Shoulder Dystocia

Question 1

What are the complications of shoulder dystocia

Answer 1

Brachial plexus damage → Erb’s, Klumpke’s
Hypoxia / hypoxic ischaemic encephalopathy (HIE)
Fracture of clavicle/humerus
Maternal post-partum haemorrhage (PPH)
Maternal complex tears: 3rd/4th degree perineal tears, lacerations, haematoma, uterine rupture

Question 2

What is the epidemiology of shoulder dystocia

Answer 2

Affects 0.5-0.7% of births
Brachial plexus damage occurs in 4-16% of shoulder dystocia cases
Fracture occurs in 10%
PPH occurs in 11%

Question 3

What are the risk factors for shoulder dystocia

Answer 3

Previous shoulder dystocia
Macrosomia
Gestational diabetes or DM
Narrow pelvic outlet
Short stature/high BMI
Induction of labour
Greater gestational age

Question 4

What is the management for shoulder dystocia

Answer 4

1. Sound the alert alarm and announce a shoulder dystocia
2. Direct two people to place mum into McRobert’s position and ask mum to push
3. Apply suprapubic pressure and attempt to deliver
4. Assess for episiotomy and carry out if needed
5. Posterior arm delivery
6. Internal rotation manoeuvre
7. Change position to all fours and repeat
8. Have another operator repeat maneouvres
9. Deliberate fracture of the clavicle
10. Symphysiotomy
11. Zavanelli

Question 5

What is the post-delivery management for shoulder dystocia

Answer 5

Neonatal review of baby
Paired cord pH
Anticipate and prevent PPH (Observe and administer syntometrine/syntocinon)
Document
Debrief patient
Datex

Question 6

Describe McRobert’s position

Answer 6

Woman lies flat and the hips are hyperflexed so that the thighs are as close to the abdomen as possible
Increases the AP diameter of the pelvis

Question 7

Describe suprapubic pressure

Answer 7

Bed needs to be low enough to place adequate pressure onto the shoulders to dislodge it
Apply pressure behind the anterior foetal shoulder, downward and lateral
Attempts to abduct the anterior shoulder towards the chest by pushing on its posterior aspect
Aims to decrease the bisacromial diameter, rotating the anterior shoulder into the wider oblique angle of the pelvis

Question 8

Describe posterior arm delivery

Answer 8

place hand into the birth canal and pull the arm through by the inferior hand. Once arm is delivered, ask mum to push and attempt delivery
Reduces the diameter of the foetal shoulders or bisacromial diameter

Question 9

Describe the internal rotation manoeuvre

Answer 9

insert a hand over the posterior shoulder and push forward, then placing a hand on the anterior shoulder and pushing back to rotate baby