Week 7

Question 1

What happens in shoulder dystocia?

Answer 1

The head delivers but the anterior shoulder fails to follow

Question 2

What causes shoulder dystocia?

Answer 2

 Failure of shoulders to rotate into anterior-posterior diameter following delivery of head (failure of full restitution/external rotation)

 Anterior shoulder caught under symphysis pubis

 Often due to large baby
–But 50% associated with normal size baby cause is unknown

Question 3

what are the risk factors for shoulder dystocia?

Answer 3

 Mother over 35

 Maternal weight > 90kg

 Large baby (Macrosomia) –most common
– Poorly controlled T1DM/gestational diabetes

 High maternal birth weight

 Previous shoulder dystocia or instrumental delivery (ie forceps)

 Platypelloid pelvis-
– anteriorposterior diameter reduced

 Unknown

Question 4

What are some complications of shoulder dystocia?

Answer 4

 Increased perineal trauma

 Post partum haemorrhage (PPH)

 Psychological trauma/post natal depression

 Trauma/injury to foetus: brachial plexus trauma, fractured clavicle or humerus and hypoxic brain injury

 If the shoulder dystocia last >5 minutes there is an increased chance of foetal death and brain damage
28th

Question 5

What do you need to look for to recognise shoulder dystocia?

Answer 5

 Failure of head to advance and – the baby appears to bury its chin in perineum

 As the anterior shoulder is wedged
– It does not enter the pelvis
– Failure of restitution of head

 Turtle sign –head retracts (bobbing of head)

 About 5-7 minutes to deliver the rest of the foetusafter the delivery of the head

Question 6

What are some warning signs of shoulder dystocia?

Answer 6

 Warning signs
–Often long first & second stage
– Pushing prolonged BUT not always
– Difficulty in delivering the face & chin

Question 7

What is the McRoberts manoeuvre?

Answer 7

 Initial management for Shoudler Dystocia

 Effective 70-90% of the time

 Lie woman on back
–? Pillow under buttocks

 On edge of bed

 knees drawn up to chest

 Deliver foetus As normal

Question 8

What physiological changes does the McRoberts Manoeuvre achieve?

Answer 8

 Elevates anterior shoulder & rotates the symphysis pubis

 Pushes posterior shoulder over sacrum

Question 9

What is the Rubens 1 technique?

Answer 9

Suprapubic pressure

 Have 3rd party pushing down on anterior shoulder for 30 secs.

 Have 3rd party “rock” on anterior shoulder for further 30 secs.

Question 10

What do you do once the head is delivered with shoulder dystocia?

Answer 10

Record time right away cos you got 5-7 minutes to deliver the baby

Question 11

What is the Gaskin Manoeuvre?

Answer 11

 Up to 83% successful
 Roll woman over on to “all fours”
 exploits the effects of gravity
 Opens diameters of the pelvis
 Increased space in hollow of sacrum
 Facilitates delivery of posterior shoulder & arm.

Question 12

What is the Rubins 2 manoeuvre?

Answer 12

– Rotate anterior shoulder in forward direction bu sticking your hand/finger in there

Question 13

What is the wood screw manoeuvre?

Answer 13

– Rotate posterior shoulder simultaneously in same direction

Question 14

What order do you do the manoeuvres in for shouldr dystocia??

Answer 14

• McRoberts
• Rubens 1
• Gaskin
• Rubins 2 with Wood screw
• Reverse wood screw

Question 15

What is the process of delivering the posterior arm?

Answer 15

 A hand is inserted into the vagina along the sacral curve to locate the posterior arm or hand

 Foetal arm is taken across its chest and delivered

 Anterior shoulder should be easy to deliver

Question 16

How common are breech births?

Answer 16

• About 25% of foetus will be in breech at some stage throughout the pregnancy
• 20% chance if delivered at 28/40
• 3-4% remain in breech patterns at term

Question 17

What is a breech birth?

