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Chapter 6 Shoulder Dystocia

Jason Marcus Definition A delivery that needs additional obstetric manoeuvres to deliver the shoulders, after gentle downward traction on the fetal head has failed, because the fetal anterior shoulder is impacted against the maternal pubic symphysis. Risk Factors

Increased maternal BMI

Diabetes

Assisted delivery

Previous shoulder dystocia

Post-dates pregnancy

Fetal macrosomia

Risk factors have poor predictive value, but the more risk factors there are, the greater the chance of shoulder dystocia. Diagnosis

Failure of the shoulders to deliver with the standard amount of maternal effort and

moderate traction on the fetal head.

Retraction of the fetal head against the perineum, called the turtle sign. The earlier the

diagnosis is made the better the chances of a positive outcome for mother and baby.

Management It is important to remain calm and to act quickly. The HEELPERR mnemonic has been devised as a clinical tool to provide a structured framework in managing shoulder dystocia. It does not serve as an algorithm but as an aid to memory about what to do. The sequence of the manoeuvres has not yet been systematically reviewed. The baby needs to be delivered within 5 minutes.

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H Call for Help Be sure to state that youre dealing with a dystocia and not just saying you need help. It would be beneficial to also call for someone who is competent in neonatal resuscitation.

E Patients buttocks to the Edge of the bed E Evaluate for Episiotomy To make space when performing the entry manoeuvres but it does not reduce the dystocia L Lift the Legs (McRoberts manoeuvre) Flex and abduct maternal legs so that the thighs rest on the maternal abdomen. P SupraPubic pressure

Pressure is applied over the fetal anterior shoulder by an assistant while maintaining downward traction on the fetal head. If possible, ask the assistant to apply the pressure in the direction that the baby is facing so as to push the impacted shoulder forward

E Entry manoeuvres Attempt to rotate the anterior shoulder forward into the oblique diameter and under the pubic symphysis. If this does not help, attempt rotation of the shoulders by applying pressure posteriorly on the anterior shoulder and anteriorly on the posterior shoulder. If unsuccessful attempt rotation in the opposite direction.

R Remove the posterior arm This may help in decreasing the bisacromial diameter. Flex the fetal elbow and deliver the arm by sweeping the arm over the anterior fetal chest wall. Be mindful of potentially causing a fractured humerus.

R Roll the patient Roll the patient onto all-fours which may help dislodge the impaction by means of gravity

Radical manoeuvres may need to be considered if the preceding measures fail. Seek expert, experienced advice. The importance of documenting the sequence of events is extremely important, along with effective communication with the parents after what is a very traumatic event for all. It remains paramount to be extremely vigilant in all births and to be familiar with the various manoeuvres so that the management of such an unpredictable emergency can ensure a positive outcome for mother and baby.