Shoulder dystocia

Question 1

Shoulder dystocia - def

Answer 1

Any delivery that requires additional obstetric manoeuvres after gentle downward traction on the head has failed to deliver shoulders

Question 2

Shoulder dystocia - path

Answer 2

Anterior shoulder impacted against symphysis pubis

Question 3

Shoulder dystocia - risk factors

Answer 3

1. Shoulder dystocia with previous birth
2. Maternal obesity
3. Diabetes
4. Post-date pregnancy
5. Fetal macrosomia

Question 4

Shoulder dystocia - sx/dx (clinical) (2)

Answer 4

1. **Dx (clinical) = when the routine practice of gentle, downward traction of the fetal head fails to deliver the anterior shoulder
2. Suspect when fetal head retracts into perineum (turtle sign) after expulsion (bc shoulders impacted at pelvic inlet)

Question 5

Shoulder dystocia - mx

Answer 5

HELPERR

H - call for help (additional midwife, senior obstetrician, neonatologist, anaesthetist)
E - episiotomy (helps with internal manoeuvres)
L - legs into McRoberts’ (hyperflexed at hips with thighs abducted and externally rotated)
P - suprapubic pressure applied to posterior aspect of anterior shoulder to dislodge it from under symphysis pubis
E - enter pelvis for internal manoeuvres
R - deliver posterior arm by sweeping fetal arm across face and chest
R - roll over to ‘all fours’
Failure of all the above - replacement of head into vagina and CS (Zavanelli)

Order in practice:

1. McRoberts’ manoeuvre + suprapubic pressure
2. Delivery of posterior arm

Question 6

Shoulder dystocia - cx

Answer 6

Fetal

1. Hypoxia and neurological injury (cerebral palsy)
2. Brachial plexus palsy
3. Fracture of clavicle/humerus

Maternal

1. PPH
2. Genital tract trauma (including 3rd and 4th degree perineal tears)