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Essay 318 - Shoulder dystocia

Posted by Mark C.
a) This is an emergency situation which needs immediate assessment and management to prevent fetal and maternal morbidity. Call for help from consulant obstetrician / senior obstetrician on call, SHO, labour ward coordinator, experienced midwife, anaesthetist and paediatrician. Midwife needs to record times of all the procedures, whilst SHO ensures 14G cannula is inserted and FBC, G&S, clotting screen taken in view of increased risk of PPH and emergency procedures.
The patient and her partner need to be informed of what is happening, advised to keep calm and listen to our advice. The patient needs to get in lithotomy position unless already in position. Assessed for episiotomy and performed if needed. Her legs should be hyperflexed at the hips (McRobert\'s position) to straighten the sacral curve which allows shoulder delivery in over 80% of cases.
After 30sec if not delivered apply suprapubic pressure from the posterior aspect of the baby\'s anterior shoulder to decrease bisacromial distance. If unsuccessful after 30 sec internal manipulation is attempted, initially inserting two fingers of one hand and applying pressure anterior to the posterior shoulder. If after 30 sec not delivered the second hand is used to push anterior to the anterior shoulder and posterior to the posterior shoulder (reversing direction of previous manouvre) for 30 sec. These manouvres are used to help rotation and dislodgment of the shoulders.
If unsuccessful posterior arm delivery is attempted but this is associated with increased risk of humeral fracture. If this manouvre does not work the mother may be asked to turn on all fours is she can (cannot be used with epidural). This manouvre should increase AP diameter and may be enough to deliver shoulders.
If this routine is unsuccessful it may be repeated again. If there is no progress cleidotomy or symphysiotomy or Zavanelli\'s manouvre may be attempted although these are seldomly needed.
After baby is delivered, assessment performed by paediatrician and active management of third stage is required due to high risk of PPH. Syntometrine IM can be given unless patient suffers from hypertensive disease in which case oxytocin IM can be used. If suspicious of PPH prophylactic IV oxytocin at 10IU/hr can be used.
Everything needs to be explained to the patient and partner as this is an emotionally traumatic episode. Ensure proper documentation including time of delivery of head, time of shoulder delivery, which shoulder was posterior, manouvres performed should there be any litigation in the future. Incident report needs to be filled.

b) Explain to the patient that almost 50% of shoulder dystocia occur in babies less than 4500g. There will be an increased risk of shoulder dstocia in a subsequent pregnancy hence we would advise against home birth.
She will need monthly growth scans after 24 weeks to assess for macrosomia.
There is no indication for elective caesarian section because she had shoulder dystocia.
Should she be diabetic advise strict glucose control as this increases the risk further. If her BMI is increased weight loss is also advocated.
Written information should be provided and accurate documentation of what was discussed and the patient\'s wishes clearly noted.
Posted by Sarika N.
You are called urgently to attend a spontaneous vaginal delivery because of difficulties delivering the shoulders. (a) Discuss and justify your management [15 marks].
Diagnosis of shoulder dystocia should be established by employing routine traction in axial direction. The difficulty with delivering face and chin, tight head on the perineum, failure of head restitution and shoulders to descend suggest of shoulde dystocia. associated with high perinatal morbidityand mortality, maternal morbidity is increased. Systematic approach is important. Call for extra help with seniour obstetrician, neonatologist, anaesthetist, experience midwife and allocated midwife to document the events and tining for manouvres.
Avoid fundal pressure and assessfor episiotomy.
McRoberts manoeuvre is sucsessful in 90% of cases- flexion and abduction of maternal hips. Suprapubic pressure for 30 sec to reduce biacromial diameter and rotate anterior shoulder should be applied. If above fails can either proceed to all - four position and attempt to deliver posterior shoulder first if mobile or proceed to internal manipulations.
Internal rotation manoeuvres or delivery of posterior shoulder should be attempted, depending on the clinical judgement and experience.
Third line manouvres as cleidotomy, symphysiotomy or Zavanelli manouvre( cephalic replacement) can increase maternal morbidity and mortality and should be carefully assessed. After delivery assessment for postpartum haemorryhage and 3rd , 4th degree tears should be done. Pateint and her partner should be debriefed regarding the events and complications.
(b) The woman attends for post-natal review 6 weeks later and there are no complications. The birth weight was 4600g. How would you counsel her about the management of a subsequent pregnancy? [5 marks]
The review of the notes should be done pror to appointment and if patient would like to discuss the events again it should be explained.
