Shoulder dystocia Flashcards Preview

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Flashcards in Shoulder dystocia Deck (32)
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1
Q

What is the definition of SD?

A

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

2
Q

What are the mechanisms of a SD?

A
  1. normal mechanism of labour
  2. shoulders attempt to enter the pelvis in the AP diameter of the pelvic brim
  3. Shoulders fail to spontaneously traverse the pelvis after fetal head has been delivered
3
Q

What are the 2 types?

A

Anterior shoulder impacts the maternal symphysis pubis

Posterior shoulder impacts on the sacral promontory

4
Q

Which type of SD is more common?

A

Anterior shoulder impacted on maternal symphysis pubis

5
Q

What is the incidence of SD?

A

0.1% to 3%

6
Q

What is the incidence in diabetic mothers of babies with bw less than 4kg?

A

1%

7
Q

How much occurs in babies less than 4kg?

A

50%

8
Q

Antenatal risk factors (9)

A
Obesity (gest diabetes) 
over 35 years 
diabetes 
multigravida 
prev shoulder dystocia 
prev big baby 
post maturity 
short stature 
hx of pelvic injury
9
Q

What are the 5 recommendations from CESDI?

A
  1. anticipate
  2. initiate early involvement of senior medical personnel
  3. senior paed for resus
  4. policy/guidelines for management
  5. regular training and drills
10
Q

Who do we induce to prevent SD?

A

IOL to reduce risk for mat diabetes with suspected macrosomia

11
Q

What are the 6 potential morbidities?

A
  • pph 11%
  • 4th degree tear 3.8%
  • ruptured uterus by fundal pressure
  • brachial plexus injury 4-16%
  • fractured clavicle
  • humeral fracture associated with delivery of posterior arm 2-12%
12
Q

What is the brachial plexus?

A

network of nerves that conducts signals from spine to the shoulder arm and hand
injuries are damage to those nerves

13
Q

what are the symptoms of brachial plexus injury?

A

Limp/paralysed arm
Lack of muscle control in the arm/hand/wrist
Lack of feeling or sensation in arm/hand

14
Q

How many SD result in BPI?

A

4-16%

15
Q

What can cause a BPI?

A

some due to excessive force by DR

some due to propulsive force from mother

16
Q

What is it important to document about a SD?

A

Which arm was posterior

17
Q

6 Intrapartum risk factors for SD

A
  • slow progress in 1st stage
  • arrest of progress at 8cm
  • prolonged 2nd stage requiring augmentation
  • instrumental delivery
  • slow delivery of face/chin
  • turtle necking
18
Q

How much does fetal pH drop by per minute?

A

0.04

19
Q

Management of a shoulder dystocia (5)

A
  1. anticipate
  2. if there are risk factors inform senior staff
  3. do not cut the cord if around the neck
  4. 3P’s DO NOT : Pull excessively, push on fundus, pivot fetal head
  5. Record keeping
20
Q

What are the 3 P’s you shouldn’t do?

A

Pull excessively
Push on fundus
Pivot fetal head

21
Q

What is a cleidotomy?

A

Surgical separation of the clavicles to allow delivery of fetus with broad shoulders

22
Q

What is the zavanelli manouevre?

A

Pushing baby back up into uterus for a CS

23
Q

Clinical management (4)

A

2222-obs team, neonatal
Explain to mother
Pushing discouraged
Attempt to deliver baby with gentle axial traction

24
Q

What is mcroberts and how do we do it?

A

Lie bed flat
Thighs to abdomen
Attempt delivery with gentle axial traction

Flattens lumbo sacral lordosis
Flexes fetal spine
Rotates symphysis pubis anteriorly
Attempt to deliver baby with gentle axial traction

25
Q

what is suprapubic pressure?

A

Apply on fetal side of back

Reduces shoulder diameter by abducting the shoulders

Rotates anterior shoulder into oblique pelvic diameter

Shoulder should slip under symphysis pubis with normal traction

Either continuous or rocking motion

26
Q

How do we enter with a SD?

A
  • consider epis if not able with hand
  • enter posteriorly via sacral hollow
  • attempt either of the following internal maneouvres depending on the situation
    1. press on anterior or posterior aspect of the posterior shoulder
    2. Rotate shoulders into oblique diameter
    3. Stop suprapubic pressure
27
Q

How do we deliver the posterior arm?

A

-grasp the wrist and posterior arm should be gently grasped and withdrawn in a straight line

28
Q

What can removing the posterior arm do?

A

12% have humeral fracture

29
Q

If removing posterior arm unsuccessful what do you do?

A

Roll onto all 4’s, try again, then roll back and try again

30
Q

What should you record keep? 10

A
  • time of delivery of head
  • direction head and fetal back are facing
  • manoeuvres performed and timing
  • staff present
  • time of delivery of body
  • condition of baby APGARs
  • Cord gases
  • Datix
  • Debrief
  • Documentation
31
Q

What are the 3rd line manoeuvres?

A

Fracture clavicle
Zavanelli manoeuvre
Muscle relaxation
Symphsiotomy

32
Q

What is important to think of in the next pregnancy?

A

Risk of repeat 1-2%
Risk of permanent bpi 0.03%
risk of lscs