14 March - In-Depth Notes on Shoulder Dystocia

• Shoulder Dystocia: A complication during childbirth where the baby's shoulder gets stuck after the head is delivered.

• Occurs when the width of the baby's shoulders exceeds the diameter of the pelvic inlet.

• Typically, the anterior shoulder becomes stuck against the pubic symphysis.

• Affects approximately 0.5% to 1% of births.

• Analogy: Similar to a truck getting stuck under a bridge due to its width.

• The anterior shoulder fails to pass through the pelvic inlet, hindering progress during contractions.

• Risk Factors:

• Previous history of shoulder dystocia increases risk.

• Growth charts of previous pregnancies should be reviewed.

• Large for gestational age infants are at higher risk, but any size can be affected.

• Maternal factors include obesity and diabetes, which may cause larger babies or affect the descent of the baby.

• Prolonged first and/or second stage of labor can contribute to dystocia.

• Definitions of Stages:

• First Stage: Dilatation of the cervix, should progress by at least 2 cm in 4 hours.

• Second Stage: Associated with pushing, should be limited (2 hours for first-time mothers, shorter for subsequent babies).

• Signs of Shoulder Dystocia:

• Turtling sign: Baby's head retreats back into the vagina after initial delivery.

• No restitution of the baby's neck position.

• Complications of Shoulder Dystocia:

• Brachial plexus injury or palsy from excessive pulling on the head.

• Clavicle fractures due to traumatic delivery efforts.

• Potential for neonatal hypoxia and encephalopathy if shoulder dystocia lasts too long.

• Increased risk of uterine atony leading to excessive blood loss.

• Management Options:

• McRoberts Maneuver: The mother flexes her legs towards her chest to widen the pelvis.

  • Increases the pelvic outlet size, which may help release the shoulder.

• Suprapubic Pressure: Applying pressure just above the pubic bone to shift the shoulder.

  • Similar hand placement to CPR technique.

• Axillary Traction: Grasping the baby's shoulder and applying gentle downward traction in line with the spine.

• Internal Maneuvers:

• Internal access can be granted through the posterior vaginal wall to reach the posterior shoulder.

• Techniques include rotating the shoulders into an oblique position to facilitate delivery.

• Final Measures:

• If all else fails, consider an episiotomy or in some rare cases, delivering the baby via cesarean after repositioning the head.

• Care for the mother includes monitoring for injuries to the perineum and uterus due to the maneuvers.

• Anticipate the need for neonatal resuscitation, as the baby may experience distress due to the complications of shoulder dystocia.

• Documentation:

• Critical to document the time of events, efforts made during maneuvers, outcomes, and detailed information on any injuries for both mother and baby.

• Have a thorough debriefing with the care team after an incident to review what happened and improve future care strategies.

• Training and Preparedness: Importance of training, familiarity with maneuvers, and preparation for unexpected complications during labor.

Shoulder Dystocia Notes

Overview

• Definition: Shoulder dystocia is a complication during childbirth where the baby's shoulder gets stuck after the head is delivered. It occurs unpredictably when the width of the baby's shoulders exceeds the diameter of the pelvic inlet, typically when the anterior shoulder becomes stuck against the pubic symphysis.

Risk Factors

• Previous history of shoulder dystocia

• Large for gestational age infants

• Maternal factors (obesity, diabetes)

• Prolonged labor stages

Signs of Shoulder Dystocia

• Turtling sign: Baby's head retreats into the vagina after initial delivery.

• No restitution of the baby's neck position.

Complications

• Brachial plexus injury or palsy

• Clavicle fractures

• Neonatal hypoxia and encephalopathy

• Increased risk of uterine atony and excessive blood loss

Management Strategies

• HELPERR Mnemonic:

• Help: Call for help immediately.

• Evaluate: Assess for signs of fetal distress.

• Leg Position: McRoberts maneuver to flex legs towards chest.

• Pressure: Suprapubic pressure on the pubic bone.

• Entry: Internal maneuvers if previous steps fail.

• Release: Axillary traction or alternative methods.

• Remember: Document and prepare for potential complications.

• McRoberts Maneuver: Flexing the mother's legs to widen the pelvis.

• Suprapubic Pressure: Applying pressure just above the pubic bone.

• Axillary Traction: Grasping the baby's shoulder and applying downward traction in line with the spine.

• Rubin Maneuver: Rotate the shoulders into an oblique position to facilitate delivery.

• Wood Screw Maneuver: Internal rotation technique involving gentle rotational force on the shoulder.

• Removal of Posterior Arm: Step-by-step procedure (refer back to lecture slides):

  1. Position the mother appropriately.

  2. Insert hand to grasp the posterior arm and gently pull it across the baby.

  3. Ensure proper alignment to facilitate release of the shoulder.

Importance of All Fours Position

• Being in an all-fours position may help relieve pressure and allow better fetal alignment, facilitating shoulder release during dystocia.

Episiotomy Guidelines

• Indicate an episiotomy when:

• Prolonged shoulder dystocia

• Fetal distress is evident.

• Consider how and when to perform based on clinical judgment and situation.

Last Resort Maneuvers

• Consider performing an episiotomy, or in some cases, delivering the baby via cesarean after repositioning the head if all other methods fail.

Post-Birth Care

• Monitor the mother for injuries and potential complications.

• Anticipate the need for neonatal resuscitation as complications could arise during shoulder dystocia.