Shoulder Dystocia

Question 1

You are trying to deliver the baby and although the baby’s head has been delivered, you are having difficulty trying to get the shoulders out. What do you do?

Answer 1

Impression
After delivery of the head but difficulty with shoulder, I am concerned about a shoulder dystocia. This is an obstetric emergency and I am aiming to manage this emergently to ensure successful and safe delivery of the baby as soon as possible.

Question 2

Shoulder dystocia - Clinical predictors/risk factors

Answer 2

Clinical predictors/risk factors

• turtle-neck sign: retraction after delivery of the head
• failed restitution
• arrested active phase of labour

Risk factors

• Macrosomia, male, post-term
• AMA, GDM, obesity, Hx of shoulder dystocia, induction of labour, pelvic abnormalities

Question 3

Shoulder dystocia - important complications

Answer 3

Important complications
Maternal:
- perineal tears
- PPH

Fetal

• bradycardia
• HIE due
• brachial plexus injury (Erb’s palsy)
• clavicle/humeral fractures, other traumatic injury

Question 4

Shoulder dystocia - Management

Answer 4

Management
HELPERR protocol
H - call for Help
E - Episiotomy (Evaluate the need for)
L - Legs (McRobert’s manoeuvre; legs to nips)
P - Pressure on suprapubic area
E - Enter (internal manoeuvres: Rubin I, Rubin II
R - removal of posterior arm
R - roll woman onto all 4’s and try same routing

Last resort measures

• Zavanelli - push babies head back into uterus and perform an emergency caesarean
• Cleidotomy: break the calvicle to assist delivery of anterior shoulder
• Symphisiotomy: dividing the anterior fibres of the symphysial ligament

Ongoing:

• arrange for appropriate post-natal care of mum and baby
• documentation of all steps taken
• neonatologist referral if any indication of brachial plexus injury