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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: July 1, 2015
Expiration Date: July 1, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 10+, has been reviewed and is acceptable for up to 13.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins April 29, 2015. Term of approval is for one year from this date. Each weekly update is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 13.0 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Program ID 1504207. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 – 9, 2015 – Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

Last week 361 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 189 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Induction of Labor for Suspected Fetal Macrosomia Between 37 Weeks and 38 6/7 Weeks Gestational Age May Reduce Shoulder Dystocia

Reference: Lancet 2015 June 27;385(9987):2600 (level 2 [mid-level] evidence)

Fetal macrosomia and large for gestational age status are associated with an increased risk of neonatal and maternal complications including shoulder dystocia and emergency cesarean section (Aust N Z J Obstet Gynaecol 2009 Oct;49(5):504). Prophylactic cesarean delivery and early term induction of labor have each been suggested to prevent delivery complications and continued fetal growth. Neither strategy, however, is recommended for routine use in pregnant women with suspected fetal macrosomia (Obstet Gynecol. 2002 Nov;100(5 Pt 1):1045, RCOG 2012 Mar PDF). A previous Cochrane review of 3 randomized trials found no significant reduction in the risk of shoulder dystocia with labor induction. However this result is limited by most included women being at ≥ 40 weeks gestation and the small number of trials found (Cochrane Database Syst Rev 2000;(2):CD000938). A recent randomized trial compared labor induction vs. expectant management in 822 pregnant women with singleton fetus at gestational age of 36-38 weeks with estimated weight > 95th percentile for gestation age. Induction occurred within 3 days of randomization at gestational age between 37 weeks and 38 6/7 weeks.

The primary outcome was a composite of significant shoulder dystocia, clavicle or long bone fractures, brachial plexus injury, intracranial hemorrhage, or death. Significant shoulder dystocia was defined as difficulty delivering the shoulders not resolved by McRoberts maneuver, usually combined with suprapubic pressure, or births with > 60 second interval between delivery of head and body. Overall, induction of labor occurred in 89% of women randomized to induction vs. 28% in the expectant management group. The primary composite outcome occurred in 2% of neonates with labor induction vs. 6% with expectant management (p = 0.004, NNT 25). In analyses of individual outcomes, labor induction was associated with a reduction in significant shoulder dystocia (1% vs. 4%, p < 0.05, NNT 34) as well as any shoulder dystocia (4% vs. 8%, p < 0.05, NNT 25). In addition, one concern with labor induction is the risk of increasing cesarean section rates, but in this trial, induction was associated with an increase in spontaneous vaginal delivery (59% vs. 52%, p < 0.05, NNT 15) and no significant differences in rates of cesarean section or assisted vaginal delivery. There were no significant differences in other maternal adverse outcomes or in rates of neonatal fractures and no cases of brachial plexus injury, intracranial hemorrhage, or neonatal death.

The trial was terminated early due to slow recruitment after enrolling 822 women, with the original plan calling for 1,000 women. Nonetheless, this trial was still much larger than previous trials evaluating labor induction for fetal macrosomia and was therefore better powered to detect differences in outcomes presenting in a small percentage of newborns. Most of the trials in the previous Cochrane review were small, with only 372 births and 18 cases of shoulder dystocia in the 3 trials combined (Cochrane Database Syst Rev 2000;(2):CD000938). In this trial, other neonatal adverse outcomes, including admission to the neonatal intensive care unit and hyperbilirubinaemia, were similar between groups, suggesting labor induction did not increase the risk of morbidity to either mother or child. It is worth noting, however, that previous studies have found increased morbidity in a large cohort of infants delivered electively at 37-39 weeks, although there was no subgroup analysis of infants who were large for gestational age. Overall, the new results suggest that induction of labor may be a preferred option in early term neonates with suspected macrosomia.

For more information see the Shoulder dystocia topic in DynaMed.

EBSCO Health’s New DynaMed Plus Delivers Trusted, Evidence-Based Content to Physicians on Any Platform

EBSCO Health recently launched DynaMed Plus, a cross-platform, evidence-based clinical decision support tool that provides clinicians with the ideal blend of evidence and expertise to help them determine optimal patient care paths.

DynaMed Plus helps medical professionals quickly find evidence-based answers to make the best treatment decisions in any location. With DynaMed Plus, clinicians (and their patients) will benefit from:

  • Quickest time-to-answer—Including intelligent auto-suggest, direct-to-section search results, exact match summary display, dynamic linking and quick access to relevant calculators.
  • Concise, accurate overviews and recommendations—For the most common conditions as well as evidence-based recommendations for action.
  • Comprehensive image library—Over 4,000 full-color medical graphics and images to help clinicians make the best decisions.
  • Rigorous editorial process—Subject-specific experts review topics on a daily basis using the DynaMed Plus proprietary evidence-based methodology and quality assurance process.
  • Access to specialty content—Clinicians can view thousands of topics covering emergency medicine, cardiology, oncology, infectious disease, pediatrics, obstetrics and gynecology, and much more.
  • Anywhere, anytime accessDynaMed Plus can be used on iOS and Android mobile devices, making access fast and easy, and providing clinicians with an intuitive and elegant mobile experience.

To read the press release and for more information on DynaMed Plus, click here. For free trial information, click here.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.