Shoulder Dystocia and Uterine Rupture

Question 1

What is shoulder dystocia?

Answer 1

Head arrives but shoulders won’t after gentle downwards traction

Question 2

What causes shoulder dystocia?

Answer 2

Anterior shoulder stuck against symphysis pubis due to failure of rotation. Can also have posterior shoulder impacted against sacral promontory.
Foetal deterioration will be rapid

Question 3

What are the main issues with shoulder dystocia?

Answer 3

Foetal death
Asphyxia with resulting hypoxic damage – baby starts to breath but can’t expand lungs and cord compressed – cerebral palsy
Birth trauma (Erb’s palsy, cervical spine injury and fracture bones - clavicles)
Intracranial haemorrhage
Maternal trauma – PPH, 3rd and 4th degree tears and psychological

Question 4

What are the risk factors for shoulder dystocia?

Answer 4

Macrosomic foetus
Obese mother 
Diabetic mother
Post term pregnancy 
All instrumental delivery especially rotational 
Previous history of shoulder dystocia 
Lack of progress in 1st or 2nd stage

Question 5

What is the process for managing shoulder dystocia?

Answer 5

HELPERR
Help – call for help
Episiotomy – SD is a bony problem, but this may help with internal manoeuvres – not always necessary
Legs – Legs into McRoberts position – push the ladies’ legs against her chest – flattens sacrum hopefully letting the shoulder drop below symphysis pubis.
Pubic pressure - Suprapubic pressure – press on back of baby - rocky movements or constant
Enter Pelvis
• Rubin II – pressure on posterior aspect of anterior shoulder
• Wood’s screw – combine above with pressure on anterior aspect of the posterior shoulder to rotate the baby 180 degrees
• Reverse Wood’s screw – anterior aspect of anterior shoulder and posterior aspect of posterior shoulder
Release – release posterior arm by flexing elbow and sweeping foetal hand across chest and face to release posterior shoulder
Roll – roll over to all 4s (Gaskin manoeuvre)

Question 6

What should you be prepared for during and after management of shoulder dystocia?

Answer 6

Time keeping important
PPH is likely
Neonatal team should always be called early
Assess for genital tract trauma after

Question 7

What is a uterine rupture?

Answer 7

Full thickness disruption of the uterine muscles. Can extend to involve the bladder or broad ligament.

Question 8

What are the two types of uterine rupture?

Answer 8

Complete – peritoneum is also torn, and uterine contents can escape into peritoneal cavity
Incomplete – peritoneum overlying the uterus is intact

Question 9

What are the risk factors for uterine rupture?

Answer 9

Previous caesarean section (classical has highest risk) 
Previous uterine surgery 
IOL
Obstruction of labour 
Multiple pregnancy 
Multiparity 
Congenital abnormality of the uterus

Question 10

How does uterine rupture usually present?

Answer 10

Sudden severe abdominal pain persisting between contractions
Shoulder tip pain
Vaginal bleeding
Regression of presenting part
Scar tenderness and palpable foetal parts
Hypovolaemic shock
Foetal distress

Question 11

How should a suspected uterine rupture be investigated?

Answer 11

USS if pre-labour setting
During Labour high risk should be CTG monitored
If any non-reassuring signs, then C section is likely and rupture noted then

FBC and cross match

Question 12

How should you manage a uterine rupture?

Answer 12

ABCDE
Delivery foetus via caesarean
Repair or removal of the uterus