Previous shoulder dystocia and the baby above 4,5 kg are the risk factors. Screening for gestational diabetes and monitoring the fetal weight by growth scans can be helpful to exclude fetal macrosomia.
There is a reccurence rate of shoulder dystocia between 1 and 16%. Either caesarean section or vaginal delivery is appropriate after previous shoulder dystocia, the decision should be made by the patient and her paretner.
Posted by SRABANI M.
SM
a. This is an emergency situation which can be associated with high perinatal mortality &morbidity as well as high maternal morbidity.Hence I would call for extra help immediately. I would call a senior obstetrician, senior midwife, senior anaesthetist & paediatric resuscitation team.Maternal pushing should be discouraged as it will cause more impaction of shoulder leading to worsening of the situation.The patient should be evaluated for episiotomy.This involves positioning the woman in lithotomy to perform episiotomy & also allowing access to vagina for further manoeuvres. The woman’s legs should be in McRobert’s position which is flexion & abduction of maternal hips, positioning her thighs onto her abdomen.This increases the lumbosacral angle & is single most efective manoeuver with delivery rates as high as 90%.It has low rate of complication & hence should be tried first. Suprapubic pressure to the back of the fetal shoulder causes reduction of bisacromial diameter & to rotate the anterior shoulder to the oblique position , causing it to slip under the symphysis pubis & therefore facilitate delivery.Suprapubic pressure should be applied for 30 seconds & there is no difference in efficacy between continuous or rocking movement. If these two simple manoeuvres fail ( McRoberts’ & suprapubic pressure),vagina is entered to allow internal manipulations like Wood screw and reverse screw manoeuvres.these are designed to rotate anterior shoulder from under symphysis pubis to allow delivery. If the Screw manoeuvres are unsuccessful, then posterior arm may be delivered directly or via rotation of the fetal trunk using the arm.this has got high complication rate including humeral fracture.Another option is rolling the woman onto all four position which may cause displacement of shoulder allowing delivery.Individual circumstances should guide whether all-four-position or internal manipulation should be tried first.For a slim, mobile lady without epidural anaesthesia & single midwife present, all –four –position would be preferred whereas for less mobile lady with epidural & presence of senior obstetrician , internal manipulation can be tried.
If the baby is still not delivered, symphysiotomy , cleidotomy or Zavenelli manoeuvre should be tried. These are very rare.Cleidotomy is bending claviclewith finger or surgical division, Zavenelli is replacement of fetal head into vagina & deliver by caesarean section. Zavenelli is appropriate for bilateral shoulder dystocia. Maternal safety in this procedure is unknown & high proportion of foetuses have irreversible hypoxia- acidosis by this stage.Similarly in symphysiotomy , high risk of maternal morbidity & poor neonatal outcome can be present.After delivery , birth attendants should be careful about possibility of PPH & third & fourth degree perineal tear.Everything should be documented clearly

b. Counselling should involve informing the lady about recurrence rate of shoulder dystocia which may be between 1% to 6%.It is not recommended to advice elective caesarean section in subsequent pregnancy routinely but factors like previous neonatal /maternal injury & their severity, fetal size & maternal choice should be considered during recommendation for the next delivery.She should also be informed that shoulder dystocia may not be predicted in her next pregnancy but because she had shoulder dystocia in this pregnancy, next pregnancy should be of high risk category & hence a senior experienced obstetricin should be involved.Also she should be informed that fetal size is not a good predictor of shouder dystocia although there is a relationship present.She should have serial growth scan to avoid complication for macrosomia & also she should have her glucose level checked to exclude diabetes mellitus which is a risk factor for shoulder dystocia. Finally , she should be informed about advantages & disadvantages of different plans of management ( induction of labour. Caesarean section or awating spontaneous labour) in her future delivery
c.
Posted by H H.
Hhh
This is an emergency situation associated with increased perinatal mortality and morbidity in addition to increased maternal morbidity. There should be guidelines and protocols for management of such an emergency, which are regularly rehearsed and audited , and incidents are properly studied by risk management teams from which lessons learned are dissiminated to staff.
