward sidelong flexure of the foetal caput was associated with a 30 % addition in brachial rete stretch ( 18.2 % ) compared with axial placement of the caput ( 14 % ) .
Furthermore, the foetal caput is in an unnaturally distorted place in relation to the shoulders, as the shoulders remain in the AP diameter at the recess while the caput has rotated in the AP diameter at the mercantile establishment { Sandmire, 2009 # 6162 } . The badness of the hurt may depend on the grade of grip, writhing and extension of the foetal caput { Sandmire, 2008 # 6057 } . The usage of force feeling devices has shown that the applied extremum grip forces are about 47 N for everyday bringings, 69 N for hard bringings, and 100 N for bringings complicated by shoulder dystocia, proposing that, as the badness of dystocia additions, stronger grip is normally observed [ 86 ] .
Even in bringings non complicated by shoulder dystocia the forces applied during downward grip can be frequently underestimated as significant forces were found to hold been used in many OBPP instances [ 30 ] . Direct compaction of the symphysis pubic bone against the brachial rete may besides be a conducive factor to injury [ 13 ] .
OBPP may happen regardless of the figure and type of manoeuvres used in instances of shoulder dystocia [ 12,14,69 ] , but the trouble to accomplish bringing of the shoulders and the demand for extra manoeuvres is correlated to the hazard of OBPP. Experimental surveies utilizing pelvic and foetal theoretical accounts, tactile feeling baseball mitts and computerised informations acquisition systems have besides shown that as the trouble of the bringing increases with increasing grip forces, there is a concentration of force on the brachial rete from exogenously applied sidelong flexure [ 87 ] . In these experiments it was demonstrated that the wider the foetal shoulder girth, the greater the force demands and the higher the incidence of hurt. In contrast, the McRoberts manoeuvre appeared to cut down the grade of brachial rete stretching. Slightly more than 10 % of the shoulder dystocia instances that resolve with the McRoberts ‘ manoeuvre entirely have brachial plexus hurt [ 78 ] . After an unsuccessful McRoberts ‘ manoeuvre, brachial plexus hurt rates range from 15.7 % if bringing is achieved by the Woods ‘ manoeuvre to 31.8 % if bringing of the posterior arm is undertaken [ 14 ] .
Intrauterine causes
As several instances of OBPP occur in the absence of grip or any known hazard factors, hurts to the brachial rete may be caused by the normal forces of labour and bringing. In one of the first surveies proposing that OBPPs are non needfully caused by clinician-applied grip, it was estimated that 26 out of the 51 OBPP instances were non associated with a bringing complicated by shoulder dystocia. { Gordon, 1973 # 615 } . Since so, several other surveies have shown that about half of all OBPPs are non associated with shoulder dystocia [ 5,12,13,18,19 ] and many instances have non been preceded by a hard bringing or grip on the anterior shoulder [ 20,79,80 ] . Harmonizing to different series, up to 20 % of lasting OBPPs are non associated with shoulder dystocia { Chauhan, 2005 # 48 } { Sandmire, 2009 # 6162 } . Jennett et al [ 18 ] concluded that brachial plexus hurt might be the consequence of intrauterine maladaptation and should non be needfully considered as leading facie grounds of birth procedure hurt.
In the absence of shoulder dystocia, OBPP occurs by a different mechanism [ 81 ] . The bulk of OBPPs in the absence of shoulder dystocia ( 67.7 % ) appear to impact the posterior arm [ 59,84 ] . OBPPs of the posterior arm ( 39 % of all OBPPs { Gherman, 1998 # 114 } ) or after cesarean bringing suggest an intrauterine cause [ 3,4,18,19,27,38,82,83 ] . Brachial plexus stretching may be caused by an wedged posterior shoulder on the sacral headland while the propulsive forces of labour cause farther descent of the foetus { Sandmire, 2002 # 79 } . OBPPs may besides be secondary to compaction of the brachial rete on the sacral headland. Sandmire and DeMott { Sandmire, 2009 # 6162 } back up the impression that after the caput is delivered, the posterior shoulder can non be obstructed as the distance from the headland to the vaginal mercantile establishment ( 12-13 centimeter ) is excessively long to allow obstructor of the posterior shoulder and the foetal cervix can non be stretched that far { Sandmire, 2002 # 79 } , It is hence of paramount importance to document the place of the caput and shoulders in a instance of shoulder dystocia, as this type of hurt caused by impaction of the posterior shoulder on the sacral headland is unrelated to any action of the clinician and should non be considered negligent.
