Shoulder dystocia

Question 1

Definition of SD

Answer 1

birth of the shoulders requiring additional manoeuvres after routine axial traction has failed.

impaction of the fetal anterior shoulder on the maternal symphysis pubis or posterior shoulder on the maternal sacral prominence

Question 2

antenatal Risk factors for SD

Answer 2

• LGA baby (macrosomia >4500g)
• Maternal diabetes
• High BMI
• prolonged pregnancy / postdates
• previous shoulder dystocia
• IOL

Question 3

intrapartum risk factors:

Answer 3

• prolonged first stage
• prolonged 2nd stage
• induction of labour
• oxytocin infusion
• assisted delivery of head

Question 4

Maternal complications

Answer 4

• PPH
• birth trauma
• increased risk of 3rd and 4th degree tears
• SI joint dislocation
• symphyseal separation
• nerve damage to lateral femoral
• uterine rupture
• bladder rupture

Question 5

neonatal complications

Answer 5

• brachial plexus injury
• clavicular or humeral fractures
• hypoxic ischaemic encephalopathy
• cerbral palsy
• neonatal death

Question 6

recognition of SD

Answer 6

• slow birth of the head, face and chin
• head tight against perineum / vulva (turtling)
• delay or failure to restitute

Question 7

Initial actions:

Answer 7

• Diagnose with gentle axial traction (fails)
• declare the emergency and press bell
• briefly inform the woman what is happening and to listen carefully to instructions
• 3 ps (position, pressure, PV)

Question 8

POSITIONS

Answer 8

• Mcroberts (knees to nips, feet out, no pillows, bed down)
• all fours (hands and knees)
• running start (one leg up)
• side lying, one leg up (epidural compatible - so is mcroberts)

Question 9

PRESSURE

Answer 9

• stand on side of fetal spine
• cpr hands above symphysis pubis
• continuous rocking motion down and away

Question 10

PV manoeuvres

Answer 10

GAIN CONSENT & preferably wear sterile gloves
enter with hand in posterior aspect
- axillary traction (armpit - down and follow sacral curve)
- remove posterior arm (sweep face and remove to allow space)
- turn shoulder diameter into oblique either clockwise or anti (woodscrew)

Question 11

prepare for:

Answer 11

• pPH
• neonatal rescus

Question 12

post-birth considerations

Answer 12

• thorough perineal and genital tract assessment
• thorough neonatal examination for wellbeing and injuries
• debrief with woman and health practitioners
• documentation
• safety first