Shoulder Dystocia

• Shoulder dystocia vaginal cephalic birth that requires additinal obstetric manouevres to assist the birth of the infant after gentle traction has failed.

• It occurs when the anterior shoulder impacts the symphysis pubis, or less commonly the posterior shoulder on the sacral promontory

• Can cause serious long term morbidity for both mother and baby and is largely unpredictable. (Walsh et al, 2014)

• Wide variation in reported incidence of shoulder dystocia, and is a commonly litigated complication of childbirth resulting in massive economic loss of £100million in legal costs, and significant distress for parents and families (NHS litigation authority, 2012)

Majority of cases occur in women with no risk factors. Shoulder dystocia is unpredictable and therefore unpreventable therefore staff should be alert at any vaginal birth. There are a number of risk factors however these are poorly predictive even in combination. 

Antenatal

• Prev SD
• Macrosomia (although over 50% of SD incidences for babies <4000g) (Rouse et al, 1999)(RCOG, 2012)
• Gestational Age (due to increasing fetal size) (Chauhan et al, 2014)
• Maternal Diabetes Mellitus 
• Maternal obesity  

Labour

• Prolonged 1^st stage or  2^nd stage 
• Augmentation 
• Instrumental vaginal birth (Dall'Asta, 2016)

• Communication can be impaired under stress. (PROMPT, 2017) advises the SBAR format is succinct and effective, especially in emergencies when prompt decision making and action is required (Siassokos et al, 2010). 
• The message should be 
• formulated
• addressed to specific individuals
• delivered
• acknowledged
• acted upon 

Communication should utilise non-verbal communication, accurate terminology and respect, being clear concise and calm. 

Women and birth partners should also be communicated with. If possible, a staff member should be allocated to convey messages to them; the cause, the condition of the baby, and immediate and ultimate aims of treatment. (Bristowe et al, 2012). 

• Recognise Shoulder Dystocia difficulty of birth of face, chin, tight application, chin retraction, depressing perineum "turtle necking" anterior shoulder failing to release with maternal effort and or routine axial traction. 
• Call for help - midwife coordinator, experienced obstetrician, maternity team assistance, neonatal team, consultant obstetrician and anaesthatist 
• state "this is shoulder dystocia." time to be marked down or clock started
• Discourage pushing, lie flat and move buttocks to edge of mattress (if on bed)
• McRoberts Manouevre: thighs to abdomen (consider all fours McRoberts if lone birth attendant (Bruner et al,1999.) Routine axial traction
• Suprapubic pressure with routine axial traction
• Only consder episiotomy if unable to gain access of whole hand in sacral hollow 
• Manouevres dependant on clinical circumstance; deliver posterior arm or internal rotational manouevres each with routine axial traction
• If failure to release  
• All fours (if appropriate) or repeat above again
• Consider cleidotomy, Zavanelli manoevre or symphysiotomy 
• Baby to be referred for consltant neonatal review if any concerns 

Need for review by consultant midwife/ neonatologist after birth and consultant neonatal review if concerns 

• Resuscitation if necessary
• APGARs
• Cord gases 
• If wel; feeding support and skin to skin etc
• Risk of stillbirth
• Hypoxia 
• Brachial Plexus Injury
• Humeral and clavicular fracture 

All procedures involved would maintain asespsis in line with infection control and Aseptic Non Touch Technique to prevent infection and contamination. 

This would include appropriate PPE, including sterile gloves and thorough hand hygiene. 

(WHO, 2009) (Sax et al, 2007)

Maternal

• Increased risk of PPH - recommend active 3rd stage syntometrine/ syntocinon
•  3 and 4^th degree tears/ episiotomy
• Uterine rupture 
• Psychological trauma 

Neonatal

• Neonatal outcomes include risk of brachial plexus injury
• permanent nerve damage
• Hypoxic ischaemic encephalopathy [HIE]
• death  (Chauhan et al, 2014)

(Mackenzie et al, 2007)

Documentation

of difficult and potentially traumatic birth essential. It should include a clear explanation of manouevres used, such as they are reproducable by another. Pro formas can be used. This must include: 

time of birth of head, manouevres performed, timing and sequence, traction applied, time of birth of body, staff in attendance and time they arrived, condition of baby, umbilical cord blood acid-base measurements (cord pH or lactate), direction baby facing at birth i.e which shoulder was impacted at time of dystocia - left or right. 

Debriefing

Frightening and potenitally traumatic experience. Parents should be informed about what is happening and what is being done to help, and give clear instructions during emergency. contemperaneous communication if possible increases patients feeling of safety. (Sissakos et al, 2011). 

Communication and explanation essential - Birth afterthoughts and datix 

McRoberts

• Effective intervention; reported success rates between 90% and 50% (Hoffman et al, 2011). 
• Low rate of complication, non-invasive 
• Legs are hyperflexed against abdomen in order to lift buttocks off of bed, rotating the pelvis. (Lok et al, 2016)
• Increases relative aneteroposterior diameter of pelvic inlet 
• Prophylactic Mcroberts is ineffective and not recommended (RCOG, 2012)

Routine Axial Traction

Same degree as traction as normal birth, in an axial direction. SD is a bony problem, not an issue of tissue so manouvres are required. 

Suprapubic pressure

• Reduces fetal diameter bisacromially and rotating anterior shoulders into wider oblique diameter of pelvis, freeing anterior shoulder. 
• Should be in downward and lateral direction, neither rocking or continuous pressure more effective than the other. (Hill et al, 2020) 

Shoulder dystocia is an unpredictable, acutely life-threatening obstetric emergency, with significant risk of harm to the infant if managed inappropriately. 

Effective and sustainable multi- professional training is crucial in reducing these risks and improving maternity care and safety. 

The PROMPT programme has resulted in significant improvements in reducing preventable harm

• permanent neonatal brachial plexus injury
• 50% reduction in hypoxic brain injury [HIE] 
• 34% reduction in maternal deaths 
• 91% reduction in litigation costs (North Bristol Trust)

 (NHSLA 2012)

Increased maternal and infant morbidity is associated with shoulder dystocia as previously discussed.

This could be due in part to environmental factors such as more sedentary lifestyles, higher caloric intakes and increased stress leading to increased rates of Gestational diabetes mellitus (Giannibulo, 2019)

The presence of GDM has important implications for both the baby and the mother. As regard baby complications, GDM is associated with a significantly increased risk of macrosomia, shoulder dystocia, birth injuries as well as neonatal hypo glycemia and hyperbilirubinemia, genetic risk for the development of obesity, diabetes and/or metabolic syndrome in childhood. As regard mother complications, GDM is a strong risk factor for the development of permanent diabetes later in life (40% in 10 subsequent years) and GDM in successive pregnancies (35%), stress urinary incontinence and mixed urinary incontinence, doubled risk for overactive bladder during premenopausal period, cardiovascular morbidity.

(Giannibulo, 2019)