Complications in Labour Flashcards
What is shoulder dystocia? How serious is it?
This is when the fetal anterior shoulder becomes impacted (or trapped) behind the pubic symphysis which prevents delivery
It is an OBSTETRIC EMERGENCY and action is needed quickly
How common is shoulder dystocia? What risk factors make it more common?
Overall incidence of 0.2%
More common in large babies (macrosomia - GDM)
Accounts for 8% of intrapartum deaths
Other RFx include: Post-dates, obese mother, male fetus, high parity, prolonged first stage, forceps delivery
Are there any warning signs of shoulder dystocia? How does it cause problems?
After the delivery of the fetal head if the head retracts against the vagina/vulva this is known as TURTLE HEADING and is a warning sign for dystocia
As the fetal body is in the tight pelvic cavity the umbilical cord is trapped between fetal trunk and pelvic wall occluding it - this can rapidly lead to feel hypoxia and death. 50% of deaths will occur within 5 mins
What are some complications of shoulder dystocia?
Most common are brachial plexus injuries from downward traction of the head during multiple attempts at delivery
ERB’S palsy can occur due to damage of nerve roots C5-6 or KLUMPKE’S palsy can occur due to damage of nerve roots at C7-T1
Maternal complications such as genital tract trauma and atonic postpartum haemorrhage
How do we manage shoulder dystocia?
Management stages summarised by HELPERR
***Attemp each manoeuvre for a maximum of 30s before moving on
HELP - urgently bleep obstetric team
EPISIOTOMY - evaluate for need of episiotomy
LEGS to McRobert’s position (knees to chest)
PRESSURE (suprapubic) push down on suprapubic region - continue head traction throughout
ENTER - fingers into vagina at 5 and 7 o’clock and perform the Wood Screw and Reverse Wood Screw manoeuvre
REMOVE the posterior arm
ROLL OVER - turn mother over to all fours - can free anterior shoulder. If not try to deliver the posterior shoulder
What are the ‘last resort’ measures in shoulder dystocia?
Symphysiotomy - split the symphyseal joint with scalpel
Fracture one or both of the foetus’s clavicles to reduce bisacromiall distance
Zavanelli manoeuvre - replace the head with flexion and rotation and then delivering by C/S
How many degrees of perineal tears are there and what defines them?
4
FIRST DEGREE - minor teat to the labia and vagina
SECOND DEGREE - tear to the bulbocavernosus and superficial transverse perineal muscle
THIRD DEGREE - inclusion of the external anal sphincter
FOURTH DEGREE - inclusion of internal anal sphincter and rectal mucosa
How should perineal tears be managed?
Tears from second degree onwards will likely need some form of stitches and third and fourth degree tears will need prophylactic antibiotic therapy
For abx therapy refer to trust policy but broad spectrum cover of gram negative enterococci is important (cerfuroxime, metronidazole)
Stitches can be done by midwife
