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Shoulder dystocia: Risk factors, predictability,
and preventability
Shobha H. Mehta, MD
a,n
, and Robert J. Sokol, MD
b
a
Department of Gynecology, Obstetrics, and Women's Health, Henry Ford Health System, MI
b
Department of Obstetrics and Gynecology, Wayne State University School of Medicine, MI
a r t i c l e i n f o
Keywords:
Shoulder dystocia risk factors
Macrosomia
Diabetes
Operative vaginal delivery
a b s t r a c t
Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts
of obstetricians both novice and experienced. While outcomes that lead to permanent
injury are rare, almost all obstetricians with enough years of practice have participated in a
birth with a severe shoulder dystocia and are at least aware of cases that have resulted in
signicant neurologic injury or even neonatal death. This is despite many years of research
trying to understand the risk factors associated with it, all in an attempt primarily to
characterize when the risk is high enough to avoid vaginal delivery altogether and prevent
a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as
1648%. The study of shoulder dystocia remains challenging due to its generally retro-
spective nature, as well as dependence on proper identication and documentation. As a
result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent
one by performing a cesarean delivery remains high. While ultimately it is the injury that is
the key concern, rather than the shoulder dystocia itself, it is in the presence of an
identied shoulder dystocia that occurrence of injury is most common.
The majority of shoulder dystocia cases occur without major risk factors. Moreover, even
the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore
cannot be reliably predicted, and the only preventative measure is cesarean delivery.
& 2014 Elsevier Inc. All rights reserved.
Overview of risk factors
There are copious studies elucidating risk factors associated
with shoulder dystocia.
13
They are limited, however, by their
retrospective nature, as well as the dependence on the proper
identication and documentation of shoulder dystocia, gen-
erally reported to be 0.23.0%
4
but with some studies suggest-
ing a higher rate.
57
In addition, all risk factors have the
drawback of poor positive predictive value; many patients
with one or more risk factors go on to deliver without event.
In the following section, we review each of the major risk
factors associated with shoulder dystocia, with the accumu-
lated evidence to associate them with shoulder dystocia as
well as predictability, building a case for the continued
difculty in prevention of shoulder dystocia.
Macrosomia
Macrosomia is considered to be the most signicant deter-
minant of risk for shoulder dystocia.
8
Approximately half of
all shoulder dystocias occur in large-for-gestational-age
infants.
911
The incidence of shoulder dystocia increases with
http://dx.doi.org/10.1053/j.semperi.2014.04.003
0146-0005/& 2014 Elsevier Inc. All rights reserved.
n
Corresponding author at: Department of Gynecology, Obstetrics, and Women's Health, Henry Ford Health System, 3031 West Grand
Blvd, 8th oor, Detroit, MI 48202.
E-mail address: smehta3@hfhs.org (S.H. Mehta).
S E M I N A R S I N P E R I N A T O L O G Y 3 8 ( 2 0 1 4 ) 1 8 9 1 9 3
each 500 g increase in birth weight (BW), reaching a 10-fold
increase by 4500 g.
9,12
Stotland et al., reviewing over 146,000
deliveries in California between 1995 and 1999, found the
shoulder dystocia incidence to be 1.5% with BW 2500
3999 g, 8.8% with BW 40004499 g, 17.4% with BW 4500
4999 g, and 23.3% with BW Z5000 g. An adjusted odds ratio
(OR) for shoulder dystocia was 6.29 (CI: 5.836.77) for BW
40004999 g, 13.05 (CI: 11.7014.56) for BW 45004999 g, and
17.52 (CI: 13.5422.68) for BW Z5000 g.
12
Macrosomia is limited as a risk factor by its poor predictive
value. Overall, 7090% of all macrosomic fetuses deliver with-
out sequelae.
11,13
The incidence of shoulder dystocia is 1%
with BW o4000 g
14
but because of the higher proportion of
deliveries o4000 g, this weight range [average-for-gestational-
age infants] accounts for 4060% of all shoulder dystocia.
