Shoulder dystocia

Question 1

What is the definition of SD?

Answer 1

A vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed

Question 2

What are the mechanisms of a SD?

Answer 2

1. normal mechanism of labour
2. shoulders attempt to enter the pelvis in the AP diameter of the pelvic brim
3. Shoulders fail to spontaneously traverse the pelvis after fetal head has been delivered

Question 3

What are the 2 types?

Answer 3

Anterior shoulder impacts the maternal symphysis pubis

Posterior shoulder impacts on the sacral promontory

Question 4

Which type of SD is more common?

Answer 4

Anterior shoulder impacted on maternal symphysis pubis

Question 5

What is the incidence of SD?

Answer 5

0.1% to 3%

Question 6

What is the incidence in diabetic mothers of babies with bw less than 4kg?

Answer 6

1%

Question 7

How much occurs in babies less than 4kg?

Answer 7

50%

Question 8

Antenatal risk factors (9)

Answer 8

Obesity (gest diabetes) 
over 35 years 
diabetes 
multigravida 
prev shoulder dystocia 
prev big baby 
post maturity 
short stature 
hx of pelvic injury

Question 9

What are the 5 recommendations from CESDI?

Answer 9

1. anticipate
2. initiate early involvement of senior medical personnel
3. senior paed for resus
4. policy/guidelines for management
5. regular training and drills

Question 10

Who do we induce to prevent SD?

Answer 10

IOL to reduce risk for mat diabetes with suspected macrosomia

Question 11

What are the 6 potential morbidities?

Answer 11

• pph 11%
• 4th degree tear 3.8%
• ruptured uterus by fundal pressure
• brachial plexus injury 4-16%
• fractured clavicle
• humeral fracture associated with delivery of posterior arm 2-12%

Question 12

What is the brachial plexus?

Answer 12

network of nerves that conducts signals from spine to the shoulder arm and hand
injuries are damage to those nerves

Question 13

what are the symptoms of brachial plexus injury?

Answer 13

Limp/paralysed arm
Lack of muscle control in the arm/hand/wrist
Lack of feeling or sensation in arm/hand

Question 14

How many SD result in BPI?

Answer 14

4-16%

Question 15

What can cause a BPI?

Answer 15

some due to excessive force by DR

some due to propulsive force from mother

Question 16

What is it important to document about a SD?

Answer 16

Which arm was posterior

Question 17

6 Intrapartum risk factors for SD

Answer 17

• slow progress in 1st stage
• arrest of progress at 8cm
• prolonged 2nd stage requiring augmentation
• instrumental delivery
• slow delivery of face/chin
• turtle necking

Question 18

How much does fetal pH drop by per minute?

Answer 18

0.04

Question 19

Management of a shoulder dystocia (5)

Answer 19

1. anticipate
2. if there are risk factors inform senior staff
3. do not cut the cord if around the neck
4. 3P’s DO NOT : Pull excessively, push on fundus, pivot fetal head
5. Record keeping

Question 20

What are the 3 P’s you shouldn’t do?

Answer 20

Pull excessively
Push on fundus
Pivot fetal head

Question 21

What is a cleidotomy?

Answer 21

Surgical separation of the clavicles to allow delivery of fetus with broad shoulders

Question 22

What is the zavanelli manouevre?

Answer 22

Pushing baby back up into uterus for a CS

Question 23

Clinical management (4)

Answer 23

2222-obs team, neonatal
Explain to mother
Pushing discouraged
Attempt to deliver baby with gentle axial traction

Question 24

What is mcroberts and how do we do it?

Answer 24

Lie bed flat
Thighs to abdomen
Attempt delivery with gentle axial traction

Flattens lumbo sacral lordosis
Flexes fetal spine
Rotates symphysis pubis anteriorly
Attempt to deliver baby with gentle axial traction

Question 25

what is suprapubic pressure?

Answer 25

Apply on fetal side of back

Reduces shoulder diameter by abducting the shoulders

Rotates anterior shoulder into oblique pelvic diameter

Shoulder should slip under symphysis pubis with normal traction

Either continuous or rocking motion

Question 26

How do we enter with a SD?

Answer 26

• consider epis if not able with hand
• enter posteriorly via sacral hollow
• attempt either of the following internal maneouvres depending on the situation
  1. press on anterior or posterior aspect of the posterior shoulder
  2. Rotate shoulders into oblique diameter
  3. Stop suprapubic pressure

Question 27

How do we deliver the posterior arm?

Answer 27

-grasp the wrist and posterior arm should be gently grasped and withdrawn in a straight line

Question 28

What can removing the posterior arm do?

Answer 28

12% have humeral fracture

Question 29

If removing posterior arm unsuccessful what do you do?

Answer 29

Roll onto all 4’s, try again, then roll back and try again

Question 30

What should you record keep? 10

Answer 30

• time of delivery of head
• direction head and fetal back are facing
• manoeuvres performed and timing
• staff present
• time of delivery of body
• condition of baby APGARs
• Cord gases
• Datix
• Debrief
• Documentation

Question 31

What are the 3rd line manoeuvres?

Answer 31

Fracture clavicle
Zavanelli manoeuvre
Muscle relaxation
Symphsiotomy

Question 32

What is important to think of in the next pregnancy?

Answer 32

Risk of repeat 1-2%
Risk of permanent bpi 0.03%
risk of lscs