10/11) Labour & Delivery - Shoulder dystocia

Question 1

Incidence of shoulder dystocia

Answer 1

1 in 150 (0.7%)

Question 2

Rate of maternal PPH after shoulder dystopia

Answer 2

11%

Question 3

Rate of obstetric anal sphincter injury after SD

Answer 3

3.8%

Question 4

Rate of brachial plexus injury after SD

Answer 4

10%

Question 5

Proportion of brachial plexus injuries which result in permanent neurological disability

Answer 5

10% (46% due to substandard care)

Question 6

Rate of humeral fractures associated with SD

Answer 6

2-12% in cases where posterior arm delivered

Question 7

Nerve roots involved in Erb’s palsy

Answer 7

C5/C6

Question 8

Proportion of significant SD cases which can be predicted by risk factors

Answer 8

16%

Question 9

Risk of recurrence after previous SD

Answer 9

1-25% (10 x increased risk)

Question 10

Risk of SD in diabetic patients

Answer 10

2-4x increased risk for same birthweight

Question 11

Risk factors for SD

Answer 11

• Previous SD
• Macrosomia
• Diabetes
• IOL
• Augmentation
• Instrumental delivery
• Delay in 1st or 2nd stage
• BMI >30

Question 12

Proportion of cases of SD occurring with EFW <4kg

Answer 12

48%

Question 13

Prevention of SD

Answer 13

• IOL does not prevent SD in non-diabetic mothers with macrosomic baby
• IOL at term may reduce SD risk in diabetic mothers with macrosomic baby
• CS may reduce morbidity in DM >4.5kg or non-DM >5kg

Question 14

Management of SD

Answer 14

• HELP
• STOP PUSHING
• McRoberts
• Suprapubic pressure
• Internal manoeuvres
• All fours
• 3rd line techniques (cleidotomy, symphysiotomy, Zavanelli)

Question 15

Describe McRoberts

Answer 15

Hip flexion and abduction.

Straightens lumbosacral angle, widens AP diameter and rotates pelvis.

Question 16

Success rate of McRoberts

Answer 16

90%

Question 17

Success rate of all fours

Answer 17

83%

Question 18

Internal manoeuvres

Answer 18

Insert whole hand into sacral hollow (episiotomy if required for access). If posterior arm felt flexed then grab wrist and deliver posterior arm by pulling in a straight line. If posterior arm extended behind baby then aim for internal rotation by applying pressure to posterior aspect of posterior shoulder (or anterior aspect of posterior shoulder).