1518
Another major limiting factor of BW is the difculty in
predicting it accurately. This is the case whether utilizing
maternal perception, Leopold maneuvers, or current use of
ultrasound. Most literature on the relationship of offspring
weight to shoulder dystocia utilizes BW after delivery, not
projected estimated fetal weight (EFW), which of course is not
available to the physician at the time of critical decision-
making regarding counseling, preparation, labor, and delivery
of the patient. While EFW underestimation does not appear
to be related to an increased rate of shoulder dystocia,
19
it is
not completely clear what knowledge of the true BW would
have on the rates of shoulder dystocia, neonatal injuries, or
cesarean delivery. Melamed et al.
20
did nd that the cesarean
delivery rate was 22.5 times higher when the EFW was 4000
4499 g, regardless of actual BW.
Diabetes mellitus
Mothers with diabetes are at increased risk for having shoulder
dystocia than their non-diabetic counterparts. Diabetes
increases the overall risk of shoulder dystocia by more than
70%.
21
This is due in part to the higher BW of infants of diabetic
mothers. Langer et al.,
22
in a population of greater than 75,000
patients, found that the incidence of macrosomia was 21%
among diabetic mothers vs. 7.6% among non-diabetics.
Furthermore, gram for gram, the incidence of shoulder
dystocia and injury is higher in diabetic mothers. This is
thought to be related to the physiologic differences in growth
of offspring of diabetic mothers, who have larger shoulder
and extremity circumferences, higher percentage body fat,
and thicker upper extremity skin folds,
2325
an asymmetry of
somatic growth ahead of overall growth.
26
Even milder
diabetics have higher rates of shoulder dystocia; A1 (diet-
controlled gestational diabetics) had a higher rate of shoulder
dystocia than the general population (3% vs. 0.9%).
27
Keller
et al.
28
found that the incidence of shoulder dystocia was
11.4% among A1 diabetics and 14.6% among A2 (medication-
requiring) diabetics.
As with other risk factors, diabetes remains limited by its
poor positive predictive value. Diabetes, whether gestational
or pre-existing, has a sensitivity of 7.2%, specicity of 94.4%,
positive predictive value of 1.4%, and negative predictive
value of 98.9% for the occurrence of shoulder dystocia.
8
Operative vaginal delivery
Operative vaginal delivery is associated with an increased risk
of shoulder dystocia with a relative risk of 4.628.0, depending
on station of application and other risk factors.
4
A study
including over 175,000 deliveries with birth weight of infants
over 3500 g (3% SD rate) by Nesbitt et al.
21
found that shoulder
dystocia increased by approximately 3545% in vacuum- or
forceps-assisted deliveries. For non-diabetic mothers with
assisted deliveries, this translated to shoulder dystocia rates
of 8.6% for infants weighing 40004250 g, 12.9% for infants
42504500 g, 23% for 45004750 g, 29% for infants 47505000 g.
Adjusted OR with assisted delivery was 1.9 (p 0.0001).
In addition to macrosomia, a randomized trial of forceps vs.
vacuum delivery by Boll et al.
6
demonstrated a stronger
association for shoulder dystocia with vacuum delivery.
Previous shoulder dystocia
The occurrence of shoulder dystocia in a pregnancy increases
the risk of recurrence in a subsequent pregnancy. For those
patients who undergo a trial of labor with a successful
vaginal delivery, the rate of shoulder dystocia appears to be
10-fold higher than the general population.
29
The best pre-
dictors of injury in these patients appear to be BW (as it
compares to index shoulder dystocia delivery BW) and
severity of prior neonatal injury.
30
The risk of recurrence
appears to be signicantly increased with increasing off-
spring BW, 29.2% with BW 45000 g and prior history vs.
17.4% with BW 45000 g and no prior history.
31
For those
patients with an EFW less than the BW of the index shoulder
dystocia delivery, or who lack a history of permanent brachial
plexus injury, trial of labor may be reasonable.
Maternal obesity/excessive weight gain
It has been speculated that obesity leads to an increased risk
of shoulder dystocia due to an increase in soft tissue within
the maternal pelvis, which impedes vaginal deliverya
dystocia due to soft tissues.
32
Some studies have shown a
higher prevalence of obesity in pregnancies with shoulder
dystocia, appearing to double the risk,
3335
and to increase the
severity of injury when it does occur following shoulder
dystocia.
