2.1 - Shoulder Dystocia - Exam Flashcards
Shoulder Dystocia
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
Risk Factor
- 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
Management
- 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
if delivery is unsuccessful then the mangement algorithm should be repeated
If delivery is imppossible
- 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
Identify risk factors for shoulder dystocia
Macrocosmic baby
PPH
GDM
High BMI
Pelvic Trauma
Previous shoulder dystocia
Prevention
- 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)
Post delivery
- 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/
Queensland policies
Perineal bundle
What signs would alert you to shoulder dystocia
No further descent - head is born but unable to deliver body
chin pressed against the vulva
What does the “truck” analogy describe
baby’s head through the pelvis and the shouldler become stuck under the pubic bone
What does the bridge analogy describe
When do you place your hands in a CPR position
to apply subpubic pressure on the fetal shoulder not the pubic bone
Diagnositc axial traction
pull head in direction of the spine
The majority of shoulder dystoica cases occur in births where the infant is <4500 gm and there are no identifiable risk factors
True
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
less than 5 minutes
when applying suprapubic pressure in the the case the midwife should stand on then maternal right and apply pressure right to left
yes
Exam: McRoberts
- remove lower section of the bed
- legs to abdo hyperflex
- need extra hands for each thigh if possible
Exam: Rubins 11
pringle manoeuvre
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
Exam: Wood’s screw Manoeuvre
- 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.
Exam: nuchal cord
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.
