Shoulder Dystocia

Question 1

What is the definition of shoulder dystocia?

Answer 1

• difficulty in delivery of the shoulder after delivery of the foetal head.
  
  • need for additional manoeuvres
  • time delay between head and shoulder delivery.

Question 2

What is the cause of shoulder dystocia?

Answer 2

• bony obstruction
  
  • foetal bisacromial diameter (distance b/w shoulders- too wide for AP diameter of pelvis.
• position
  
  • anterior foetal shoulder wedged under maternal symphysis pubis
  • uncommonly posterior shoulder impacted onto sacral promintory
• unique to vaginal delivery with cephalic presentation

Question 3

What is the presentation of shoulder dystocia? When should it be suspected?

Answer 3

• difficulty with birth of the face and chin.
• head born tightly applied to vulvus.
• the chin retracts into the perineum (the turtle sign)
• anterior shoulder does not birth with normal downward traction.

Question 4

What are foetal complications from shoulder dystocia?

Answer 4

Bad;

• bone fracture
  
  • clavicle
  • humerus
• transient brachial plexus palsy

Very bad:

• permanent brachial plexus palsy (Erb’s C5/6 pick up sticks) and Klumpke’s C8 (lay them straight)-T1)

Extremely bad:

• asphyxia - hypoxic ischaemic encephalopathy
• death

Question 5

What are maternal complications from shoulder dystocia?

Answer 5

• birth canal trauma
• haemorrhage
• uterine rupture
• very prolonged psychological impact

Question 6

What are the risk factors for shoulder dystocia?

Answer 6

• antepartum
  
  • prior Hx
  • fetal macrosomia (>4.5kg)
  • maternal DM
  • post-term pregnancy
  • male fetal gender
  • maternal obesity
• intrapartum
  
  • prolonged labour
  • induction of labour
  • augmented labour
  • instrumental delivery

Question 7

What is the treatment of shoulder dystocia?

Answer 7

• HELPERR - any order for manoeuvres - reassurance vital.
  
  • call for help - senior, midwife - STOP pushing - note time
  • evaluate for episiotomy
    
    • position (space, over the end of the bed)
  • Legs - McRoberts maneouvre (abduct and hyperflex thighs onto maternal abdomen bilaterally - mobilised SI joint)
  • Pressure (suprapubic) Rubin 1 - after McRoberts
  • Enter - rotational manoevres - post aspect of anterior shoulder. corkscrew manoevres (head to ceiling, more room)
  • Remove posterior arm (Barnum) - antecubital fossa pressure, posterior hand sweep. Drag arm down and out. WORKS
  • Roll patient onto all fours (Gaskin) - go on all 4s - opens the pelvis.
• last resorts:
  
  • deliberate cleidotomy - snap clavicle
  • Zavanelli restitution - push back with caesarean
  • Hysterotomy - internally push out
  • symphysiotomy - intentional symphysis pubis incision and opens pelvis - DON’T DO IT
• NEVER rotate fetal head
• Avoid excessive traction
• avoid fundal pressure

Question 8

Prevention of Shoulder Dystocia?

Answer 8

• anticipatory prophylactic maneouvres
  
  • forceps
  • maternal obesity
• C-section for presumed macrosomia
  
  • challenge - margin of error for US
• early induction of labour for presumed macrosomia - do it more.

Question 9

Acronym for RFs of shoulder dystocia?

Answer 9

DOPE:

• diabetes
• obesity
• position
• everything else