36,37
An independent relationship between maternal
obesity and shoulder dystocia has been questioned, however,
including in a study by Robinson et al., which found a crude
OR of 2.1 for maternal obesity (CI: 1.43.2). However, following
multivariate logistic regression, maternal obesity was no
longer a signicant risk factor for shoulder dystocia.
38
Because of the powerful relationship between maternal
obesity and diabetes and fetal macrosomia,
39
two signicant
risk factors of shoulder dystocia, it may be more difcult to
discern the impact of maternal obesity independently on
shoulder dystocia. Furthermore, only 5% of obese women
(4250 lb) experience shoulder dystocia.
40
Labor dysfunction
Studies have found an association between labor abnormal-
ities and the occurrence of shoulder dystocia; however, the
S E M I N A R S I N P E R I N A T O L O G Y 3 8 ( 2 0 1 4 ) 1 8 9 1 9 3 190
type of disorders noted varies between studies. Acker et al.
noted arrest disorders in the 30003499 g group and protrac-
tion while arrest disorders in the 35003999 g group with
subsequent shoulder dystocia.
14
In the macrosomic group,
they found no labor abnormalities in the 40004499 g group,
while arrest disorders were noted in the 4500 g group with
subsequent shoulder dystocia.
9
Other studies have found
abnormalities in the rst phase of labor.
41,42
A few studies
have noted a prolonged second stage of labor in those
patients with shoulder dystocia,
1,3,42
one study showed an
increased incidence of SD from 11% to 39%.
3
This nding has
been noted particularly in nulliparous patients in some
studies.
43,44
Still others have found no labor abnormalities
associated with shoulder dystocia,
45
and one study found a
precipitous second stage to be associated with shoulder
dystocia.
46
These varying ndings, and again a large number
of patients with abnormalities in labor pattern who ulti-
mately have an uneventful vaginal delivery, make labor
abnormalities another poor predictor of shoulder dystocia.
There are suggestions, though, that such a nding, particu-
larly in the setting of fetal macrosomia, is a reason to avoid
an operative vaginal delivery.
1,9,44
Combinations of risk factors
As alluded to above, several studies have found that a
combination of risk factors signicantly increases the risk of
shoulder dystocia and should be avoided. One of the rst
examples of this was by Benedetti et al.,
1
who in 1978
published an article noting that the combination of macro-
somia 44000 g, prolonged second stage, and midpelvic oper-
ative vaginal delivery led to a 21% incidence of shoulder
dystocia and a high rate of neonatal injury. Mehta et al.
44
also
noted that in the setting of fetal macrosomia and second
stage of labor more than 2 h, performance of assisted vaginal
delivery led to an increased rate of shoulder dystocia. Other
studies have also cautioned against the use of operative
vaginal delivery in the setting of macrosomia, including the
one by Ouzounian et al.
10
that found that at BW 44000 g,
vacuum delivery led to an OR of 13.7 for shoulder dystocia; for
BW 44500 g with vacuum, the OR was 21.5. Still others have
examined the use of operative vaginal delivery in the setting
of maternal diabetes and macrosomia, nding shoulder
dystocia incidence of 12.2% for BW 40004250 g, 16.7% for
42504500 g, 27.3% for 45004750 g, and 34.8% for 4750
5000 g.
21
Predictability
Following a retrospective analysis of shoulder dystocia cases
and risk factors, Nocon et al.
17
stated that shoulder dystocia is
an unpredictable event; infants at risk for permanent injury are
virtually impossible to predict. Gross et al.
2
in their study of
risk factors concluded that for neonates Z4000 g, shoulder
dystocia cannot be predicted by clinical characteristics or labor
abnormalities, and that the occurrence of shoulder dystocia is
not an evidence of medical malpractice. Gherman et al.,
4
in a
comprehensive review of shoulder dystocia in 2006, stated that
when evaluated in a prospective fashion pre-pregnancy and
antepartum risk factors have exceedingly poor predictive value
for prediction of shoulder dystocia. Lewis et al.
47
found that
only 25% of all shoulder dystocia cases had one or more
signicant risk factors. Moreover, Geary et al.
