Shoulder dystocia

definition
a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed.

pathophysiology
It occurs when the anterior shoulder becomes impacted against the symphysis pubis or the posterior shoulder becomes impacted against the sacral promontory. Anterior impaction tends to be more common, but infrequently, both anterior and posterior impaction can occur.

Risk factors
Antenatal Post-term pregnancy High parity Previous history of shoulder dystocia Previous large babies Maternal obesity (weight > 90kgs at delivery) Maternal age over 35 years Maternal diabetes and gestational diabetes Excessive weight gain in pregnancy Clinically large baby/symphysis-fundal height measurement larger than dates Fetal growth > 90th centile on ultrasound scan (fetal macrosomia) Intrapartum Birthing in a semi-recumbent position on a bed can restrict movement of the sacrum and coccyx (McGeown 2001) Prolonged labour, notably protracted late first stage (usually between 710cm) with a cervix that is loosely applied to the presenting part Oxytocin augmentation Prolonged second stage Mid-pelvic instrumental delivery
http://www.midirs.org/development/studentmidwife.nsf/B2F0D90AEC3F15BF8025764A00462EB9/$File/Shoulder%20Dystocia.pdf

Factors associated with shoulder dystocia

Pre-labour Previous shoulder dystocia Macrosomia >4.5kg Diabetes mellitus Maternal body mass index >30kg/m2 Induction of labour Intrapartum Prolonged first stage of labour Secondary arrest Prolonged second stage of labour Oxytocin augmentation Assisted vaginal deliver
RCOG 2012 http://www.rcog.org.uk/files/rcogcorp/GTG%2042_Shoulder%20dystocia%202nd%20edition%202012.pdf

Maternal complications: Postpartum haemorrhage (approximately twothirds will have a blood loss >1000 ml) (Benedetti & Gabbe 1978) Soft tissue trauma Third or fourth degree perineal tears (extension of episiotomy) Fetal and neonatal complications: Fetal hypoxia or neonatal asphyxia potential for neurological damage Brachial plexus injury Erbs Palsy/Klumpkes paralysis (Tiran 2003) Fractures to the clavicle or humerus Intrapartum fetal death
http://www.midirs.org/development/studentmidwife.nsf/B2F0D90AEC3F15BF8025764A00462EB9/$File/Shoulder%20Dystocia.pdf

 H E L P E R R

Call for help Evaluate for episiotomy Legs (the McRoberts manoeuvre) Suprapubic pressure Enter manoeuvres (internal rotation) Remove the posterior arm Roll the woman/rotate onto all fours

Documentation
Time of birth of the head Direction baby facing Procedures required to birth the shoulders and length of time of each procedure Time of delivery Staff in attendance Condition of baby and resuscitation required Babys weight

The McRoberts' manoeuvre

Suprapubic pressure

Delivery of the posterior arm

Timely management of shoulder dystocia requires prompt recognition. The attendant health carer should routinely observe for:
difficulty with delivery of the face and chin the head remaining tightly applied to the vulva or even retracting (turtle-neck sign) failure of restitution of the fetal head failure of the shoulders to descend.

Management
Rationales Managed systematically (HELPERRD) Call for help, state problem clearly Improved perinatal outcomes Time is essential. Up to five minutes, otherwise high risk of fetal hypoxic ischaemic injury. Additional midwife, obstetrician, neonatal resuscitation team, anaesthetist.

Discourage maternal pushing

McRoberts manoeuvre : the woman lie flat with pillows removed from under her back. Legs hyperflexed. Position the maternal thighs on her abdomen. Apply suprapubic pressure from the side of the fetal back in a downward and lateral direction just above the symphysis pubis, pushing the anterior shoulder towards the fetal chest for around 30 seconds. episiotomy Wood manoeuvre: press on the anterior or posterior aspect of the posterior shoulder.

May exacerbate impaction of the shoulders.

Flexion and abduction of the maternal hips. It straightens the lumbosacral angle, rotates the maternal pelvis towards the mothers head and increases the relative anterior-posterior diameter of the pelvis. It reduces the fetal bisacromial diameter and rotates the anterior fetal shoulder into the wider oblique pelvic diameter. The shoulder is then freed to slip underneath the symphysis pubis with the aid of routine axial traction. Allow the more space to facilitate internal vaginal manoeuvres. Pressure on the posterior shoulder to the chest can reduce the shoulder diameter by adducting the shoulder. It also rotates the shoulder into the wider oblique diameter. Adduct and rotate the anterior shoulder into the oblique diameter Reduce the diameter of the fetal shoulders by the width of the arm. Humeral fractures

Rubin manoeuvre: apply pressure on the anterior shoulder Deliver the posterior arm : the fetal wrist should be grasped and the posterior arm should be gently withdrawn from the vagina in a straight line.

Primary postpartum haemorraghe

Blood loss from the vaginal in excess of 500 ml and occurring within 24 hours of delivery.

Four Ts
Tone atonic uterus Anaemia Multiple pregnancy Polyhydramnios Macrosomia Maternal obesity Grand multiparity APH placenta praevia Fibroids Precipitate/prolonged labour Induced labour/ augmented labour Full bladder Caesarean section Uterine abnormalities Previous PPH Tissue incomplete placental separation, retained products Mismanagement of third stage Trauma lacerations to the genital tract Uterus, vagina, perineum, labia, cervix Operative birth Thrombin blood coagulation disorder Severe preeclampsia Antepartum haemorrhage Amniotic fluid embolus Intrauterine death Sepsis Existing clotting disorders

First-line drug therapy

Syntometrine (oxytocin 5 unit and ergometrine 0.5 mg) IM Syntocinon 5 unit IV Syntocinon 40 unit in 1 L Hartmanns solution at 250 ml/hour IV infusion Ergometrine 0.25 mg IM

Cord prolapse
Descent of the umbilical cord through the cervix alongside or past the presenting part with ruptured membranes.

Risk factors
General Low birth weight < 2.5 kg Prematurity < 37 weeks Polyhydramnios Malpresentation (breech presentation, transverse lie) High presenting part Fetal congenital anomalies Multiparity Second twin Procedure related Artificial rupture membranes External cephalic version Internal podalic version Stabilising induction of labour Applying fetal scalp electrode Rotational instrumental delivery

 Recognise Call for help Relieve cord compression Knee-chest position or Left-lateral with a pillow under left hip Elevate the presenting part Stop oxytocin if is in progress Gently handle and replace the cord back into the vagina Continuous EFM Assessment for delivery