Shoulder dystocia Flashcards
scenario
Zoe is a 25 year old diabetic woman, at term with her first pregnancy, she has been attending the consultant led maternity unit and the diabetic clinic. She is married and works as a part time taxi driver. Zoe has a BMI so 32 . She was an induction of labour and has been in the second stage of labour for 1 and a half hours. There has been slow decent of the head and difficulty in delivery of the chin.
What is suspected to have happened
Shoulder dystocia
What factors led to this conclusion
Induction of labour
long 2nd stage of an hour and a half
SSlow decent of the head
difficulty delivery the chin
how would i manage this situations
introduce myself
PPE
Check under covers and do routine axil traction with contractions- shoulders aren’t coming which confirm shoulder dystocia.
Pull emergency buzzer
Discourage pushing as can further impact the shoulder
For purpose of close leave room and 2222 call- obstrician team, charge midwife, neonatal staff, let theatre know and any other available staff to help.
When help arrives give sbar -recommend we try deliver the boys safely using different position, catahterise and cannulate once delivered.
get emergency trolly
Use HELPERR
Already called for Help
Evaluate for episiomy if not done already.
This is not to widen the outlet to allow the shoulder to pass through as a shoulder dystocia is a a shoulder stuck behind a boney structure (the shoulder haven’t pass through the brim of the pelvis) and not a soft tissue- this is so there is more room to do internal manuvers if necessary.
The woman has a large perinuim tear so not required.
Legs into Mcroberts
With assistance her the womans legs up to mcroberts when the thighs are touching the abdomen.
Lie woma flatter with pillow removed and in a left lateral position to avoid aortic exclusion
Thsi chances the pelvic diameters
flattens the sacral promontory and straightens the womans spine allowing for more room for the anterior shoulder to be lifted adn allows the posterior shoulder to go over the sacrum and into the pelvis.
Using routine axil traction is applied to attempt to deliver the baby- doesn’t deliver
All postions and manoeuvres should be done for 30 seconds each.
Remove end of the bed and to gain easier access now
super pubic pressure
Identify the back of the fetus which is the opposite side to the way the head is facing.
Use your hands in the CPR position and press down on the posterior aspect of the anterior shoulder to help push th shoulder into the oblique diameter of the pelvis or abducting the shoulder which will reduce the bisicromal diameter try release it under th symphysis pubis
This is done while someone else is doing axil traction.
If this doesn’t work can also use the same postion however using a rocking back and forth way to realise the shoulder
Both of these should be done from 30 seconds and recorded.
Internal manoeuvres
Aim is to reduce the bisicromal diameter and free the impacted shoulder or move the shoulders into the oblique diameter which will aid the delivery.
The roomiest part of the pelvis is the posterior- insert fingers into the posterior part of the vagina
Place fingers on the posterior aspect of the posterior shoulder and push towards fetal chest- this should collapse the fetal girdle and reduce the bisicromal diameter or move the anterior shoulder under the symphasis pubis
routine axil traction
If nor work
Insert two finger into the vagina onto the anterior aspect of the posterior shoulder again pushing the should now towards the back of the baby - to aid delivery and move the anterior shoulder under the symphysis pubis into the widest diameter of the pelvis
If not successful
Insert two fingers posteriorly and the move upwards placing fingers on the posterior aspect of the anterior shoulder and pushing down towards fetal chest to try aid delivery
Removing the posterior arm
If all previous fails- remove the posterior arm
insert hand in pringal grip posterior and locate posterior arm
Once the farn is located flex the elbow and bring the arm in a sweeping motion across the anterior chest wall and out.
Removing this arm diminishes the bisicromal diameter and allow the baby to move into the hollow of the pelvis
Routine axil traction is attempted to deliver baby
Slowly delivery the bay onto mums chest
Assess by neontal staff and use appear score and cord bloods taken
Roll onto hands and knees
If none of before worked can roll woman onto hands and knees
Sometimes the change in poison can free the impacted shoulder and aid to deliver the baby.
However if not all previous discussed manoeuvres can be done apart from the superpubic pressure
All done for 30 seconds
Further manoeuvres
Cleidotomy- purposeful fracture of the babies clavicle to try reduce the bisicromal diameter and free the shoulder however this is sometimes fracture can sometimes happen anyway.
Symphysiotomy- minimally invasive procedure- scalpel inserted and the joint supporting ligaments are in-sized using a pivoting movement to increase the diameter of the pelvis
Last resort is Zavanelli -the fetal head is rotated manually and pushed back up into the abdomen and emergency section is to occur
After baby is delivered
Sort woman back on bed
Insert two cannulas grey wide bore- none touch a septic technique- date and times and flushed by trained professional.
We need ves access in case the need for fluids nad drugs due to trauma
Bloods taken- group and save incase the need of transfusion as higher risk of PPH. Full blood count.
Catheterisation- a septic none touch technique to assess fluid output as incase oof trauma to bladder.
documented on Fluid balance chart
Post partum observation on a mews chart every 15mins.
Documentation
Time of head delivery
diagnosis of shoulder dystocia
emergency buzzer
222 call
who was here adn what the deon
Manuouvers tried
when boys was born
apgar scores
blood loss
Trauma
cannulation
catheterisation
maternal outcome
fluid balance chart
mews chart
cord bloods
debrief
Date time and sign