Mathematical theoretical accounts have been used to gauge the exogenic and endogenous forces on the brachial rete during shoulder dystocia [ 89 ] . The endogenous forces were estimated to be 4 to 9 times higher than the clinician-applied forces ( 91.1 to 202.5 kPa vs 22.9 kPa ) proposing that self-generated endogenous forces may lend well to OBPP. However the writers of this survey acknowledged that their theoretical account did non account for a figure of confusing factors including soft tissue opposition, the dissipation of force throughout the womb or the compound consequence of grip and compaction forces. Further unfavorable judgment on this theoretical account focused on the gross premises made for the impaction site, the parametric quantities specifying the endogenous force distribution and the broad scope of contact force per unit areas between the foetal cervix and the symphysis pubic bone, which includes values that in existent life would transcend the fatal bounds [ 90 ] .
Harmonizing to a little series, all of the 6 OBPPs following atraumatic cesarean subdivision had relentless hurt after a twelvemonth [ 85 ] . Brachial rete hurts have occured even when cesarean bringing was performed in early labour [ 82,85 ] .
Uterine anomalousnesss, such as a lower uterine section fibroid or an intrauterine septum, may ensue in unnatural intrauterine force per unit areas and hurt to the brachial rete [ 85 ] . OBPP and phrenic nervus paralysis associated with a bicornuate womb have besides been reported [ 80 ] .
Allen et Al, utilizing delivering simulators found that greatest stretch occurred in the posterior brachial rete during descent in non-shoulder dystocia bringings, whereas anterior brachial rete stretch, rotary motion, and extension were similar among non-shoulder dystocia, one-sided and bilateral shoulder dystocia bringings. The writers concluded that shoulder dystocia per Se does non present extra hazard of brachial rete stretch over everyday bringings [ 91 ] . However, they admitted that they did non command for loss of musculus tone secondary to hypoxia, the simulations were undertaken merely in occiput anterior place and the continuance of the 2nd phase in their experiment was less than 2 proceedingss.
Although these experiments have improved our cognition on the mechanisms of hurt, clinical verification of their consequences is virtually impossible due to the emergent nature of shoulder dystocia and methodological and ethical issues around clinical research on the foetus during labour.
Prediction and Prevention
Our ability to foretell OBPP is rather limited as the bulk of the affected babies have no identifiable hazard factors [ 67 ] . In a series of 63 OBPPS most of the patients were nondiabetic ( 89 % ) , nonobese ( 76 % ) , had normal labour ( 91 % ) , and did non hold an assisted bringing ( 79 % ) . No hazard factors were identified in about 30 % of OBPP instances in another survey by Peleg et al [ 27 ] . Multiple logistic arrested development analysis utilizing prenatal, intrapartum, and neonatal factors predicted merely 19 % of the brachial rete hurts in the series of Perlow et Al [ 54 ] . Donnelly et Als have besides concluded that OBPP is non predictable by hazard factor hiting or analysis of the partogram [ 63 ] .
Shoulder dystocia, a major hazard factor for OBPP is mostly unpredictable. Statistical theoretical accounts have been developed to gauge this hazard utilizing combinations of birth weight, maternal tallness and weight, gestational age and para [ 92,93 ] . The presence of multiple hazard factors appears to be a forecaster for shoulder dystocia [ 94 ] . Designation of hazard factors and an prenatal direction with tight control of glucose degrees in pregnant adult females with diabetes may cut down the incidence of foetal macrosomia and shoulder dystocia.
A program for bringing in high hazard instances should include a multidisciplinary squad attack with a senior accoucheuse or an experient obstetrician available at the 2nd phase.
