Shoulder Dystocia

Question 1

How is it defined?

Answer 1

A complication of vaginal cephalon delivery. A delivery requiring additional obstetric manoeuvres to release the shoulders after head has been delivered and gentle downward traction has failed.

Question 2

What is the incidence in the UK?

Answer 2

1:200 deliveries

Question 3

What complications can occur?

Answer 3

Maternal and fetal morbidity
PPH
Perineal tears - whether manoeuvres used or not
Brachial plexus injuries - 10% left with permanent injury

Question 4

What risk factors are there?

Answer 4

Fetal macrosomia 
High maternal BMI
DM 
Prolonged labour 
Induced/augmented labour 
Assisted vaginal delivery 
Previous shoulder dystocia

Question 5

It usually occurs due to impaction of the anterior fetal shoulder on..

Answer 5

The maternal pubic symphysis

Question 6

How is it managed?

Answer 6

Help: extra midwives, labour ward coordinator, senior obstetrician, neonatologist, anaesthetist, scribe for timing manoeuvres
Episiotomy: to give space for internal manoeuvres, the episiotomy itself won’t relieve the shoulder dystocia (but not always necessary)
Legs: place in McRobert’s position
Suprapubic pressure to improve the effectiveness of McRobert’s- with flat of hand laterally in direction baby facing, continuously or rocking motion while applying steady traction to fetal head
Enter pelvis for internal manoeuvres
Roll other onto all fours
Others

Question 7

Describe the McRoberts position

Answer 7

Hyperflexed lithotomy
Flexion and abduction of hips, bringing thighs towards abdomen - increases the AP angle of the pelvis
It straightens the lumbosacral angle and rotates symphysis superiorly
Helps to relive the impacted shoulder to enter pelvis without manipulating the fetus

Question 8

When brachial plexus injury is discussed legally (it is a common cause for litigation) is damage to the posterior or anterior shoulder considered unlikely to be due to action by the healthcare professional?

Answer 8

Posterior shoulder

Question 9

Should oxytocin be administered?

Answer 9

No

Question 10

Should maternal pushing be encouraged?

Answer 10

No

Question 11

Should fundal pressure be used?

Answer 11

No - associated with high neonatal complication rate and may result in uterine rupture

Question 12

What are the other third line manoeuvres?

Answer 12

Maternal symphysiotomy
Zavanelli - replacement of the fetal head to reverse the movements of labour and return head to the flexed occipito-anterior position for Caesarian delivery - baby likely severely acidotic at this stage