2.1 - Shoulder Dystocia - Exam

Question 1

Shoulder Dystocia

Answer 1

a vaginal cephalic delivery that requires the use of additional obstetric manoeuvres following the delivery of the head and failure to deliver the body by using gental traction
Is a bony obstruction when the fetal shoulder impacts on the symphysis pubis or less commonly the sacral promontory

Question 2

Risk Factor

Answer 2

• Previous shoulder dystocia
• Macrosomia > 4500
• Diabetes mellitus
• Raised maternal BMI
• Induction of labour
• prolonged first stage
• secondary arrest
• prolonged second stage
• Oxytocin augmentation
• Operative vaginal delivery
• single best predictor is previous shoulder dystocia
• at present ther is no clinically proven predicator model that can be used
• the majority of cases occur in deliveries with no identifiable risk factor with fetal weight <4500 g

Question 3

Management

Answer 3

• The management of shoulder dystocia requires timely, yet controlled manoeuvres to aid delivery of the baby
• Fetal pH drops by 0.04 per minute hence delivery within 5 minutes is usually associated with a good outcome, provided initial ph was normal
• Care must be taken to avoid overzealous traction being applied, as this can result in irreversible damage (brachial plexus injury)
• Good communication between birth attendant and parturient as well as other attending healthcare professionals is essential. all members of the team should clearly informed that they are attending a should dystocia emergency
• Senior neonatal staff should be present at the delivery due to the expectation of the need for neonatal resuscitation
• Stop maternal pushing (as this can exacerbate impaction) and do not appy fundal pressure
• shoulder dystocia is a bony obstruction all manoeuvres are therefore employed to create more space in the pelvis or rotate and dislodge the shoulder to facilitate delivery

Question 4

if delivery is unsuccessful then the mangement algorithm should be repeated
If delivery is imppossible

Answer 4

• Cephalic replacement and LSCS
• Symphysiotomy (not recommended unless knowledge and skill available due to maternal morbidity
• Cliedotomy - deliberate fracture of the fetal clavicles usually only if the fetus is dead

Question 5

Identify risk factors for shoulder dystocia

Answer 5

Macrocosmic baby
PPH
GDM
High BMI
Pelvic Trauma
Previous shoulder dystocia

Question 6

Prevention

Answer 6

• Induction of labour does not prevent shoulder dystocia in non-diabetic women with suspected fetal macrosomia
• Previous shoulder dystocia reamins one of the best predictors of further shoulder dystocia
• Elective CS should be considered in pregnancies complicated by preexisting/gestional diabetes with est fetal weight >4500 grams
• Elective CS or vaginal delivery is apporpriate for future pregnancies following shoulder dystocia (this is a joint decision that should be made by the woman and her carers)

Question 7

Post delivery

Answer 7

• anticipate and be prepared for postpartum haemorrhage
• examine perineum carefully for third/fourth-degree tears
• Ensure cord bloods are sent
• fully debrief the parturient and birth partners and members of staff present
• provide the mother with written information ROCG leaflet
• Risk Managerment documentation:
  *fully document all notes in a comphreshensive and legible manner
  include: time of delivery of the head and time of delivery of the body
  anterior shoulder at the time of dystocia (right or left)
  The manoeuvres performed (Timing, sequence)
  Estimated blood loss at delivery
  cord bloods
  Vaginal/perineal examination findings
  Return to see the mother and baby at a later stage for further debriefing
  Arrange a 6/52 postnatal consultant appointment for further counselling, if required

https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/shoulder-dystocia-patient-information-leaflet/

Question 8

Queensland policies
Perineal bundle

Question 9

What signs would alert you to shoulder dystocia

Answer 9

No further descent - head is born but unable to deliver body
chin pressed against the vulva

Question 10

What does the “truck” analogy describe

Answer 10

baby’s head through the pelvis and the shouldler become stuck under the pubic bone

Question 11

What does the bridge analogy describe

Question 12

When do you place your hands in a CPR position

Answer 12

to apply subpubic pressure on the fetal shoulder not the pubic bone

Question 13

Diagnositc axial traction

Answer 13

pull head in direction of the spine

Question 14

The majority of shoulder dystoica cases occur in births where the infant is <4500 gm and there are no identifiable risk factors

Answer 14

True

Question 15

The timeframe for delivery of a shoulder dystocia is recommended on the rationale of fetal pH not dropping too low and thus being associated with a postive outcome.
The ideal timeframe from delivery of the head to completion of the birth in shoulder dsystocia is

