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Flashcards in Shoulder dystocia Deck (32)
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1

What is the definition of SD?

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

2

What are the mechanisms of a SD?

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

What are the 2 types?

Anterior shoulder impacts the maternal symphysis pubis
Posterior shoulder impacts on the sacral promontory

4

Which type of SD is more common?

Anterior shoulder impacted on maternal symphysis pubis

5

What is the incidence of SD?

0.1% to 3%

6

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

1%

7

How much occurs in babies less than 4kg?

50%

8

Antenatal risk factors (9)

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

9

What are the 5 recommendations from CESDI?

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

Who do we induce to prevent SD?

IOL to reduce risk for mat diabetes with suspected macrosomia

11

What are the 6 potential morbidities?

- 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

What is the brachial plexus?

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

13

what are the symptoms of brachial plexus injury?

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

14

How many SD result in BPI?

4-16%

15

What can cause a BPI?

some due to excessive force by DR
some due to propulsive force from mother

16

What is it important to document about a SD?

Which arm was posterior

17

6 Intrapartum risk factors for SD

- 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

How much does fetal pH drop by per minute?

0.04

19

Management of a shoulder dystocia (5)

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

What are the 3 P's you shouldn't do?

Pull excessively
Push on fundus
Pivot fetal head

21

What is a cleidotomy?

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

22

What is the zavanelli manouevre?

Pushing baby back up into uterus for a CS

23

Clinical management (4)

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

24

What is mcroberts and how do we do it?

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

what is suprapubic pressure?

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

How do we enter with a SD?

-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

How do we deliver the posterior arm?

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

28

What can removing the posterior arm do?

12% have humeral fracture

29

If removing posterior arm unsuccessful what do you do?

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

30

What should you record keep? 10

-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