Shoulder Dystocia

Why would you perform an episiotomy before performing maneuvers in a shoulder dystocia?

- An episiotomy would be needed if there is no room to enter either fingers or a hand (pringle shaped) in the sacral hollow of the vagina and there is no room to perform maneuvers.

Why is shoulder dystocia considered an obstetric emergency?

- Cord compression. - Inability for lung expansion to occur. - pH drop by 0.04 per minute.

What is erbs palsy?

- Damage to the nerve roots C5-C6, upper arm is flaccid, lower arm extended. - This normally lasts for up around 12 months.

What is brachial palsy?

- Due to non-engagement of one shoulder, the distance between the vaginal outlet and pelvic inlet is 5cm. - This causes stretching.

Where do you "enter" when performing maneuvers in a shoulder dystocia?

- Entry point should be posteriorly into the sacral hollow of the vagina.

What are the risk factors of shoulder dystocia for the neonate?

- Fractures ton the clavicle. - Fetal hypoxia (resus). - Neurological damage. - Brachial plexus. - Erbs Palsy. - Klumpkes palsy.

How do you prevent a shoulder dystocia?

- IOL will not prevent a shoulder dystocia in non-diabetic women if macrosomia is suspected. - If GDM, IOl at term reduces the incidence rate of shoulder dystocia. - ELCS should be considered if diabetic and EFW is over 4.5kg. - Women should be seen in a specialist clinic.

What is Rubin's 2 maneuver?

- Insert the hand and locate the posterior aspect of the anterior shoulder. - Pressure should be applied aiming to move the shoulder into the wider oblique diameter of the pelvis. - This reduces the bisacromial diameter. - Continue to apply suprapubic pressure.

What is the woodscrew maneuver?

- Insert whole hand into vagina and locate the posterior aspect of the anterior shoulder. - Insert other hand and find anterior aspect of posterior shoulder. - Rotate in the same direction as Rubin II. - This abducts the posterior shoulder but it may aid rotation of the shoulders into the wider oblique diameter of the pelvis. - Normal axial traction can be applied if successful.

What are the risk factors of shoulder dystocia for mother?

- PPH - Perineal trauma - Uterine rupture (fundal pressure). - Soft tissue damage (cervix, vagina, perineum). - Infection. - PTSD.

What is Klumpkes palsy?

- Paralysis of the forearm and hand with no finger movements.

What are the pre-labour risk factors for shoulder dystocia?

- Previous shoulder dystocia. - Macrosomia. - Diabetes. - IOL. - BMI over 30kg/m2.

What are the intrapartum risk factors for shoulder dystocia?

- Prolonged 1st stage. - Prolonged 2nd stage. - Oxytocin augmentation. - Instrumental delivery.

How would you recognise a shoulder dystocia?

- Slow/ difficult delivery of the head. - Neck does not appear. - Chin retracts against the perineum. - Turtle necking. - Restitution may of may not occur. - No further traction. - No descent with gentle traction.

What is the reverse woodscrew maneuver?

- The fingers that were behind the anterior shoulder are moved down to the posterior aspect of the posterior shoulder. - The fingers that were behind the posterior shoulder and moved to the anterior aspect of the anterior shoulder. - Attempt to rotate in the opposite direction.

What is the evidence surrounding the prediction of macrosomia?

- The rate of shoulder dystocia if over 4kg is 10%. - The rate of shoulder dystocia if over 4.5kg is 23%. - The rate of shoulder dystocia if under 4kg is 48%. - USS weight is unreliable.

How do you define shoulder dystocia?

- Vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed. - Failure of the shoulders to deliver after the next uterine contraction after the birth of the head. - The anterior shoulder impacts on the maternal symphysis pubis after the birth of the head, preventing the birth of the body.

What does the second "E" stand for in H.E.L.P.E.R.R?

CONSIDER EPISIOTOMY/ ENTER - The aim is to free the anterior shoulder by internal maneuvers. - There are a wide range of internal maneuvers that can be attempted to do this.

What does the first "E" stand for in H.E.L.P.E.R.R?

END PUSHING - Good communication is required with the woman and her birth partner. - Explain the situation. - Continued pushing may cause more impact between the anterior shoulder and symphysis pubis.

What is the acronym for plan of care for a shoulder dystocia?

H.E.L.P.E.R.R.

What does the "H" stand for in H.E.L.P.E.R.R?

HELP - Call for help (2222, 999, emergency buzzer.) - State obstetric emergency, use SBAR tool, ask for obstetrician, paediatrition, coordinator and help.

What does the "L" stand for in H.E.L.P.E.R.R?

LEGS INTO MCROBERTS - Flexion and abduction of the maternal hips positioning maternal thighs onto her abdomen. - Sacral promontory flattens, maternal lumbar spine straightens, may enable symphysis pubis to rotate and release the fetal shoulder. - Works in 90% of cases.

What does the "P" stand for in H.E.L.P.E.R.R?

SUPRAPUBIC PRESSURE (RUBIN 1) - Performed at the side of the fetal back in a downward/ lateral motion. - Continuous or intermittent pressure is applied. - This is done for a minimum of 30 seconds. - May reduce the bisacromial diameter and aid rotation of the anterior shoulder.