Initiation of labour
Initiation of labour has been antecedently recommended in instances of suspected macrosomia, in order to cut down the hazard of shoulder dystocia and birth hurt, nevertheless, a Cochrane reappraisal showed that initiation of labour for nondiabetic adult females with suspected foetal macrosomia does non look to cut down the hazards of maternal or neonatal morbidity [ 95 ] .
Cesarean Section
The hazard of brachial plexus hurt is lower in cesarean bringings [ 3,96 ] . If identifiable hazard factors are present, an elected cesarean delivery bringing might forestall OBPP. Yeo et al suggested that bringings by elected cesarean subdivision for birthweights in surplus of 4kg would forestall 44 % of shoulder dystocias and halve the perinatal mortality among births with shoulder dystocia with a 2 % subsequent addition of the cesarean subdivision rate [ 97 ] . On the other manus, Gilbert et Al found that 92 % of the high hazard patients ( diabetic adult females delivered by operative vaginal bringing with babies of & gt ; 4.5kg birthweight ) did non hold OBPP and cesarean bringing would hold been unneeded [ 22 ] . Although macrosomia is normally associated with OBPP, Rouse et Al [ 32 ] found no benefit to elected cesarean bringing in adult females with estimated foetal weights of & gt ; 4.5 kilogram, unless they were besides diabetic. These writers estimated that when elected cesarean bringing was performed for estimated foetal weights of a‰?4.5kg, 3695 cesarean delivery bringings would be required for the bar of one permanent OBPP, whereas a policy of elected cesarean delivery bringings for birthweights of a‰?4kg was associated with 2345 several cesarean bringings. For diabetic adult females, more favorable ratios for cesarian bringings were estimated: 443 bringings with the 4.5kg policy, and 489 bringings with the 4kg policy. Ecker et al [ 38 ] besides suggested that at most birth weights, the figure of cesarean bringings necessary to forestall a individual hurt is high. In this survey, it was estimated that in nondiabetic adult females, between 19 and 162 cesarean subdivisions would hold been necessary to forestall a individual brachial rete hurt and among diabetic adult females between 5 and 48 extra cesarean delivery subdivisions would hold been required. The writers could hence non recommend the everyday usage of cesarean bringing in instances of macrosomia. The Royal College of Obstetricians and Gynaecologists recommends that elected cesarean subdivision can be considered in diabetic adult females when the estimated foetal weight is & gt ; 4.5kg and in nondiabetic adult females when the estimated foetal weight is & gt ; 5kg [ 98 ] . Nonetheless, some writers advocate a policy of offering elected cesarean bringing to adult females with kids with lasting OBPP [ 22 ] .
Maneuvers at bringing
For the bar of shoulder dystocia, contraceptive manoeuvres at bringing ( McRobert ‘s manoeuvre and suprapubic force per unit area ) have been evaluated, but there is deficiency of clear grounds to back up their modus operandi usage [ 99 ] .
Management of shoulder dystocia
The purpose of direction should be bar of foetal asphyxia, while avoiding foetal and maternal hurt. The go toing accoucheuse or obstetrician should be able to acknowledge a shoulder dystocia instantly and continue through a bit-by-bit sequence of manoeuvres to hasten bringing.
Knowledge of the constructs that underlie manoeuvres and the practical inside informations of their executing appears much more effectual than cognition of the precise definitions or eponyms of each manoeuvre ( Crofts et al. 2008 ) .
First line manoeuvres
Mc Roberts manoeuvre involves acute flexure of the hips while the adult female is on supine place. This place straightens the lumbosacral angle, leting descent of the posterior shoulder. The maternal pelvic girdle is perpendicular to the way of the maternal expulsive forces.
Gonik et al [ 88 ] , utilizing computing machine silent person theoretical accounts showed that with lithotomy placement, both endogenous and exogenic bringing forces were associated with brachial rete stretching during shoulder dystocia ( the per centum of brachial rete nervus stretch was 15.7 % vs 14.0 % , severally ) . McRoberts positioning resulted in 53 % less brachial rete stretch ( 6.6 % ) .