When faced with such situation, I would call for help from midwives , residents,anesthetist,porters,inform consultant .Time count is started and observed by one of midwives. Calm patient, put in lithotomic position if was not so, and assess the situation. Flex both thighs toward her abdomen while abducting and externaly rotating the thighs at the hip joint, this would straighten the lumbosacral joint and help to dislodge the anterior shoulder from above the syphilis pubis . If this fail ,suprapubic pressure (done by an assistant) in addition to the previous maneuvere is done to dislodge anterior shoulder of baby and adduct it so as to reduce the bis acromial diameter and allow anterior shoulder to fall.According to unit protocols both maneuveres may be used together from the start.These maneuveres would lead to success in 80-90% of cases.
If fail , I would enter with my hand through the vagina (2ry maneuveres) and try to rotate the anterior or posterior shoulder(Wood screw or reverse wood screw) to get into the wider oblique diameter and allow the anterior shoulder to fall. If this fail I would follow the posterior shoulder up along the arm and press at the cubital fossa of baby arm to allow me to bring the posterior arm down through the vagina,rolling it in front of baby chest, this would allow the anterior shoulder to fall down.
If these fail, I would change the position of patient, Roll on four, this might help the anterior shoulder to dislodge.
If this fail,I would be left with more drastic procedures, breaking baby clavicle(need experience-reduce bis acromial diameter), symphysiotomy( widen pelvic diameters), Zavanelly procedure( push head back and do cesarean section).
After delivery,cord blood taken for PH. Neonatologist to receive baby for resuscitation. Mother examined for tears. Documentation, time from delivery of head to delivery of baby, face of baby looking to left or right (for medico legal reasons), APGAR score and staff attending. Patient debriefed and incident report filled. GP informed.



I would counsel her in a sympathetic manner, considering that she is anxious and would not like to go through this experience again , how ever I would not guarantee to her that this would not occur again, for despite her previous baby was 4.6KG , 50% or about half of shoulder dystocia occur with average sized babies. Her chance of having another experience increase,as recurrence rate is 1 - 17 %.
I would go through her notes and see if she has Diabetes and its control, her BMI and stature, progress of labour in previous delivery and which maneuveres done to releive her shoulder dystocia. If only Iry maneuveres were used is a good sign,but again no guarantee.
Risks to the baby of shoulder dystocia explained and the method of delivery is according to her wishes.

Posted by R J.
Shoulder dystocia is an emergency condition and can lead to increased maternal morbidity ,perineal tears and poatpartum haemorrhage and increased perinatal morbidity and moratality.perinatal morbidity in the form of brachial plexus injury ,fracture clavicleand fetal hypoxia.
Shoulder dystocia occurs when either one or both shoulders are above the pelvic brim.Make sure that the womans buttocks are at the edge of the table as manouvres can be tried effectively in this position.woman should be in lithotomy position .Call for help from midwife, senior obstetrician, neonatologist and anesthetist.episiotomy is to be given so that manouvres can be done easily and third and fourth degree tears can be prevented.maternal pushing should be discouraged as it can lead to further impaction of shoulders.fundal pressure should be avoided.MAC ROBERT\'S manouvre can be done as a first line procedure as it has can deliver the shoulders in 90% of cases and has low complication rates.this manouvere is usually combined with suprapubic pressure in downwards direction.In this manouvre womans legs are abducted and flexed over the abdomen with the help of an accoucher so that the sacral curve is straightened and ant shoulder goes below the pubic symphyses.If still shoulders cannot be delivered then second line manouvres to be tried.Delivery of posterior arm or internal rotation of shoulders .
in woods screw manouvre internal rotation of shoulder is done by 180 degrees sothat post shoulder comes under pubic symphyses and anterior shoulder which was still above pubic symphyses goes under the sacral promontary and then posterior shoulder is delivered and then anterior shoulder.
if still shoulders not delivered then third line manouvres to be tried.cutting of clavicle in order to reduce the bisacromial diameter It can lead to fetal injury.symphysiotomy can be done in order to increase the diameter of pelvic brim .cephalic reduction ie, zavenelli\'s manouvre is tried as last resort and is associated with high complication rates.
After the delivery of the baby the condition should be explained to the woman and her partner and also about the procedures done.Documentation is one of the important steps in dealing with shoulder dystocia.recording of time of delivery of head .timming of call given and the timming of arrivals and the steps taken should be documented clearly.
neonatologist should be present to assess the babys condition record of the apgar scare and cord ph should be there.
b)At her postnatal visit it is important to review her antenatal and intrapartum records to look for the risk factors.obesity, , macrosomia,prolonged first stage or second stage of labour which can give rise to shoulder dystocia.She should be told about recurrence risk of shoulder dystocia.IN her subsequent pregnancy oral glucose tolerance test at booking is advisable if dystocia due to macrosomia.
