Shoulder dystocia

Question 1

Recognition of shoulder dystocia.

Answer 1

• Difficulty with delivery of the face and chin.
• The head remaining tightly applied to the vulva or even retracting.
  -Failure of restitution of the fetal head.
• Failure of shoulders to descend.

Question 2

Initial Timings.

Answer 2

• Document timing of the delivery of the head.
  -Document time of birth of the body.
• Note the interval in-between.

Question 3

Summon appropriate assistance

Answer 3

• Use emergency call bell to call for help, immediately after recognition.
• Upon arrival of further staff state clearly “this is a shoulder dystocia”.
• Ask first arrival to call 2222 and state shoulder dystocia.
• Ask for paediatric team in event of neonatal resuscitation, obstetric team and the most senior obstetrician available.
• Further support of members of staff e.g. runner to bring equipment and a scribe to document timings.

Question 4

MCRoberts manoeuvre

Answer 4

• At initial recognition put the legs into McRoberts.
• If the legs are up straighten their legs.
• Then bend the knees all the way up to their chest.
• This alone can resolve the shoulder dystocia so with maternal effort apply some gentle axial traction.

Question 5

Super pubic pressure

Answer 5

• If not resolved apply some super pubic pressure to abduct the anterior shoulder.
• Hands in a CPR grip and apply constant super pubic pressure.
• This can be done continuously for 30 seconds, or rocking for 30 seconds.
• Then try with maternal effort and gentle axial traction to birth the baby.

Question 6

Consider episiotomy

Answer 6

• If not resolved evaluate for an episiotomy.
• Episiotomy will not resolve the impaction but may provide some additional space to start the maternal manoeuvres.

Question 7

Demonstration of posterior arm.

Answer 7

• Enter the vagina and birth the posterior arm. In practice this is a typical first manoeuvre, as it is usually the most successful.
• Support the baby’s head.
  -With entire hand enter into the vagina and reach along feeling for the elbow.
• Gently sweep the hand across the head.
• This will change the diameters of the shoulders and the baby will birth.

Question 8

Demonstrate internal rotation manoeuvres.

Answer 8

• Start in McRoberts.
• Enter whole hand into the vagina.
  -Start by trying to rotate the posterior shoulder.
• Place pressure first on the anterior aspect of the posterior shoulder.
• To rotate the baby to an oblique diameter.
• If that hasn’t worked move fingers round and put some pressure of the posterior aspect of the posterior shoulder.
• If this doesn’t work, then use the second hand to move inwards place some pressure on the posterior aspect of the anterior shoulder to rotate.
• The other option is to use both hands to rotate the whole baby round.
• Maintain the force and you should be able to feel that the baby is starting to rotate.
• Encourage maternal effort and apply axial traction the baby should birth.

Question 9

Roll and repeat

Answer 9

• If this has not worked ask them to roll over and repeat the manoeuvres in an all four position.
• Consider asking a more experienced person in the room to carry out manoeuvres.

Question 10

Prepare for neonatal resuscitation.

Answer 10

• Already checked equipment and prepped the resucitair before birth.
• Anticipate that you may need to do a full resuscitation either led by the most senior person in the room or the paediatric team if present.

Question 11

Documentation, record keeping and incident form.

Answer 11

• To do the procedure I would be communicating timings of each procedure to the scribe.
• Note the time of head delivery, time of body delivery, the interval in-between, time of any manoeuvres.
• Also debrief the family at an appropriate time, to discuss what we have done.
• Debrief with the staff to look at learning points.

Question 12

Consider operative procedures. (not requiered)

Answer 12

• If not resolved some operative can be considered including fracturing the baby’s clavicle to change the diameters of the shoulders and the pelvis.

Question 13

Recording of the fetal heart (not required)

Answer 13

• May have had a ctg of intermittent auscultation in process. Would be best to monitor fetal heart.

Question 14

Third stage management (not required)

Answer 14

• Gain consent for managed 3rd stage.
• Administer oxytocin with consent, to prevent risk of PPH.