RANZCOG - shoulder dystocia

Question 1

what is the definition of shoulder dystocia?

Answer 1

Vaginal cephalic delivery that requires extra manouvers to deliver the fetus after the head has delivered and gentle traction has failed

Question 2

List the risk factors for shoulder dystocia

Answer 2

Pre labour:
	- Previous shoulder dystocia
	- Macrosomia
	- GDM
	- Maternal obesity
Intrapartum:
	- Prolonged 1st stage
	- Prolonged 2nd stage
	- Labour augmentation
        - Instrumental delivery

Question 3

what is the incidence of shoulder dystocia?

Answer 3

0.6-0.8% (PROMPT)

Question 4

List 2 maternal adverse outcomes associated with shoulder dystocia

Answer 4

PPH 11%

3rd and 4th degree tears 4%

Question 5

List 4 neonatal adverse outcomes associated with shoulder dystocia

Answer 5

• brachial plexus injury
• clavicle fracture
• brain injury
• death

Question 6

what is the incidence of brachial plexus injury?

Answer 6

• Brachial plexus injury 1:1000
  
  • Most resolve with no ongoing neurological injury 1/10,000 with ongoing injury
  • <10% result in permanent neurological dysfunction
  • The larger the infant the more likely to suffer BPI

Question 7

What can you comment on regarding prevention strategies for shoulder dystocia?

Answer 7

• If diabetic - elective IOL at 38/40 vs elective CS can reduce risk
  
  • If not diabetic then IOL earlier not proven to reduce risk
  • In diabetic women (pre-existiing or GDM) with baby 4.5kg or greater then El CS recommended to reduce risk of shoulder dystocia
  • NNT 443
    Non diabetic women should be recommended CS if >5kg

Question 8

list 4 features that would alert you to shoulder dystocia

4 features to recognise shoulder dystocia

Answer 8

• Difficulty with the delivery of the face and chin
  
  • The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)
  • Failure of restitution of the fetal head
    
    • Failure of the shoulder to descend

Question 9

what are the management steps for a shoulder dystocia?

Answer 9

• call for help
• start timer
• McRoberts manouever
• suprapubic pressure
• delivery of posterior arm
• internal rotational manouevers
• consider all 4s position
• start over

If unable to resolve despite above - consider Cleidotomy, Zavanelli manoeuvre or symphysiotomy

Question 10

what is a cleidotomy?

Answer 10

• intentional surgical fracture of clavicle

Question 11

what is the Zavanelli manoeuvre?

Answer 11

vaginal replacement of the fetal head followed by CS