Shoulder dystocia

    Cards (33)

    • Shoulder Dystocia
      Vaginal cephalic birth that requires additional obstetric manoeuvres to assist the birth of the infant after gentle traction has failed
    • Anterior shoulder impacts behind symphysis pubis OR Posterior shoulder impacts on sacral promontory
    • There is a wide variation in the reported incidence of shoulder dystocia
    • Studies published between 1985 and 2016 have reported incidences between 0.1% to 3.0%
    • In England, between 1st April 2000 and 31st March 2010, the NHS Litigation Authority paid over £103 million in legal compensation for preventable harm associated with shoulder dystocia (250 claims)
    • Risk Factors
      • Previous Shoulder Dystocia
      • Prolonged First stage
      • Macrosomia >4.5kg
      • Prolonged Second Stage
      • Gestational Age
      • Oxytocin Augmentation
      • Diabetes Mellitus
      • Assisted Vaginal Delivery (Forceps or Vaccuum)
      • Maternal BMI >30
      • In many cases no risk factors are present
    • Recognition
      1. When head is born, it remains tightly applied to vulva
      2. Slow/difficult delivery of head and face
      3. 'Turtle-neck' - chin retracts and depresses perineum
      4. Failure of restitution of fetal head
      5. Failure of the shoulders to descend
      6. Routine axial traction can be used to diagnose SD, but any other traction should be avoided
    • McRoberts' Manoeuvre
      1. Ask mother to stop pushing
      2. Call for Help
      3. Lie the mother flat
      4. With 1 assistant either side, hyperflex her legs against her abdomen
      5. Apply routine axial traction
    • Rationale for McRoberts' Manoeuvre
      • Increases relative anteroposterior diameter of pelvis
      • Rotation of symphysis pubis
      • Straightening of sacrum relative to lumbar spine
    • Historically statistics suggest 90% success rate for McRoberts' Manoeuvre, but recent studies as low as 25%
    • Suprapubic Pressure
      1. Pressure applied to the fetal back just above the maternal symphysis pubis in a downward and lateral direction
      2. Routine axial traction
      3. Aim to resolve SD by reducing fetal bisacromial diameter and rotating the anterior shoulder into the wider oblique diameter of the pelvis
      • No evidence that rocking or continuous pressure is more effective
      • No evidence need 30 seconds to be effective
    • Delivery of the Posterior Arm
      1. Fetal wrist should be grasped and the posterior arm should be gently withdrawn from the vagina in a straight line
      2. If posterior arm straight and against body, applying pressure with a thumb to the antecubital fossa may flex the arm
    • Delivery of the posterior arm is associated with humeral fractures with a reported incidence between 2% and 12%
    • Internal Rotational Manoeuvres
      1. Press on the anterior or posterior aspect of the posterior shoulder
      2. Reducing fetal bisacromial diameter (pressure on posterior aspect)
      3. Rotating the anterior shoulder into the wider oblique diameter of the pelvis
      4. Use the maternal pelvic anatomy to aid descent of the shoulders
      5. Can be combined with suprapubic pressure
    • Potential Complications

      • Maternal: PPH, 3rd or 4th degree tears, Uterine Rupture, Psychological Distress
      • Neonatal: Stillbirth, Hypoxia/HIE, Fractures (humeral or clavicle), Brachial Plexus Injury
    • Brachial Plexus Injury
      • Erb's Palsy: most common injury. Upper arm is flaccid and the lower arm extended and rotated towards the body with the hand held in a classic 'waiters tip' posture. Up to 90% of Erb's palsies recover by 12 months
      • Klumpke's palsy: less common. Hand is limp, with no movement of the fingers. Recovery rate is lower (40% at 12 months)
      • Total Brachial Plexus Injury: Total sensory and motor deficit of entire arm, making it completely paralysed with no sensation. Full functional recovery without surgery rare
      • Horner Syndrome: caused by sympathetic nerve injury resulting in contraction of the pupil and ptosis of the eyelid on the affected side
    • Shoulder Dystocia
      Vaginal cephalic birth that requires additional obstetric manoeuvres to assist the birth of the infant after gentle traction has failed
    • Anterior shoulder impacts behind symphysis pubis OR Posterior shoulder impacts on sacral promontory
    • There is a wide variation in the reported incidence of shoulder dystocia
    • Studies published between 1985 and 2016 have reported incidences between 0.1% to 3.0%
    • In England, between 1st April 2000 and 31st March 2010, the NHS Litigation Authority paid over £103 million in legal compensation for preventable harm associated with shoulder dystocia (250 claims)
    • Risk Factors
      • Previous Shoulder Dystocia
      • Prolonged First stage
      • Macrosomia >4.5kg
      • Prolonged Second Stage
      • Gestational Age
      • Oxytocin Augmentation
      • Diabetes Mellitus
      • Assisted Vaginal Delivery (Forceps or Vaccuum)
      • Maternal BMI >30
      • In many cases no risk factors are present
    • Recognition
      1. When head is born, it remains tightly applied to vulva
      2. Slow/difficult delivery of head and face
      3. 'Turtle-neck' - chin retracts and depresses perineum
      4. Failure of restitution of fetal head
      5. Failure of the shoulders to descend
      6. Routine axial traction can be used to diagnose SD, but any other traction should be avoided
    • McRoberts' Manoeuvre
      1. Ask mother to stop pushing
      2. Call for Help
      3. Lie the mother flat
      4. With 1 assistant either side, hyperflex her legs against her abdomen
      5. Apply routine axial traction
    • Suprapubic Pressure
      Pressure applied to the fetal back just above the maternal symphysis pubis in a downward and lateral direction
    • Suprapubic Pressure
      • Aim to resolve SD by reducing fetal bisacromial diameter and rotating the anterior shoulder into the wider oblique diameter of the pelvis
      • No evidence that rocking or continuous pressure more effectiveness
      • No evidence need 30 seconds to be effective
    • Delivery of Posterior Arm
      1. Fetal wrist should be grasped and the posterior arm should be gently withdrawn from the vagina in a straight line
      2. If posterior arm straight and against body, applying pressure with a thumb to the antecubital fossa may flex the arm
    • Delivery of Posterior Arm
      Reduces the diameter of the fetal shoulders
    • Delivery of the posterior arm is associated with humeral fractures with a reported incidence between 2% and 12%
    • Internal Rotational Manoeuvres
      1. Press on the anterior or posterior aspect of the posterior shoulder
      2. Reducing fetal bisacromial diameter (pressure on posterior aspect)
      3. Rotating the anterior shoulder into the wider oblique diameter of the pelvis
      4. Use the maternal pelvic anatomy to aid descent of the shoulders
      5. Can be combined with suprapubic pressure
    • Potential Complications
      • PPH
      • Stillbirth
      • 3rd or 4th degree tears
      • Hypoxia/HIE
      • Uterine Rupture
      • Fractures (humeral or clavicle)
      • Psychological Distress
      • Brachial Plexus Injury
    • Brachial Plexus Injury
      • Erb's Palsy: most common injury. Upper arm is flaccid and the lower arm extended and rotated towards the body with the hand held in a classic 'waiters tip' posture. Up to 90% of Erb's palsies recover by 12 months
      • Klumpke's palsy: less common. Hand is limp, with no movement of the fingers. Recovery rate is lower (40% at 12 months)
      • Total Brachial Plexus Injury: Total sensory and motor deficit of entire arm, making it completely paralysed with no sensation. Full functional recovery without surgery rare
      • Horner Syndrome: caused by sympathetic nerve injury resulting in contraction of the pupil and ptosis of the eyelid on the affected side
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