Answer 15

less than 5 minutes

Question 16

when applying suprapubic pressure in the the case the midwife should stand on then maternal right and apply pressure right to left

Answer 16

yes

Question 17

The three aims of manoeurvres to manage should dsystocia are

Answer 17

Increase - the functional size of the pelvis
Decrease the bisacromial diameter of the fetus
Change the relationship of the bisacromial diameter to the bony pelvis

Question 18

You are caring for Greta and on the birth of her baby’s head you suspect shoulder dystocia can call for help. the team arrive and the following mcroberts manoeuvre, supra-pubic pressure is applied.
During suprapubic pressure you will

Answer 18

apply routine axial traction of the fetal head

Question 19

You are caring for Greta and on the birth of her baby’s head you suspect should dystocia can call for help. You have previously identified the fetal back to be on the maternal ride side. The team arrive and following McRoberts manoeuvre and suprapubic pressure is applied

Answer 19

from the maternal right side applying pressure from maternal right to left

Question 20

Greta has had a prolonged second stage and after difficulty delivery of the head, you recognise “shoulder Dystocia” and you call for help.
Your first action is to initiate McRoberts manoeuvre
The aim of this is to

Answer 20

increase the relative anterposterior diameter of the pelvic inlet by reducing lumbosacral lordosis

Question 21

Greta has had a prolonged second stage and after difficulty delivery of the head, you recognise “shoulder Dystocia” and you call for help.
Your first action is to initiate McRoberts manoeuvre and suprapubic pressure has been unsuccessfull and the senior midwife says she is going to proceed with “internal manoeuvres”. One of the desired outcomes of performing interenal manoeuvres is to

Answer 21

rotate the shoulder of the fetus out of the AP plane of the maternal pelvis

Question 22

Greta has had a prolonged second stage and after difficulty delivery of the head, you recognise “shoulder Dystocia” and you call for help.
Your first action is to initiate McRoberts manoeuvre and suprapubic pressure has been unsuccessful
the aim of this manoeuvre is to

Answer 22

reduce the bisocromial diameter and rotate the anterior shoulder of the fetus into the oblique pelvic diameter

Question 23

RWH - should dystocia guideline

Answer 23

https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/shoulder-dystocia-guideline_280720.pdf

Question 24

Exam: What is shoulder dystocia

Answer 24

• a vaginal cephalic delivery that requires the use of additional obstertric manoeurves following the delviery of the fetal head
• unable to delivery the body by using gentle traction
• this is a bony obestruction where the shoulder impacts the symphysis pubis
• less likely but can occur at the sacral promontery

https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/shoulder-dystocia-guideline_280720.pdf

Question 25

Exam: Risk factors of should dystocia

Answer 25

* previous shoulder dystocia * macrosomia baby >4.5 kg * GDM or DM maternal mother * raised maternal BMI * induction of labour * prolonged first stage of labour * oxytocin augmentation * operartive vaginal delivery * secondary arrest * there is no clinically proven predicator model that can be used * mojority of cases occur in the delivery with no identifiable risk factors <4.5kg * **single best predictor is previous should dystocia**

Question 26

Exam: Explain the potential morbidity and mortality associated with shoulder dystocia and how they relate to management strategies.

Answer 26

* Nerve damage - brachial plexus nerve damage c5-c8 to t1 - A total brachial plexus injury is characterized by total sensory and motor deficit of the entire arm. Sympathetic nerve injury (Horner syndrome) can result in contraction of the pupil and ptosis of the eyelid on the affected side. Full recovery is rare without surgical intervention. Prognosis can be poor. * Erb’s palsy is the most common brachial plexus injury and is characterised by a flaccid upper arm, an extended lower arm rotated towards the body and a hand in the ‘waiter’s tip’ position. Erb’s palsy generally recovers within 12 months. * Klumpe’s Palsy is less common and is characterized by a limp hand and no movement of the fingers. Recovery rate is lower than Erb’s palsy with around 40% recovery within 12 months. * Fracture clavicle * Hypoxia * Hypoxia related * Uterine rupture * PPH * 3rd & 4th degree tear * death * birth trauma

Question 27

Exam: Explain the midwife’s role and professional responsibilities in reference to recognition and management of shoulder dystocia.