Answer 17

Baby’s lie is longitudinal but the foetal buttocks lie in the lower segment of the uterus.

Question 18

What are the causes & risk factors (mum) of breech births?

Answer 18

– Previous breech birth
– Uterine malformations e.g. bicornuate uterus
– Prematurity
– Multiple pregnancy
– Low lying placenta/Placenta praevia
– Oligohydramnios

 Excessive intrauterine space
– Grand multiparity-lax uterus
– Polyhydramnios

Question 19

What are the causes & risk factors (baby) of breech births?

Answer 19

– Foetal abnormalities
• Anencephalic

– Foetal death in utero
– Decreased foetal activity
– Impaired foetal growth
– Short umbilical cord
– Sometimes for no particular reason!

Question 20

What are some obstetric complications of breech births?

Answer 20

– Cord Prolapse
– Prematurity/PROM
– Higher chance of foetal disability
– Higher incidence of poor perinatal outcomes
– Foetal hypoxia
– Entrapment of the head
– Head and neck trauma
– Placental separation (premature)

Question 21

What are the types of breech positions?

Answer 21

• complete
• frank
• footling
• knee

Question 22

what is a complete breech position

Answer 22

The thighs & knees are flexed and the feet close to buttocks.
– common in mulitgravidas

Question 23

What is Frank breech position?

Answer 23

 Legs flexed at hip with straight knees. The legs lie alongside the trunk with feet near the head.

Common in primigravidas

45-50% of breeches. Most common

Question 24

What is Footling breech position?

Answer 24

 One or both knees/hip are extended and the feet are the presenting part

 Common in preterm

Question 25

What is KNEE breech position?

Answer 25

One or both hips are extended and the knees are flexed. The knees present below the buttocks Less than 5% of breech presentations

Question 26

How can you diagnose breech?

Answer 26

```  History  Ultrasound  Presenting part:-Foetal bottom-Feet  Swollen/bruised genitalia  Meconium (black toothpaste colour and consistency) ```

Question 27

What is the golden rule of breech?

Answer 27

– “Hands off the breech” • Unless necessary to interfere • Minimal handling

Question 28

How do you delivery a breech birth?

Answer 28

 Hands off the breech as it delivers - Legs and feet should delivery spontaneously - If not: use 1 finger and place behind the knee and deliver by gentle flexion and abduction of the hip –then do the other leg  Ensure infant’s back is uppermost – If not uppermost: hold the bony part of the pelvis and rotate between contractions until back is uppermost • Avoids the abdominal organs  Keep foetus’ body covered and warm – use a clean warm towel  Ask mother to push out infants shoulders – Most babies will be able to – If unable perform “Lovesetsmanoeuvre”

Question 29

What ius Lovesets manoeuvre?

Answer 29

Grasp foetus by the pelvis & pull gently while rotating 90º feel for the anterior shoulder  Flex arm down & out  Reverse rotation  Deliver other shoulder

Question 30

What do you need to do when delivery the head in Lovesets manoeuvre?

Answer 30

 Allow 1-2mins. – For head to enter pelvis  Allow infant to hang for 1-2min. –Gradually hairline will appear  Do not attempt to hurry delivery of head – avoids sudden change in intracranial pressure

Question 31

What is the modified Mauiceau-Smellie-Veit Manoeuvre?

Answer 31

After nape of neck appears:  Lay Foetus astride your right arm – with palm supporting chest  Two fingers are on babes cheek bones – Flexing foetus’ head down  Two fingers of the left hand – hooked over the shoulders with the middle finger pushing the occiput to aid flexion

Question 32

What is the Burns-Marshall manoeuvre?

Answer 32

 Foetus is allowed to hang by own weight – encourages descent & flexion  Once nape of neck and hairline seen, – the baby’s ankles are grasped & – with slight traction – the trunk is carried in a wide arc over the mother’s abdomen  Other hand supports perineum  Prevents sudden delivery of the head  Once the mouth is clear the baby can breathe &  Take time to complete the delivery of the cranium