Shoulder Dystocia

Most common form of shoulder dystocia

Where the anterior shoulder becomes impacted against the symphysis pubis

What percentage of infants weighing 2500-4000g are affected

0-3%

Fetal outcomes

1. Birth asphyxia and fetal acidosis 2. Brachial plexus injury - loss of movement in arm due to nerve damage at the shoulder 3. Erb's palsy - permanent paralysis of the arm due to nerve damage 4. Clavicle fracture 5. Humerus fracture 6. Associated hypoxic brain injury 7. Death 8. Phrenic nerve damage which is required for movement of diaphragm BE PREPARED FOR RESUSCITATION (COATES 2011 and GABRIEL KING 2010)

What procedures would the obstetrician consider if the above was ineffective?

1. Deliberate fracture of the clavicle 2. Zanvanelli manoeuvres - replace head in vagina and perform C Section 3. Symphyotomy - cut into symphysis pubis normally in third world countries

Postnatal care

1. Ensure thorough paed check to exclude and treat any injuries 2. Physio for baby and mum 3. Debrief of parents and staff 4. Obtain cord samples 5. DOCUMENT - what time head delivered, what time shoulders delivered, what manoeuvres were used and who performed them

Maternal outcomes

1. Ruptured uterus 2. Soft tissue damage 3. 3rd and 4th degree tears 4. Anal sphincter damage 5. PPH 6. Symphyseal separation (separation of the symphysis pubis) (COATES 2011 and GABRIEL - KING 2010)

Warning signs of shoulder dystocia

1. Slow restitution of the head or absent restitution 2. 'Turtle necking' where baby's chin retracts into the perineum 3. Head 'bobbing' as head stretches out in attempt to deliver but retracts back as shoulders become lodged (ALL ABOVE GABRIEL-KING 2010) 4. Slow delivery of the head (COATES 2011)

Risk factors

1. previous shoulder dystocia 2. Macrosomic baby (>4.5kg) 3. Maternal diabetes 4. Maternal BMI (>35) 5. Post term pregancy 6. Prolonged labour 7. Prolonged second stage 8. Instrumental deliveries 9. Augmentation 10. Abnormal pelvis (COATES 2011)

What is the diameter of the shoulders

11-12cm bisacromial diameter

What percentage of infants between 4000-4500g

5-7% (RCOG 2005)

Why does a diabetic mother have increased risk of macrosomic baby?

Baby subjected to high insulin levels which increase growth and fat laid down over chest

Why does post dates increase likelyhood of shoulder dystocia

Because the chest and shoulders continue to grow post dates

ALL ABOVE

COATES 2011 and Gabriel - King 2010

H

Call for help 2222 - state obstetric emergency. Midwife in charge/senior midwife. Scribe. Pediatrician. Obstetricians. Anaethetist Call 999 if homebirth

E

Enter the vagina: 1.Rubin 2 Manoeuvre - because the baby's head is tight against the perineum there is little room to enter the vagina anteriorly so enter posteriorly and move fingers up to posterior aspect of the anterior shoulder and exert pressure on the scapula in an attempt to move it from the anterior posterior to the oblique position. 30-60 seconds. 2. Woodscrew manouevre - keep fingers on the posterior aspect of the anterior shoulder and place fingers of other hands on the anterior aspect of the posterior shoulder. Rotate shoulder in an attempt to flex anterior shoulder and extend posterior shoulder to move shoulders into oblique diameter to aid delivery. 30-60 seconds. 3. Reverse woodscrew - move the fingers in the Rubin position down the the posterior aspect of the posterior shoulder and remove other hand from the vagina. Apply pressure on the posterior shoulder in an attempt to move the shoulder into the oblique diameter but in the opposite direction to the woodscrew. 30-60 seconds.

E

Evaluate for episiotomy - this is in order to reduce trauma to the vagina during manouevre and NOT to aid delivery of shoulders

Definiton

Failure of the shoulders to traverse the pelvis following delivery of the head (Smeltzer 1986)

What acronym can help assist midwives in the management of shoulder dystocia?

HELPERR devised by Advanced Life Support in Obstetrics (ALSO 2004)

L

Legs into McRoberts position - Flatten back of the bed. Assist mother to flex hips and bring thighs onto abdomen, knees pointing toward the chest. Increases anterior - posterior pelvic diameters. Straightens the lumbosacral lordosis. Flexes fetal spine. Keep legs in Mc Roberts while attempting other manouevres. Effective in dislodging anterior shoulder over 40% of cases.

How can uterine rupture and further impaction against symphysis pubis be avoided?

NO FUNDAL PRESSURE NO MATERNAL PUSHING (COATES 2011)

P

Pressure - apply supra pubic pressure with hands in CPR style position just above the symphysis pubis. Need to determine whether fetal back is on left or right. Apply constant pressure for 30-60 seconds in an attempt to abduct the anterior shoulder and decrease the bisacromial diameter. After 30-60 seconds of constant pressure try a rocking pressure for 30-60 seconds. During the manouevre the other midwife would be applying traction in an attempt to deliver the baby

R

Remove posterior arm. Insert finger posteriorly into vagina and locate posterior arm. Flex elbow toward the chest and sweep the arm across the chest following natural movement to prevent fracture. This reduces the bisacromial diameter and allows the baby to drop down into the pelvic hollow - freeing the trapped anterior shoulder. 30-60 seconds

How often can you repeat the HELPERR procedure

Repeat again once if baby's heart rate is acceptable and cord has not been cut - repeat in all fours position.

R

Roll onto the all four position. The anterior shoulder will now be posterior. This position increases pelvic diameters. Free the anterior shoulder with gentle downward traction, then delivery the posterior shoulder and body with gentle upward traction. ALWAYS TRY AND DELIVER THE SHOULDER NEAREST THE CEILING FIRST. 30-60 seconds.