Week 7 Flashcards
What happens in shoulder dystocia?
The head delivers but the anterior shoulder fails to follow
What causes shoulder dystocia?
Failure of shoulders to rotate into anterior-posterior diameter following delivery of head (failure of full restitution/external rotation)
Anterior shoulder caught under symphysis pubis
Often due to large baby
–But 50% associated with normal size baby cause is unknown
what are the risk factors for shoulder dystocia?
Mother over 35
Maternal weight > 90kg
Large baby (Macrosomia) –most common
– Poorly controlled T1DM/gestational diabetes
High maternal birth weight
Previous shoulder dystocia or instrumental delivery (ie forceps)
Platypelloid pelvis-
– anteriorposterior diameter reduced
Unknown
What are some complications of shoulder dystocia?
Increased perineal trauma
Post partum haemorrhage (PPH)
Psychological trauma/post natal depression
Trauma/injury to foetus: brachial plexus trauma, fractured clavicle or humerus and hypoxic brain injury
If the shoulder dystocia last >5 minutes there is an increased chance of foetal death and brain damage
28th
What do you need to look for to recognise shoulder dystocia?
Failure of head to advance and – the baby appears to bury its chin in perineum
As the anterior shoulder is wedged
– It does not enter the pelvis
– Failure of restitution of head
Turtle sign –head retracts (bobbing of head)
About 5-7 minutes to deliver the rest of the foetusafter the delivery of the head
What are some warning signs of shoulder dystocia?
Warning signs
–Often long first & second stage
– Pushing prolonged BUT not always
– Difficulty in delivering the face & chin
What is the McRoberts manoeuvre?
Initial management for Shoudler Dystocia
Effective 70-90% of the time
Lie woman on back
–? Pillow under buttocks
On edge of bed
knees drawn up to chest
Deliver foetus As normal
What physiological changes does the McRoberts Manoeuvre achieve?
Elevates anterior shoulder & rotates the symphysis pubis
Pushes posterior shoulder over sacrum
What is the Rubens 1 technique?
Suprapubic pressure
Have 3rd party pushing down on anterior shoulder for 30 secs.
Have 3rd party “rock” on anterior shoulder for further 30 secs.
What do you do once the head is delivered with shoulder dystocia?
Record time right away cos you got 5-7 minutes to deliver the baby
What is the Gaskin Manoeuvre?
Up to 83% successful Roll woman over on to “all fours” exploits the effects of gravity Opens diameters of the pelvis Increased space in hollow of sacrum Facilitates delivery of posterior shoulder & arm.
What is the Rubins 2 manoeuvre?
– Rotate anterior shoulder in forward direction bu sticking your hand/finger in there
What is the wood screw manoeuvre?
– Rotate posterior shoulder simultaneously in same direction
What order do you do the manoeuvres in for shouldr dystocia??
- McRoberts
- Rubens 1
- Gaskin
- Rubins 2 with Wood screw
- Reverse wood screw
What is the process of delivering the posterior arm?
A hand is inserted into the vagina along the sacral curve to locate the posterior arm or hand
Foetal arm is taken across its chest and delivered
Anterior shoulder should be easy to deliver
How common are breech births?
- About 25% of foetus will be in breech at some stage throughout the pregnancy
- 20% chance if delivered at 28/40
- 3-4% remain in breech patterns at term
What is a breech birth?
Baby’s lie is longitudinal but the foetal buttocks lie in the lower segment of the uterus.
What are the causes & risk factors (mum) of breech births?
– Previous breech birth – Uterine malformations e.g. bicornuate uterus – Prematurity – Multiple pregnancy – Low lying placenta/Placenta praevia – Oligohydramnios
Excessive intrauterine space
– Grand multiparity-lax uterus
– Polyhydramnios
What are the causes & risk factors (baby) of breech births?
– Foetal abnormalities
• Anencephalic
– Foetal death in utero – Decreased foetal activity – Impaired foetal growth – Short umbilical cord – Sometimes for no particular reason!
What are some obstetric complications of breech births?
– Cord Prolapse – Prematurity/PROM – Higher chance of foetal disability – Higher incidence of poor perinatal outcomes – Foetal hypoxia – Entrapment of the head – Head and neck trauma – Placental separation (premature)
What are the types of breech positions?
- complete
- frank
- footling
- knee
what is a complete breech position
The thighs & knees are flexed and the feet close to buttocks.
– common in mulitgravidas
What is Frank breech position?
Legs flexed at hip with straight knees. The legs lie alongside the trunk with feet near the head.
Common in primigravidas
45-50% of breeches. Most common
What is Footling breech position?
One or both knees/hip are extended and the feet are the presenting part
Common in preterm
What is KNEE breech position?
One or both hips are extended and the knees are flexed. The knees present below the buttocks
Less than 5% of breech presentations
How can you diagnose breech?
History Ultrasound Presenting part:-Foetal bottom-Feet Swollen/bruised genitalia Meconium (black toothpaste colour and consistency)
What is the golden rule of breech?
– “Hands off the breech”
• Unless necessary to interfere
• Minimal handling
How do you delivery a breech birth?
Hands off the breech as it delivers
- Legs and feet should delivery spontaneously
- If not: use 1 finger and place behind the knee and deliver by gentle flexion and abduction of the hip –then do the other leg
Ensure infant’s back is uppermost
– If not uppermost: hold the bony part of the pelvis and rotate between contractions until back is uppermost
• Avoids the abdominal organs
Keep foetus’ body covered and warm
– use a clean warm towel
Ask mother to push out infants shoulders
– Most babies will be able to
– If unable perform “Lovesetsmanoeuvre”
What ius Lovesets manoeuvre?
Grasp foetus by the pelvis & pull gently while rotating 90º feel for the anterior shoulder
Flex arm down & out
Reverse rotation
Deliver other shoulder
What do you need to do when delivery the head in Lovesets manoeuvre?
Allow 1-2mins.
– For head to enter pelvis
Allow infant to hang for 1-2min.
–Gradually hairline will appear
Do not attempt to hurry delivery of head
– avoids sudden change in intracranial pressure
What is the modified Mauiceau-Smellie-Veit Manoeuvre?
After nape of neck appears:
Lay Foetus astride your right arm
– with palm supporting chest
Two fingers are on babes cheek bones
– Flexing foetus’ head down
Two fingers of the left hand
– hooked over the shoulders with the middle finger pushing the occiput to aid flexion
What is the Burns-Marshall manoeuvre?
Foetus is allowed to hang by own weight
– encourages descent & flexion
Once nape of neck and hairline seen,
– the baby’s ankles are grasped &
– with slight traction
– the trunk is carried in a wide arc over the mother’s abdomen
Other hand supports perineum
Prevents sudden delivery of the head
Once the mouth is clear the baby can breathe &
Take time to complete the delivery of the cranium