If DM then woman should be told to have tight sugar control in her subsequent pregnancy and frequent sonography for estimated fetal weight so that if macrosomia then early induction of labour in order to avoid shoulder dystocia.she should discuss the mode of delivery beforehand.if she is obese she should be advised to reduce weight before embarking on her next regnancy.
She should be advised adequate contraception and follow up of the baby .
Posted by SYAMALRANJAN S.
SRS
(a) Discuss and justify your management [15 marks].

Shoulder dystocia is an obstertric emergency associated with increased perinatal morbidity, mortality and also maternal morbidity such as PPH, perineal damage(third /fourth degree tear).
Aim is to deliver the baby as promptly and efficiently as possible. Nearly 50% of babies may die within 5 minutes of delivery of head.
I will call for help (midwives, senior experienced obstetrician, neonatal team , anaesthetist) because of extra help.
Mother is requested not to push because that will cause further impaction of shoulders and buttocks is moved to the edge of the table for proper application of manouvres.
I will perform McRoberts manoeuvre first - single most effective intervention. It straightens the lumbo-sacral angle, rotates the maternal pelvis cephalad. Reported success rate is nearly 90% with low complication rate. May be used in conjunction with supra-pubic pressure. Pressure should be downwards and lateral( anterior shoulder towards the fetal chest). It reduces the bisacromial diameter and rotes anterior shoulder into oblique pelvic diameter and is then free to slip underneath the symphysis pubis with the aid of routine traction
If above manouvres fails to deliver, then I will try either internal rotation manouvres to rotate the shoulders obliquely or delivery of the posterior arm depending upon clinical circumstances. I will consisder episiotomy if it will make internal manouvres easily. Alternatively the all-fours position may be considered if above methods fail. Slim, mobile lady, less available assistants may be tried by all-fours positions.If all those methods fail then I will consider cleidotomy, Zavanelli manoeuvre or symphysiotomy but these are rarely needed.Immediate care of the baby by neonatal team. I will take appropriate steps for preventing and managing PPH and perineal lacerations.I will document clearly about the delivery events including time of head / body delivey / head facing after restitution / manouvres undertaken/ staffs involved / apgar score / cord blood pH. I will fill up the incident form and debrief the events to the mother / partner or family members when appropriate and support if any complications ( better by consultant if possible).

(b) The woman attends for post-natal review 6 weeks later and there are no complications. The birth weight was 4600g. How would you counsel her about the management of a subsequent pregnancy? [5 marks]

Subsequent delivery booking should be in consultant-led hospital. Casarean section or vaginal delivery may be appropriate in subsequent pregnancy. Reported recurrence rate is between 1-16%. Routine elective CS is not advisable. Factors such as severity of previous neonatal /maternal problems and the fetal size and maternal choice in subsequent pregnancy should all be considered.
Risk assessments for the prediction of shoulder dystocia are insufficiently predictive to allow prevention of the large majority of cases.
Elective caesarean section should be considered to reduce the potential morbidity for pregnancies complicated by suspected fetal macrosomia associated with maternal diabetes mellitus.

Posted by Naheed M.
