Shoulder dystocia Flashcards
At risk of shoulder dystocia
Cephalo-pelvic disproportion
Prev shoulder dystocia
Macorsomia
High BMI
Induction and assisted labour
Long slow labours and second stages
Risk for baby with shoulder dystocia
Hypoxia, death
Nerve injury - brachial plexus
Radial and clavicle fracture
When do shoulder dystocias suspected
Fail to advance after 2 or 3 pushes
When do shoulder dystocias suspected
Fail to advance after 2 or 3 pushes
HELPER
HELP
Episiotomy
Legs - mcroberts
Pressure
Enter manouvres
Remove posterior arm
Rollover and repeat
What is macroberts manouvre
Lift legs up to head - knees up - tilt coxix to allow pelvis to widen in order to deliver
What is macroberts manouvre
Lift legs up to head - knees up - tilt coxix to allow pelvis to widen in order to deliver
Pressure how do
Start putting pressure on abdomen like cardiac massage, straight then rocking 30s each
After each manouvre try and deliver
Enter manouvres
Push anterior shoulder back
Pull posterior shoulder forward
Do both at same time
Try each for 30s
What can do if HELPER doesnt work
Break the clavicle
How long to get baby out before pH drops
7 minutes
Last line of action
Sympisiotomy - split the pubic symphysis
HEad back in and caesarean section
What at risk of after shoulder dystoica?
PPH
PTSD
What is assessed in the bishop score?
Foetal station
Cervical position
Cervical dilatation
Cervical effacement
Cervical consistency
Scoring for Bishop score
Foetal station (0-3)
Cervical position (0-2)
Cervical dilatation (0-3)
Effacemtent (0-3)
Consistency (0-2)
Maximum score = 13
What score predicts successful induction of labour
> 8 on bishop score
What score predicts successful induction of labour
> 8 on bishop score
What score predicts successful induction of labour
> 8 on bishop score
What score predicts successful induction of labour
> 8 on bishop score
What does a Bishop score under 8 suggest
Cervical ripening may be required to prepare the cervix
What is a membrane sweep?
Insert a finger into cervix to stimulate cervix and begin process of labour
When will labour start after a successful membraen sweep?
48 hours
What can be inserted into the bagina to induce labour?
Prostagladnin E2 (dinoprostone) - gel, tablet or pessary
Releases prostaglandins over 24 hours
What is a cervical ripening balloon?
Silicone balloon inserted into cervix gently inflated to dilate the cervix
When is a cervical ripening balloon used over a PGE2?
Women with prev c section
Vaginal PGs have failed
Multiparous women >3 prec
What is used if vaginal PGs cant be used or havent worked
Artificial rupture of membranes with an oxytocin infusion
What is used to induce labour if intrauterine foetal death has occured?
Oral mifeprisotne (anti-progesterone) + misoprostol
What is used for monitoring the induction of labour>
Cardiotocography (CTG) - assess foetal HR and uterine contractions before and during induciton of labour
Bishops score - progress
Options when slow or no progress in labour
- Further vaginal prostaglandins
- Artificial rupture of membranes and oxytocin infusion
- Cervical ripening balloon (CRB)
- Elective caesarean section
When should most women give birth within after labour starts
24 hours
What is the main complication of vaginal PGs
Uterine hyperstimulation
What happens in uterine hyperstimulation
Contraction of uteris is prolonged and frequent -> foetal distress and compromise
What happens in uterine hyperstimulation
Contraction of uteris is prolonged and frequent -> foetal distress and compromise
What is the criteria for uterine hyperstimulation
individual uterine contractions lasting more than 2 mins
>5 uterine contractions every 10 mins
What can uterine hyperstimulation lead to?
Foetal compromuse w hypoxia and acidosis
Emergency C section
Uterine rupture
Managemnet of uterine hyperstimulation
Remocing vaginal OGs or stopping oxytocin infusion
Tocolysis (preventing birth) with terbutaline
What is failure of restitution
Head remains face down - occipito anterior - and does not turn sidewyas as expected after delivery
Turtle-neck sign
Head delivered, then retracts back into vagina
Steps to managing shoulder dystoica
Shout for help incl anaesthetics and paeds
Episiotomy
McRoberts
Pressure to anterior shoulder
Rubins manouvre
Woods screw manouvre
Zavanelli manouvre
Complications of shoulder dystocia
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury and Erb’s palsy
- Perineal tears
- Postpartum haemorrhage
Zavanelli manouvre what is
involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
Wood screw manouvre
performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.
What is rubins manouvre
involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
What is Mcroberts manouvre
involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Pressure to anterior shoulder
