Shoulder Dystocia Management

Document

* Time of birth of the fetal head * Time of birth of the baby * Times and types of all actions taken * Riskman/Riskpro

Rubins I

An assistant should attempt external manual suprapubic pressure while the accoucheur continues gentle traction. The pressure should be applied from the side of the mother that will allow the heel of the assistant's hand to move in a downward and lateral motion on the posterior aspect of the fetal shoulder. Initally the pressure can be continuous, but if delivery is not accomplished, a rocking motion is recommended. The mother is not to push while the manoeuvre is attempted for 30 seconds.

Following delivery

Assess mother for: * Any trauma * Excessive bleeding/haematoma formation * Bladder/bowel function * Pain Assess baby for: * Birth asphyxia * Brachial plexus injury * Fracture or dyslocation * Transfer to NNU if necessary

H

Call for help - Midwives, Obstetrician, Paediatrician, Anaesthetist

Debrief

Caregivers, parents and family

E

Enter - Internal Manoeuvres - the next manoeuvres attempt to rotate the feral shoulders out of the impacted position and into an oblique plane from which they can deliver. Each manoeuvre is to be attempted for 30 seconds. The mother is not to push during the manoeuvre.

E

Evaluate for episiotomy

Rubins II

Insert the fingers of one hand vaginally behind the anterior fetal shoulder, and push the shoulder towards the fetus' chest. This pressure will adduct, or collapse the shoulder girth of the fetus, reducing the diameter. Attempt to rotate the shoulders into the oblique diameter and free of the symphysis pubis, and continue delivery by normal downward traction. If this is unsuccessful, proceed to the Woods' Screw manoeuvre.

Risk Factors

It may occur unexpectedly in cephalic presentations and with no predetermined risk factors, but risk factors include: * Maternal diabetes * Maternal obesity * Fetal size * Advanced Maternal age * Previous infant > 4000g * Maternal pelvic abnormality * Maternal pelvic abnormality * History of previous shoulder dystocia

Reassure

Keep patient and partner reassured and part of all explanations

L

Legs - the McRoberts Manoeuvre involves flexing the maternal hips, thus positioning the maternal thighs up onto the maternal abdomen. This brings the pelvic inlet and outlet into a more vertical alignment, facilitating delivery of the fetal shoulders. Mother to push with contraction. Attempt for 30 seconds.

HELPERR

Mnemmonic for management of shoulder dystocia

R

Remove the posterior arm The accoucheur slides a hand along the posterior arm and presses in the antecubital fossa to release the arm. Delivery should be facilitated by ventrally rotating the arm at the shoulder with delivery over the perineum

R

Rolling the patient The patient must roll from the existing position to an all fours position to increase the true obstetrical conjugate by as much as 10mm, and the sagittal measurement of the pelvic outlet increases up to 20mm.

P

Suprapubic pressure

Woods' Screw Manoeuvre

The accoucheur uses the opposite hand to approach the posterior shoulder from the front of the fetus, and rotate the should toward the symphysis in the same direction as with the Rubin II manoeuvre. In combination, the accoucheur now had fingers of one hand behind the anterior shoulder, and fingers of the other hand in front of the posterior shoulder. With this movement, the fetal shoulders can rotate out of the impacted position and into the oblique plane, continue delivery by normal downward traction.

Reverse Woods' Screw Manoeuvre

The fingers of the entering hand are placed on the posterior shoulder from behind and the attempt is to rotate the fetus in the opposite direction as the Woods' Screw manoeuvre to the oblique plane,

Shoulder Dystocia

The need for additional obstetric manoeuvres to effect the delivery of the shoulders of the baby. It occurs when there is impaction of the anterior shoulder against the maternal symphysis pubis after birth of the fetal head, and when the bisacromial diameter (breadth of the shoulders) exceeds the diameter of the pelvic inlet.

Introduction

There is a wide variation in the repaired incidence of shoulder dystocia, but it is accepted as around 0.6%of all births. It is not always foreseeable or reasonably preventable, and there can be a high perinatal mortality and morbidity associated with the condition, even when it is managed appropriately. Unless delivery is achieved within 5-7 minutes, the baby may die from anoxia.