N.M
It is an obstetric emergency when gentle routine traction fails and obstetric manoeuvres are required to deliver the shoulder. I will call senior obstetrician, experienced midwife and other labour suite staff immediately for help. I will stop woman from pushing and the staff from giving any fundal pressure. These practices worsens shoulder impaction and If there is any oxytocin infusion going on, should be stopped immediately. I will immediately help position the woman placing buttocks at the edge of labour table and have Mc-Robert’s position (maximum flexion and abduction of legs at hip and flexion of legs at knee). This position straightens lumbosacral angle and rotates the woman’s pelvis cephalad. This help release the impacted shoulder at pubic symphysis and success rate is 90%. Mc-Robert’s position can be complemented by suprapubic pressure placing hands one on the other and applying pressure in a rocking or continous manner ( no efficacy difference between continous or rocking pressure) in a way that anterior shoulder can be pushed towards baby’s chest. 90-95% cases of shoulder dystocia deliver through these manouvers. I will inform the anaesthetist and and neonatologist and will simultaneously assign and check other tasks to labour room staff such as maternal and fetal monitoring (B.P, Pulse, Respiration, and fetal heart rate and CTG.) Intravenous line will be maintained with 2 wide bore canulae. Next, I will try wood screw manoeuvres through which i will rotate posterior shoulder to 180*this releases anterior shoulder and make posterior shoulder in anterior position. Other manoeuvres will be employed if still failed to deliver such as internal manipulation and delivery of posterior arm and all four positions (success rate 83%). Episiotomy doesn’t directly help shoulder delivery but may be needed to have more ease and room to perform the manoeuvres. For delivery of the posterior arm hand is inserted into vagina and posterior arm of the baby is delivered by sweeping it against baby’s chest and flexing at elbow. Very few cases still fail to deliver and may need other extended manoeuvres such as celidotomy, symphysiotomy or Zavanelli’s manoeuvres. These are painful and expertise and trained personnel are not easily available. If all the manoeuvres fail I will immediately shift the patient to operative room to deliver the baby by caesarean section. The time issue for baby’s survival is very short and critical with impacted shoulder and strangulated at neck. It has been observed that even normal babies survive around 7 minutes in this condition. Therefore before planning/conducting caesarean section it should be ensured that baby is alive. If woman successfully delivers vaginally the risk of postpartum hemorrhage and perineal tears should be borne in the mind and third stage should be actively managed. Vagina and perineum should be carefully examined to indentify and promptly treat any tears and lacerations. Episiotomy should be carefully stitched (if given) and ensured that it is not extended. Baby should be examined by neonatologist to identify any trauma, brachial plexus injury or Erb’s palcy.Patient should be continuously kept informed of all the situations and steps of management and her decisions about her management should be respected. Incidence form should be filled and date time of each management step success or failed, final outcome along with the names of labour room staff all should be clearly documented. It should be mentioned which shoulder was impacted as if the injury is found in the other shoulder it wouldn’t be considered by the accoucheur’s action. The woman should be counselled by senior obstetrician and debriefed in detail about the delivery. Psychological support should be provided by staff and family.
b.
Patient might be distressed and have fear about next pregnancy and delivery so in postnatal review she should be given adequate time to discuss all her fears and concerns. She should be asked if they have large babies in their families and about her previous babies (if macrosomic). She should be informed about the risks associated with macrosomia and shoulder dystocia such as diabetes mellitus and gestational diabetes. These causes should be ascertained and if present appropriate advice should be given. In Diabetes or gestational diabetes good glycemic control (through hypoglycaemic diet and drugs) before and throughout pregnancy minimise the risk of macrosomia and other associated complications. If she is obese, she should be advised to reduce weight as it is a risk for fetal macrosomia. If she is diabetic her condition should be reviewed under multidiscplinary care and she should be advised to have euglycemic state before planning pregnancy. If she had gestational diabetes she should be informed of the risk of recurrence and type- 2 diabetes mellitus and advised healthy lifestyle. There is risk of recurrence of shoulder dystocia (1-16%) but she should be reassured that it is not a routine indication for caesarean section. However in the presence of diabetes mellitus and suspected fetal macrosomia elective caesarean section can be considered to reduce maternal perinatal morbidity and mortality. Woman should be informed that there is no tool which can reliably predict shoulder dystocia. The risk factors (previous history, diabetes, maternal obesity or intrapartum risks) only predict 16% of cases. Early induction also doesn’t reduce potential morbidity associated with fetal macrosomia. Woman should be reassured that majority of shoulder dystocia in a well facilitated unit are managed safely and patient’s wishes regarding her management are respected.
Posted by Naheed M.
