Shoulder Dystocia Flashcards
(32 cards)
What is the incidence of shoulder dystocia?
0.58 - 0.7 %
1/200 ( oxford )
How shoulder dystocia occurs?
When either the anterior or less common the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory
What are the most important maternal complications caused by shoulder dystocia?
1- PPH 11 %
2- 3rd & 4th degree perineal tears 3,8%
Other: 1-bladder rupture/
2- uterine rupture/
3-symphyseal separation/
4- sacroiliac dislocation/
5-lateral fumeral cutaneous neuropathy
What is the most important fetal complication of shoulder dystocia?
Brachial plexus injury BPI 2,3 - 16 %
What is the incidence of brachial plexus injury BPI in UK ? What is the prognosis?
0.43 per 1000 live birth
Most of the cases resolve without permanent disability
10 % resulting permanent neurological dysfunction
What is the percentage of babies with BPI are born after CS?
4 - 12 % of them
It is important legally to determine whether the affected shoulder was anterior or posterior: ( posterior is unlikely to be due to action by doctor)
Can shoulder dystocia be predicted by making risk assessment?
Risk assessment of shoulder dystocia is insufficiently predictive to allow prevention
Predicted only 16 % of shoulder dystocia
What is the relationship between shoulder dystocia and fetal size?
Not good predictor
Majority of infants > 4500 g don’t develop shoulder dystocia
48% of shoulder dystocia occurs with infants < 4000 g
Infants of diabetic women have an increased risk of shoulder dystocia compared with infants of the same weight born to non diabetic women,
How much is the increase?
2 - 4 folds
Is third trimester ultrasound scan a reliable method to predict macrosomia?
Sensitivity 60 % to predict macrosomia
🚩has at least 10 % margin for error for actual birth weight
What are the factors associated with shoulder dystocia pre labour?
1- previous shoulder dystocia
2- macrosomia > 4,5 kg
3- diabetes Mellitus
4- maternal BMI > 30
5- induction of labour
What are the intrapartum factors associated with shoulder dystocia ?
1- prolonged first stage
2- secondary arrest
3- prolonged second stage
4- oxytocin augmentation
5- assisted vaginal delivery
Does early induction of labour prevent shoulder dystocia?
ℹ Only in women with gestational diabetes who have a normally grown fetus after 38 w
⛔ does not prevent shoulder dystocia in non diabetic women with a suspected macrosomic fetus
Should elective CS be recommended for suspected fetal macrosomia to prevent brachial plexus injury BPI ?
Elective CS should be considered:
In pregnancies complicated by preexisting or gestational diabetes regardless of treatment, with an estimated fetal weight > 4500 g
What are the recommendations of ACOG about the delivery of a fetus has EFW over 5 kg ?
Consideration of CS
What is the recurrence rate of shoulder dystocia?
1 - 25 %
The rate of shoulder dystocia in women who had Previous shoulder dystocia 10 times higher general population
Is previous shoulder dystocia an indication for CS ?
It is not recommended but risk factors should be considered
How is shoulder dystocia diagnosed? ( signs of shoulder dystocia)?
1- difficulty with delivery of the face and chin
2- the remaining tightly applied to the valva or retracted
3- failure of restitution of the head
4- failure of the shoulders to descend
⛔ routine traction in an axial direction can be used to diagnose shoulder dystocia
Does prophylactic McRobert position before the delivery of the fetal head prevents shoulder dystocia?
It is not recommended
Dosen’t prevent shoulder dystocia
How should shoulder dystocia be managed?
1- CALL FOR HELP: additional midwife/ experience obstetrician/ neonatal team / anaesthetist
2- Don’t do downward traction
3- DISCOURAGE pushing
4- fundal pressure should NOT be used
5- Mcroberts maneuver
6- suprapubic pressure
7- consider episiotomy
8- do either : * deliver posterior arm
* internal rotational manoeuvres
8- repeat all above
9- consider: cleidotomy / Zavanelli/ or symphysiotomy
Why is it important to manage shoulder dystocia as efficient as possible?
47 % of the babies that died did so within 5 minutes of the head being delivered ( with pathological CTG)
⚠️ very low rate of hypoxia if the head to body time was less than 5 minutes
What is the success rate for Mcroberts maneuver?
90 %
What is the role of episiotomy in the management of shoulder dystocia?
Doesn’t decrease the risk of BPI with shoulder dystocia
ONLY be considered if internal vaginal access is needed for the delivery of posterior arm or internal rotation of the shoulders
What measures should be undertaken if Mcroberts maneuver & suprapubic pressure fail ?
Internal manoeuvr OR all fours position
Should be used