48
found that the
positive predictive value of shoulder dystocia for most risk
factors was 2% and 3% when combined. The American College
of Obstetricians and Gynecologists (ACOG)
30
echoes these
thoughts in its practice bulletin on shoulder dystocia, stating
that shoulder dystocia cannot be predicted or prevented
because accurate methods for identifying which fetuses will
experience this complication do not exist.
Prevention
While it does not completely eliminate the possibility of
neonatal injury, performing a cesarean delivery can prevent
shoulder dystocia and in large part its attendant morbidities.
Rouse et al. has investigated the cost and benets of perform-
ing cesarean delivery for the primary risk factor of macro-
somia noted on fetal ultrasound. For non-diabetic women,
they found that at a 4500 g threshold, 3695 cesarean deliv-
eries are needed to avert a single brachial plexus injury at a
cost of $8.7 million per permanent injury averted. At a 4000 g
threshold, 2345 cesarean deliveries and $4.9 million are
needed to prevent one permanent brachial plexus injury.
The authors note that with the excess rate of mortality with
cesarean delivery over vaginal delivery, one maternal death
would result from every 3.2 permanent brachial plexus
injuries avoided. They summarize that while there is societal
and individual benet from avoidance of permanent brachial
plexus injury, it does not appear that a policy of elective
cesarean delivery based on these estimated fetal weight
thresholds is either medically or economically sound.
49
It
should be noted that the cesarean delivery rate in and of itself
(not to mention medical cost) has changed dramatically since
the data used to calculate these rates and costs. Now at
upwards of 30%, this high rate of cesarean delivery likely
alters the balance between the risks of shoulder dystocia and
the costs of performing cesarean delivery, though to what
extent is difcult to quantify and has not been reported.
Some have emphasized that changes in maternal pre-
pregnancy weight and weight gain may have the best pre-
ventative effect on shoulder dystocia, by decreasing the rates
of gestational diabetes and fetal macrosomia that are often
associated with it.
50
Though possibly true in theory, this is an
elusive goal that millions struggle to achieve on a daily basis
for its myriad of health benets. Until that is achieved, it may
be best to consider throughout gestation and particularly late
in labor the number of risk factors present in an individual,
with consideration of avoidance of operative delivery in
particular when these are present, and consideration of
cesarean delivery when appropriate.
Summary
Despite many studies elucidating risk factors, shoulder dys-
tocia remains generally unpredictable due to the poor pos-
itive predictive value of even the strongest risk factors.
S E M I N A R S I N P E R I N A T O L O G Y 3 8 ( 2 0 1 4 ) 1 8 9 1 9 3 191
Prevention through cesarean delivery therefore comes at a
high cost, particularly given the poor identication of those
truly at risk, and a low benet with the few number of
permanent brachial plexus injuries avoided. As a result,
shoulder dystocia remains a feared obstetrical emergency,
whose best antidote may be preparation through simulation
and other techniques illuminated in upcoming chapters.
r e f e r e n c e s
1. Benedetti TJ, Gabbe SG. Shoulder dystocia: a complication of
fetal macrosomia and prolonged second stage of labor with
midpelvic delivery. Obstet Gynecol. 1978;52:526529.
2. Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder
dystocia: a fetal-physician risk. Am J Obstet Gynecol. 1987;156:
14081418.
3. Baskett TF, Allen AC. Perinatal implications of shoulder
dystocia. Obstet Gynecol. 1995;86:1417.
4. Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B,
Goodwin TM. Shoulder dystocia: the unpreventable obstetric
emergency with empiric management guidelines. Obstet
Gynecol. 2006;195:657672.
5. Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: an
engineering study of clinician-applied forces. Obstet Gynecol.
1991;77:352355.
6. Boll JA, Rust OA, Devidas M, Roberts WE, Morrison JC, Martin
JN Jr. Shoulder dystocia and operative vaginal delivery. J
Matern Fetal Med. 1997;6:220224.
7. Beall MH, Spong C, McKay J, Ross MG. Objective denition of
shoulder dystocia: a prospective evaluation. Obstet Gynecol.
1998;179:934937.
8. Dodd JM, Catcheside B, Scheil W. Can shoulder dystocia be
reliably predicted? Aust N Z J Obstet Gynaecol. 2012;52:248252.
9. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder
dystocia. Obstet Gynecol. 1985;66:762768.
10. Ouzounian JG, Gherman RB. Shoulder dystocia: are historic
risk factors reliable predictors? Am J Obstet Gynecol. 2005;
192:19331938.
11. Gregory KD, Henry OA, Ramicone E, Chan LS, Platt LD.
Maternal and infant complications in high and normal weight
infants by method of delivery. Obstet Gynecol. 1998;92:507513.
12. Stotland NE, Caughey AB, Breed EM, Escobar GJ. Risk factors
and obstetric complications associated with macrosomia. Int J
Gynaecol Obstet. 2004;87:200206.
13. Brard J, Dufour P, Vinatier D, et al. Fetal macrosomia: risk
factors and outcome. A study of the outcome concerning 100
cases 44500 g. Eur J Obstet Gynecol Reprod Biol. 1998;77:5159.
14. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder
dystocia in the average-weight infant. Obstet Gynecol. 1986;
67:614618.
15. Sandmire HF, O'Halloin TJ. Shoulder dystocia: the incidence
and associated risk factors. Int J Gynaecol Obstet. 1988;26:6573.
16. Langer O, Berkus MD, Huff RW, Samueloff A. Shoulder
dystocia: should the fetus weighing greater than or equal to
4000 grams be delivered by cesarean section? Am J Obstet
Gynecol. 1991;165:831837.
17. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder
dystocia: An analysis of risks and obstetric maneuvers.
18. Gherman RB. Shoulder dystocia: an evidence-based evalua-
tion of the obstetrical nightmare. Clin Obstet Gynecol. 2002;45:
345361.
19. Mehta SH, Blackwell SC, Hendler I, et al. Accuracy of esti-
mated fetal weight in shoulder dystocia and neonatal injury.
Am J Obstet Gynecol. 2005;192:18771880.
20. Melamed N, Yogev Y, Meizner I, Mashiach R, Pardo J, Ben-
Haroush A. Prediction of fetal macrosomia: the consequences
of false diagnosis. J Ultrasound Med. 2010;29:225230.
21. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and
associated risk factors with macrosomic infants born in
California. Am J Obstet Gynecol. 1998;179:476480.
22. Langer O, Berkus MD, Huff RW, Samueloff A. Shoulder
dystocia: should the fetus weighing greater than or equal to
4000 grams be delivered by cesarean section? Am J Obstet
Gynecol. 1991;165:831837.
23. Cohen B, Penning S, Major C, Ansley D, Porto M, Garite T.
Sonographic prediction of shoulder dystocia in infants of
diabetic mothers. Obstet Gynecol. 1996;88:1013.
24. Cohen BF, Penning S, Ansley D, Porto M, Garite T. The
incidence and severity of shoulder dystocia correlates with
a songraphic measurement of asymmetry in patients with
diabetes. Am J Perinatol. 1999;16:197201.
25. Modanlou HD, Komatsu G, Dorchester W, Freeman RK, Bosu
SK. Large-for-gestational age neonates; anthropometric rea-
sons for shoulder dystocia. Obstet Gynecol. 1982;60:417423.
26. McFarland MB, Trylovich CG, Langer O. Anthropometric
differences in macrosomic infants of diabetic and nondiabetic
mothers. J Maternal Fetal Med. 1998;7:292295.
27. Casey BM, Lucas MJ, Mcintire DD, Leveno KJ. Pregnancy
outcomes in women with gestational diabetes compared with
the general obstetric population. Obstet Gynecol. 1997;90:
869873.
28. Keller JD, Lopez-Zeno JA, Dooley SL, Socol ML. Shoulder
dystocia and birth trauma in gestational diabetes: a ve-
year experience. Am J Obstet Gynecol. 1991;165:928930.
29. Mehta SH, Blackwell SC, Chadha R, et al. Shoulder dystocia
and the next delivery: outcomes and management. J Matern
Fetal Neonatal Med. 2007;20:729733.
30. American College of Obstetricians and Gynecologists. ACOG
practice bulletin clinical management guidelines for
obstetricians-gynecologists. No. 40. Obstet Gynecol. 2002;100:
10451050.
