Shoulder Dystocia

Question 1

Define

Answer 1

Usually occurs due to impaction of the anterior (or posterior) foetal shoulder on the maternal pubic symphysis (or sacral promontory)

Risk factors: macrosomia, high maternal BMI, GDM, prolonged labour

May not have any of the risk factors

Also note that not all babies have a high birth weight (a sig % will be less than 4kg)

S/S: difficult face/chin delivery, ‘turtling’ head (retracting back into perineum), failure of restitution, failure of shoulder descent

Question 2

Management

Answer 2

Management -> should all take <5 minutes to perform:

1. Call for senior help + discourage pushing

You DO NOT want her to push as this will cause more impact with shoulder and symphysis

Keep pulling throughout the manoeuvres

Do each manoeuvre for 30 secs

REMEMBER WHEN PERFORMING MANOUVRES YOU WANT TO PULL THE BABY TOWARDS YOU ALIGNED (SO PARALLEL)

Flatten the bed and bring the pt end of the bed

2. McRobert’s manoeuvre (legs up to abdomen) – 90% success

flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

This rotation increases the relative AP angle of the pelvis by flattening the spine (allowing extra room for the anterior shoulder) and often facilitates successful delivery

3. Suprapubic pressure - like CPR - press down on the back, trying to push the back to turn the baby

4. Either (depends on user experience / clinical indication):

• Rubin’s manoeuvre (push anterior shoulder towards baby’s chest)
• Woods’ Screw (Rubin’s + push posterior shoulder towards baby’s back à rotation)
• Deliver posterior arm

Flex elbow across the chest

then, rotate 180 and deliver the other arm

5. Evaluate for episiotomy
6. Change position to all fours and repeat the above manoeuvres
7. cleidotomy (divide clavicles) –> Symphysiotomy (sep maternal pubic forms) –> Zavanelli (reversal of normal delivery movements and doing a c-section; only really done when you have given up hope on saving the baby basically)

Question 3

Complications

Answer 3

Complication:

PPH

Perineal tears

Brachial plexus injury

• Erb’s palsy- due to upper brachial plexus injury àadducted and internal rotation, pronation of the forearm (waiter’s tip)
• NOTE: Klumpke’s palsy àdamage to lower brachial plexus and commonly affects the nerves innervating the muscles of the hand

Neonatal death