Shoulder dystocia

1. TITLE:  

Shoulder dystocia

2.0 PURPOSE: 

To provide a standardized, safely procedures for delivery of the infant before asphyxia and cortical injury occur from umbilical cord compression and impeded inspiration, and without causing peripheral neurological injury or other trauma. 

3. CONDITION/APPLICABILITY:

All Ob./GYN doctors and mid wife nurses in labor room 

4. DEFINITIONS: 

   1. Shoulder dystocia: is defined as prolongation of head-to-body delivery time of more than 60 seconds that requires additional obstetric maneuvers to deliver the fetus after gentle traction has failed. It is either the anterior, or less commonly the posterior, fetal shoulder impacts on the maternal symphysis, or sacral promontory, respectively.

5. POLICY: 

   1. To provide safe delivery in cases of shoulder dystocia, and try to minimize maternal and fetal mortality and morbidity.

   2. Physician should be aware of existing risk factors in laboring women and must always be alert to the possibility of shoulder dystocia.

6. PROCEDURE: 

   1. Risk factors include:

      1. Pre-labor:

         1. Previous shoulder dystocia                                                                   

         2. Macrosomia 4.5kg                                                                              

         3. Diabetes mellitus                                                                                  

         4. Maternal body mass index 30kg/m2 

         5. Oxytocin augmentation

         6. Induction of labor                                                                                

2. Intrapartum

   1. Prolonged first stage of labor

   2. Secondary arrest

   3. Prolonged second stage of labor

   4. Assisted vaginal delivery

2. Senior obstetrician should be available on the labor ward for the second stage of  labor when shoulder dystocia is anticipated.

3. Offer elective caesarean section for women who have gestational diabetes and whose fetus weighs more than4500 grams, or >5000g in non-diabetics and pregnancies after severe shoulder dystocia, particularly with a neonatal poor outcome.

4. Management: 

   1. Recognition:

      1. Difficulty with delivery of the face and chin

      2. The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)

      3. Failure of restitution of the fetal head

      4. Failure of the shoulders to descend.

2. Steps: HELPERR abbreviation 

   1. Help stated clearly as ‘this is shoulder dystocia’ to the arriving team (further midwifery assistance, an experienced obstetrician, a neonatal resuscitation team and an Anesthetist). The woman should be maneuvered to bring the buttocks to the edge of the bed, maternal pushing should be discouraged and Excessive head and neck traction, and fundal pressure should be avoided.

   2. Evaluate for /perform a wide episiotomy.

   3. Legs ( MC Roberts maneuver) lying woman flat and flexing her legs onto her abdomen.  Delivery should be attempted in this position for 30-60 seconds using normal traction.

   4. Pressure: apply normal head traction with assistant applying external supra pubic pressure and rocking CPR style aiming to rotate the anterior shoulder. (Robin I) 

   5. Enter: internal rotation:

      1. wood’s screw maneuver ( Robin II)  try to  rotate the shoulders  into oblique  by approaching the anterior shoulder from behind and the posterior from the front  pressing anterior shoulder forward.

      2. Reverse wood’s screw maneuver: Approach posterior shoulder from behind. Rotate fetus in opposite direction from wood’s screw maneuver.

   6. Remove posterior arm.

   7. Roll onto "all fours" and repeat all maneuvers except supra pubic 

   8. additional maneuvers .

      1. symphysiotomy.

      2. Zavanelli maneuver : cephalic replacement and caesarian section.

      3. Cleidotomy if the fetus died.

3. Post partum:  

   1. Risk of PPH, lacerations and uterine rupture, so active management 3rd stage of labor and check of perineum and anal sphincters.

   2. Cord PH to be checked and the baby should be examined for injury by a neonatal clinician.

5. Documentation: 

It is important to record within the birth record the:

1. Time of delivery of the head and time of delivery of the body.

2. Anterior shoulder at the time of the dystocia.

3. The position of the fetal head at delivery

4. Maneuvers performed, their timing and sequence

5. Maternal perineal and vaginal examination

6. Estimated blood loss

7. Staff in attendance and the time they arrived

8. General condition of the baby (Apgar score)

9. Umbilical cord blood acid-base measurements

10. Neonatal assessment of the baby.

6.  Complete clinical incident reporting form

7. postnatal debriefing.

7. RESPONSIBILITY:

The guidelines should be read, understood and acknowledged by all the responsible staff in the department.

8. FORMS/ EQUIPMENTS:

Shoulder Dystocia management pathway

9. REFERENCE: 

8.1 Green top guidelines RCOG, Shoulder dystocia No.42

8.2 Advanced Life Support Obstetrics, ALSO

8.3.Up to date 2020.

8.4.Practical Obstetric Multi-professional Training 2010.

8.5.Guidelines for Obstetrics and Gynecology, Kingdom of Saudi Arabia Ministry of Health Assistant Deputyship Minister for Hospital Affairs General Directorate of Hospitals, 2012.

10. REVISION:

11. APPROVALS:

Shoulder Dystocia management pathway