31. Overland EA, Spydslaug A, Nielsen CS, Esklid A. Risk of shoulder
dystocia in second delivery: does a history of shoulder dystocia
matter? Am J Obstet Gynecol. 2009;200:506.e1506.e6.
32. Crane SS, Wojtowycz MA, Dye TD, Aubry RH, Artal R.
Association between pre-pregnancy obesity and the risk of
cesarean delivery. Obstet Gynecol. 1997;89:213216.
33. Jensen DM, Damm P, Sorensen B, et al. Pregnancy outcome
and prepregnancy body mass index in 2459 glucose-tolerant
Danish women. Obstet Gynecol. 2003;189:239244.
34. Cedergren MI. Maternal morbid obesity and the risk of
adverse pregnancy outcome. Obstet Gynecol. 2004;103:219224.
35. Yogev Y, Langer O. Pregnancy outcome in obese and morbidly
obese gestational diabetic women. Eur J Obstet Gynecol Reprod
Biol. 2008;137:2126.
36. Allen R, Petersen S, Moore P, et al. Do antepartum and
intrapartum risk factors differ between mild and severe
shoulder dystocia? Obstet Gynecol. 2003;189:S208.
37. Poggi SH, Spong CY, Allen RH. Prioritizing posterior arm
delivery during severe shoulder dystocia. Obstet Gynecol.
2003;101:10681072.
38. Robinson H, Tkatsch S, Mayes DC, Bott N, Okun N. Is maternal
obesity a predictor of shoulder dystocia? Obstet Gynecol.
2003;101:2427.
39. Yu CK, Teoh TG, Robinson S. Obesity in pregnancy. BJOG.
2006;113:11171125.
40. Hassan AA. Shoulder dystocia: risk factors and prevention.
Aust N Z J Obstet Gynaecol. 1988;28:107109.
41. Gemer O, Bergman M, Segal S. Labor abnormalities as a risk
factor for shoulder dystocia. Acta Obstet Gynecol Scand.
1999;78:735736.
S E M I N A R S I N P E R I N A T O L O G Y 3 8 ( 2 0 1 4 ) 1 8 9 1 9 3 192
42. Gross SJ, Shime J, Farine D. Shoulder dystocia: predictors and
outcome: a ve-year review. AmJ Obstet Gynecol. 1987;156:334336.
43. McFarland M, Hod M, Piper JM, Xenakis EM, Langer O. Are
labor abnormalities more common in shoulder dystocia? Am J
Obstet Gynecol. 1995;173:12111214.
44. Mehta SH, Bujold E, Blackwell SC, Sorokin Y, Sokol RJ. Is
abnormal labor associated with shoulder dystocia in nulli-
parous women? Am J Obstet Gynecol. 2004;190:16041609.
45. Lurie S, Levy R, Ben-Arie A, Hagay Z. Shoulder dystocia: could it
be deduced from the labor partogram? Am J Perinatol. 1995;12:
6162.
46. Poggi SH, Stallings SP, Ghidini A, Spong CY, Deering SH, Allen RH.
Intrapartum risk factors for permanent brachial plexus injury.
Obstet Gynecol. 2003;189:725729.
47. Lewis DF, Edwards MS, Asrat T, Adair CD, Brooks G, London S.
Can shoulder dystocia be predicted? Preconceptual and pre-
natal factors. J Reprod Med. 1998;43:654658.
48. Geary M, McParland P, Johnson H, Stronge J. Shoulder dysto-
cia: is it predictable? Eur J Obstet Gynecol Reprod Biol. 1995;62:
1518.
49. Rouse DJ, Owen J, Goldenberg RL, Cliver SP. The effectiveness
and costs of elective cesarean delivery for fetal macro-
somia diagnosed by ultrasound. J Am Med Assoc. 1996;276:
14801486.
50. Gurewitsch ED, Allen RH. Reducing the risk of shoulder
dystocia and associated brachial plexus injury. Obstet Gynecol
Clin North Am. 2011;38:247269.
S E M I N A R S I N P E R I N A T O L O G Y 3 8 ( 2 0 1 4 ) 1 8 9 1 9 3 193