Shoulder Dystocia

Flowchart nodes

• Shoulder Dystocia 

• 'A vaginal cephalic delivery requiring additional obstetric manoeuvres to deliver the foetus after head is delivered and gentle traction has failed' (Green Top Guidelines, 2012)

• An objective diagnosis: 'a prolongation of head to body delivery time of more than 60 seconds'

• Occurs when either anterior or posterior (less common) fetal shoulder impacts on maternal symphysis or sacral promontory, respectively  

• GTG (2012) report incidences between 0.58% - 0.70% e.g. 6/7 in 1000

• SD causes significant perinatal morbidity and mortality even when managed appropriately. Maternal morbidity increases e.g. PPH (11%) plus 3rd/4th degree perineal tears (3.8%) despite the number or type of manoeuvres required to effect delivery

• Brachial Plexus Injury (BPI) is the most important fetal complication of SD, complicating 2.3% to 16% of such deliveries 

• Larger infants are more likely to suffer a permanent BPI after SD

• Risk factors - Diabetic mother = Macrosomic baby- IOL = Why hasn't labour started naturally? Artificial Contractions/ Long labour- Previous SD- High BMI = Macrocosmic baby + reduced mobility   - Assisted Delivery = Baby was struggling to descend anyway - Augmentation = Query slow progress?- Prolonged 1st stage = fatigue- Secondary arrest -48% of SD occur in normal birth weight foetus and is unanticipated

• Signs of Shoulder Dystocia- Turtle necking: head tightly applied to vuvlva or retracting- No restitution of fetal head- Failure of shoulders to descend- Difficulty with delivery of face and chin + risk of hypoxia as PH drops 0.04 per minute

• M = Core midwife, 2nd midwife, inform motherO = Senior Obstetrician, Reg, SHOA = Anaesthetist (more risk of PPH)N = Neonatal team Reg + SHO, NICU, MSWS = Scribe

• H = help from MOANs team 

• E = End pushing 

• L = legs into McRoberts. Out of lithotomy into McRoberts Flatten bed with end off to aid lateral flex on baby's spineTo widen AP diameterAids flattening of sacral promotary 

• P = Supra-pubic pressurePressure CRP grip 45 degrees at posterior aspect of anterior shoulder to rotate fetal shoulder TWO midwives must be there - DO NOT carry out solo

• E = Episotomy evaluation 

• R= Rotate baby aroundRemove posterior arm before hand into superman position as arm out Rotate baby around to posterior aspect on anterior shoulderMore space to physically enter hand to manually move/ dislodge shoulder e.g. Pringle Grip 

• R = Roll lady over onto all foursThis opens up pelvis 

• McRoberts resolves 90% of SD - (RCOG 2012)

• Supra-pubic pressure resolves 95% of SD - (RCOG 2012)

• When 'HELPERR' fails = Obstetrician - Fracture clavicle: reduce biceromal diameter - Symphisiotomy: Cutting symphis pubis - Zabenella manoeuvre: rebirth baby via mechanics of labour  

• Long term outcomes- PPH = Anaemia - Postnatal depression/ PTSDTrauma for father- Bereavement of birth plan Long term outcomes for Neonate- Jaundice of neonate- Hypoxia - Hypoglycaemia- Hypothermia- Neurological disorder- Delay going home- NICU baby - feeding issues- Bonding & Attachment issues 

• TIME CRITICAL OBSTETRIC EMERGENCY (RCOG, 2012) 

• When baby born- cord bloods from baby - hand to paed reg for resus 

• Documentation: Documentation from the scribe is taken, rationale and other missing details are added. This is kept in the mothers and babies notes for 25 years in accordance with NMC Code 2015Consent/ Choice: Consent is implied and care is provided in the women's best interests as no time for written consent (RCOG 2015)

• NMC (2008) The codeNMC (2009) Guidance for Recordkeeping Prompt (2012) Prompt Course ManualRCOG (2012) Shoulder Dystocia (Greentop guideline No.42)

• HELPERR (Jenkins, 2014)