Obstetrics (Shoulder dystocia)

Question 1

Is shoulder dystocia time critical? If so how long do you have to deliver the baby?

Answer 1

• yes it is time critical
  
  • you have 5-7 minutes to deliver the baby due to compression of the cord against the pelvic rim

Question 2

What must you take note of the timing?

Answer 2

• birth of the head
• timing of manoevres
• delivery of the body

Question 3

Shoulder dystocia notes…

Answer 3

• the newborn is likely to be compromised in this setting and require resuscitation
• during procedures, be prepared for a sudden release of resistance and be prepared to take hold of the baby
• the process of releasing the baby may cause injury - in particular clavicle fracture

Question 4

What do you do if the manoeuvres are not successful?

Answer 4

• Consult with PIPER regarding when to abandon attempts to deliver and initiate transport
• if unable to consult transport with notification
• transfer in McRoberts manoeuvre position with left lateral tilt

Question 5

Recite the Shoulder Dystocia CPG (Part 1)

Answer 5

Question 6

Recite the Shoulder Dystocia CPG (Part 2)

Answer 6

Question 7

The RWH Shoulder Dystocia Guidelines

Answer 7

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

Question 8

Which manoeuvres are performed in shoulder dystocia?

Answer 8

• McRoberts manoeuvre (knees to nipples)
• Suprapubic pressure whilst in McRobert’s position
• Gaskin ‘All Fours’ manoeuvre

Question 9

How do you for the McRobert’s manoeuvre?

Answer 9

• place the mother in a recumbent position
• hips to edge of bed enabling better access for gentle downward traction
• assist mother to grasp her knees and pull her knees/thighs back as far as possible onto her abdomen (use assistant to help achieve and maintain position)

Question 10

How do you apply suprapubic pressure whilst in McRobert’s position?

Answer 10

• Hands in CPR position behind symphysis pubis, at 45 degree angle along babys back (trying to rotate baby forward)
• Apply 30 secs firm downward pressure, then 30 sec rocking motion to get shoulder out from under rim, at rate of approx 1 per sec

Question 11

What signs indicate shoulder dystocia?

Answer 11

• normal birthing procedure fails to accomplish delivery
• prolonged head to body delivery time >60 seconds
• difficulty with birth of face and chin
• baby’s head retracts against perineum (turtle sign)
• failure of baby’s head to restitute
• failure of shoulders to descend
• difficulty reaching neck when attempting to check for cord around neck
• baby’s head colour turns purple then black

Question 12

What is a prolonged head to body time?

Answer 12

>60 seconds

Question 13

What are the next steps if it is identified that there is prolonged head to body delivery time >60 seconds

Answer 13

• note time of birth of head
• request urgent additional assistance
• explain to mother and ask her to push with focussed effort when required
• position mother with buttocks at bed egde
• apply gentle downward traction to deliver anterior shoulder

Question 14

What do you do once the delivery is accomplished in shoulder dystocia (newborn management)?

Answer 14

• manage as per new born resuscitation
• assess for clavicle injury and immobilise if necessary

Question 15

what do you do once the delivery is accomplished in shoulder dystocia (mother management)

Answer 15

• basic care
• reassure

Question 16

what do you do if the delivery is not accomplished after 30-60 seconds

Answer 16

alternate the following sequence… (spend only 30-60 seconds in each manoeuvre)

• McRoberts Manoeuvre (knees to nipples)
• Suprapubic pressure whilst in McRoberts Manoeuvre
• Gaskin Manoeuvre (all fours)

Question 17

How do you perform the Gaskin manoeuvre?

Answer 17

• rotate mother onto all fours
• hold the babys head and apply gentle downward traction - attempting to dis-impact and deliver the posterior shoulder (now uppermost)