Complications in Labour

Question 1

What is shoulder dystocia? How serious is it?

Answer 1

• 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

Question 2

How common is shoulder dystocia? What risk factors make it more common?

Answer 2

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

Question 3

Are there any warning signs of shoulder dystocia? How does it cause problems?

Answer 3

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

Question 4

What are some complications of shoulder dystocia?

Answer 4

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

Question 5

How do we manage shoulder dystocia?

Answer 5

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

Question 6

What are the ‘last resort’ measures in shoulder dystocia?

Answer 6

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

Question 7

How many degrees of perineal tears are there and what defines them?

Answer 7

4
1st DEGREE - skin only

2nd DEGREE - perineum and perineum muscle (bulbocavernosus and superficial transverse perineal muscle)

3rd DEGREE - inclusion of the EXTERNAL ANAL SPHINCTER (a<50%, b>50%, c-internal sphincter)

4th DEGREE - inclusion of rectal mucosa/epithelium

Question 8

How should perineal tears be managed?

Answer 8

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

Question 9

What are the two most common causes of instrumental delivery

Answer 9

Fetal distress

Delayed second stage

Question 10

What must you be sure of before attempting instrumental delivery and how do you assess for it?

Answer 10

• Being very aware of fetal position (particularly head position) is very important and so a lot of abdominal and vaginal palpation is important
• The cervix must also be fully dilated, the head must be at the spines or below (>0), the bladder must be empt and analgesia satisfactory

Question 11

What are the two options for instrumental delivery?

Answer 11

Forceps or ventouse

Question 12

What are the different types of forceps?

Answer 12

NON-ROTATIONAL - applied over the baby’s head along the curvature of the spine and then downward and pulling traction applied along with uterine contractions
ROTATIONAL - used to rotate baby’s head from occipital-posterior to occipital-anterior. Rotation can be, and often is, tried manually first

Question 13

What are some benefits of ventouse over forceps?

Answer 13

Less pelvic space required, less analgesia, less maternal perineal trauma (better for mum)

Question 14

What are some benefits of forceps over ventouse?

Answer 14

More successful
Obstetrician favoured
Less cephalhaematoma or retinal haemorrhage (better for baby)

Question 15

Explain the different types of C section

Answer 15

1. Immediate: <30 mins LIFE THREATENING
2. Urgent: <60 mins MATERNAL/FETAL COMPROMISE
3. Scheduled <24 hours (no compromise but needs early delivery)
4. Elective