Answer 27

Overarching principles of management 1. call for help - code pink - obstretic emergency 1. Mc Robert - legs pulled back thigh against of abdo two people one on either side, lifts pelvis off the bed 2. Subpubic pressure - pressing down using the CPR hold pressing down on the anterior shoulder (not the pelvis) to the oblique position (2 10) 3. Internal rotation - 4. Realigning the pelvis change diameters Pringle - wood screw - place whole hand inside to find the posterior shoulder pull arm straight out and up never pull downard but axil whole hand in cant feel the posterior arm try to rotate the shoulder with supapubic pressure to rotate can redo if required can move into all fours

Question 28

Exam: Outline how to facilitate release of a shoulder dystocia, including a rationale of priorities of management.

Answer 28

Overarching principles of management 1. Mc Robert 2. Rubin's 1 - Subpubic pressure 3. Rubins 11 - Internal rotation 4. Woodscrew - Realigning the pelvis change diameters Pringle all else fails The Zavanelli maneuver is generally performed only after other attempts to free the child have failed. In this maneuver, the baby's head is first rotated into position and then flexed. The doctor applies constant, firm pressure, pushing the head back into the birth canal.

Question 29

Exam: Managment

Answer 29

* Code pink - obstetric emergency

Question 30

Exam: Intrapartum risks

Answer 30

* Prolonged first stage * Prolonged second stage * augmentation of labour * Instrumental birth * uterine abruption * hypoxia of the fetus * PPH * perineal trauma *

Question 31

Exam: Recognition of shoulder dystocia

Answer 31

* There is difficulty with the birth of the face and chin * The head is born but remains tightly applied to the vulva * The chin retracts into the perineum (the turtle signs) * The anterior shoulder does not birth with normal downward. traction

Question 32

Exam: HELPERR

Answer 32

**H - Call for help** - SOAPS senior midwife, Obstetrician, Anaesthetist, Paediatrician & Scribe **E - Evaluation for epistiomy** - increases room available for further manoeuvre **L - Legs** - McRoberts - hyperflexion of thighs onto abdomen to increase the pelvic space availalbe **P - Pressure** - Rubins 1 - direct subpubic pressure aims to rotate anterior shoulder forward off the symphysis pubis, CPR grip to be used behind the fetal back **E - Enter pelvis** - Rubins 2 - The accoucheur's hand is inserted into the vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter Wood's screw manoeuvre - aims to internally rotate the anterior shoulder to become posterior and bring the new anterior shoulder below the symphysis in a corkscrew fashion **R- Remove posterior arm** - posterior arm flexed and swept over the fetal chest to exteriorize and then perform rotateion as above **R- Roll patient** onto all fours may improve the pelvic diameters and space avialable

Question 33

Exam: Manoeuvres

Answer 33

* Should be attempted for 30 seconds before moving onto the next manoeuver * Never rotate the head * Pressure on the scapula or clavicle of the fetus * AVOID: excessive traction at all times * neonatal trauma is associated with strong dowward traction that can cause permanent brachial plexus injury * AVOID: fundal pressure, also associated with brachial plexus injury, uterine rupture and haemorrhage from the potential detachment of the fundal placenta

Question 34

Exam: Emergency manoeurves

Answer 34

* Increase the functional size of the bony pelvis * Decrease the bisacromial diameter of the fetus * Change the relationship of the isacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter

Question 35

Exam: McRoberts

Answer 35

* remove lower section of the bed * legs to abdo hyperflex * need extra hands for each thigh if possible

Question 36

Exam: Rubin 1

Answer 36

* Suprapubic pressure * Place hands on the fetal shoulder (using CPR hold) and rotate the anterior shoulder into the oblique

Question 37

Exam: Rubins 11 pringle manoeuvre

Answer 37

The accoucheur’s hand is inserted into the vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter. Completion of the birth is then attempted using normal downwards traction. Internal manoeuvre cup hand at 6oclock find posterior arm deliver the posterior arm traction axil direction

Question 38

Exam: Wood’s screw Manoeuvre

Answer 38

* McRobert’s position, * the accoucheur introduces their second hand and locates the anterior aspect of the posterior shoulder. * Pressure is applied to rotate the posterior shoulder. * Completion of the birth should be attempted once the shoulders move into the oblique diameter. * If this movement is unsuccessful continue rotation through 180° and attempt delivery.

Question 39

Exam: nuchal cord

Answer 39

Nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck 360 degrees. Nuchal cords occur in about 10–29% of fetuses and the incidence increases with advancing gestation age.

Question 40

Exam: Midwifery roles & documentation

Answer 40

Documentation includes:  The time of birth of the head  Manoeuvres performed, the timing and sequence  The direction the baby is facing and which shoulder is impacted (right or left)  The time of delivery of the body  Staff in attendance  The condition of the baby at birth provide the opportunity for the mother and family for a debrief physio referral pysch referral