Directed suprapubic force per unit area can be uninterrupted or ‘rocking ‘ force per unit area on the posterior facet of the anterior shoulder which may ease adduction of the shoulders, a decrease of the bisacromial diameter and rotary motion to an oblique place.
Second line manoeuvres
Delivery of the posterior arm is undertaken by infixing the manus in the vagina posteriorly and using soft force per unit area at the antecubital pit to flex the foetal forearm, which is so grasped and swept across the foetal thorax. If bringing of the posterior arm is achieved, the anterior arm rotates posteriorly or descends behind the symphysis pubic bone as Kung et Al showed that the shoulder dimensions are reduced by 2.5cms with this manoeuvre particularly in larger foetuss ( Kung et al. 2006 ) .
Rubin ‘s manoeuvre: rotary motion of the shoulders is attempted by insertiong two fingers in the vagina behind the anterior shoulder. The shoulder is pushed frontward and the bisacromial diameter rotates into an oblique place. If unsuccessful, this can so be combined with the Woods ‘ prison guard manoeuvre.
Forests ‘ prison guard: force per unit area is applied with two fingers on the anterior facet of the posterior shoulder and use force per unit area taking to revolve the foetus towards the same way as the Rubin manoeuvre.
Reverse Woods ‘ prison guard: with two fingers behind the posterior shoulder rotary motion is attempted in the opposite way to the original Woods ‘ prison guard.
All these manoeuvres aim to revolve the shoulders and enable bringing by conveying the anterior shoulder posteriorly. Interpolation of the whole manus in the vagina may enable better push on the shoulder and facilitate rotary motion ( Crofts et al. 2008 ) .
All-fours: the adult female is on her custodies and articulatio genuss and soft grip is applied taking to present the buttocks shoulder which may fall due to gravitation and to a possible addition of the anteroposterior diameter of the maternal pelvic girdle.
Clavicular break: although the bisacromial diameter is reduced with this manoeuvre, there is an increased hazard of iatrogenic brachial rete hurt, vascular and soft tissue foetal injury.
Third line manoeuvres
Zavanelli manoeuvre involves flexure of the foetal caput, reversal of damages, rotary motion of the caput back to the occipito-anterior place, and replacing into the womb. Tocolytics and general anesthetic agents are used for uterine relaxation. The foetus is so delivered by cesarean subdivision. Although this manoeuvre has success rates of up to 92 % , it is associated with terrible fetal and maternal morbidity including foetal hurts and deceases, uterine and vaginal rupture.
Symphysiotomy requires surgical expertness and is associated with important hazards of lower urinary tract hurt. The patient is on a supine place and the thighs are abducted no more than 45IS from the midplane. A urethral catheter is inserted and the urethra is displaced laterally. Following local infiltration with lignocaine, a perpendicular pang scratch is made on the symphysis with a scalpel. The symphysis is normally partly separated by cutting through the fibers by rotational motion of the blade. This allows the anterior foetal shoulder to be disimpacted.
In instances of shoulder dystocia, the hazards of OBPP may be reduced if manoeuvres are conducted suitably and forceful downward grip of the caput is avoided ( figure 1 ) . Gonik et al [ 88 ] , showed that downward sidelong flexure of the foetal caput was associated with a 30 % addition in brachial rete stretch ( 18.2 % ) compared with axial placement of the caput ( 14 % ) .
Fundal force per unit area should be avoided as it can decline shoulder dystocia and grip combined with fundal force per unit area can be associated with neurological complications [ 57 ] . Consequences may be better and hazards of OBPP lower if there is no terror, force per unit area on the fundus, sidelong grip or pivoting of the caput at the cervix and when tortuosity or rotational motion of the caput to revolve the shoulders is avoided { Doumouchtsis, 2009 # 6174 } .
OBPP is a potentially annihilating complication of childbearing. Shoulder dystocia is merely one of a battalion of hazard factors for OBPP, most of which may be hard to foretell. Future research should be directed in prospective rating of the mechanisms of hurt, in order to enable accoucheurs, accoucheuses and other wellness attention professionals identify modifiable hazard factors, develop preventative schemes and better perinatal results.

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