N.M
It is an obstetric emergency when gentle routine traction fails and obstetric manoeuvres are required to deliver the shoulder. I will call senior obstetrician, experienced midwife and other labour suite staff immediately for help. I will stop woman from pushing and the staff from giving any fundal pressure. These practices worsens shoulder impaction and If there is any oxytocin infusion going on, should be stopped immediately. I will immediately help position the woman placing buttocks at the edge of labour table and have Mc-Robert’s position (maximum flexion and abduction of legs at hip and flexion of legs at knee). This position straightens lumbosacral angle and rotates the woman’s pelvis cephalad. This help release the impacted shoulder at pubic symphysis and success rate is 90%. Mc-Robert’s position can be complemented by suprapubic pressure placing hands one on the other and applying pressure in a rocking or continous manner ( no efficacy difference between continous or rocking pressure) in a way that anterior shoulder can be pushed towards baby’s chest. 90-95% cases of shoulder dystocia deliver through these manouvers. I will inform the anaesthetist and and neonatologist and will simultaneously assign and check other tasks to labour room staff such as maternal and fetal monitoring (B.P, Pulse, Respiration, and fetal heart rate and CTG.) Intravenous line will be maintained with 2 wide bore canulae. Next, I will try wood screw manoeuvres through which i will rotate posterior shoulder to 180*this releases anterior shoulder and make posterior shoulder in anterior position. Other manoeuvres will be employed if still failed to deliver such as internal manipulation and delivery of posterior arm and all four positions (success rate 83%). Episiotomy doesn’t directly help shoulder delivery but may be needed to have more ease and room to perform the manoeuvres. For delivery of the posterior arm hand is inserted into vagina and posterior arm of the baby is delivered by sweeping it against baby’s chest and flexing at elbow. Very few cases still fail to deliver and may need other extended manoeuvres such as celidotomy, symphysiotomy or Zavanelli’s manoeuvres. These are painful and expertise and trained personnel are not easily available. If all the manoeuvres fail I will immediately shift the patient to operative room to deliver the baby by caesarean section. The time issue for baby’s survival is very short and critical with impacted shoulder and strangulated at neck. It has been observed that even normal babies survive around 7 minutes in this condition. Therefore before planning/conducting caesarean section it should be ensured that baby is alive. If woman successfully delivers vaginally the risk of postpartum hemorrhage and perineal tears should be borne in the mind and third stage should be actively managed. Vagina and perineum should be carefully examined to indentify and promptly treat any tears and lacerations. Episiotomy should be carefully stitched (if given) and ensured that it is not extended. Baby should be examined by neonatologist to identify any trauma, brachial plexus injury or Erb’s palcy.Patient should be continuously kept informed of all the situations and steps of management and her decisions about her management should be respected. Incidence form should be filled and date time of each management step success or failed, final outcome along with the names of labour room staff all should be clearly documented. It should be mentioned which shoulder was impacted as if the injury is found in the other shoulder it wouldn’t be considered by the accoucheur’s action. The woman should be counselled by senior obstetrician and debriefed in detail about the delivery. Psychological support should be provided by staff and family.
b.
Patient might be distressed and have fear about next pregnancy and delivery so in postnatal review she should be given adequate time to discuss all her fears and concerns. She should be asked if they have large babies in their families and about her previous babies (if macrosomic). She should be informed about the risks associated with macrosomia and shoulder dystocia such as diabetes mellitus and gestational diabetes. These causes should be ascertained and if present appropriate advice should be given. In Diabetes or gestational diabetes good glycemic control (through hypoglycaemic diet and drugs) before and throughout pregnancy minimise the risk of macrosomia and other associated complications. If she is obese, she should be advised to reduce weight as it is a risk for fetal macrosomia. If she is diabetic her condition should be reviewed under multidiscplinary care and she should be advised to have euglycemic state before planning pregnancy. If she had gestational diabetes she should be informed of the risk of recurrence and type- 2 diabetes mellitus and advised healthy lifestyle. There is risk of recurrence of shoulder dystocia (1-16%) but she should be reassured that it is not a routine indication for caesarean section. However in the presence of diabetes mellitus and suspected fetal macrosomia elective caesarean section can be considered to reduce maternal perinatal morbidity and mortality. Woman should be informed that there is no tool which can reliably predict shoulder dystocia. The risk factors (previous history, diabetes, maternal obesity or intrapartum risks) only predict 16% of cases. Early induction also doesn’t reduce potential morbidity associated with fetal macrosomia. Woman should be reassured that majority of shoulder dystocia in a well facilitated unit are managed safely and patient’s wishes regarding her management are respected.
Posted by Naheed M.
Dear Dr Paul, by some mistake my answer is posted twice please ignore. thanks
Posted by Chitra.s M.
A.Shoulder dystocia is an obstetric emergency associated with increased perinatal morbidity/mortality & maternal morbidity.Additional help-senior obstetrician,anaesthesiologist,midwife & paediatric resuscitation team.A midwife is
Posted by Chitra.s M.
A.Shoulder dystocia is an obstetric emergency associated with increased perinatal morbidity/mortality & maternal morbidity.Additional help-senior obstetrician,anaesthesiologist,midwife & paediatric resuscitation team.A midwife is
Posted by Bindi J.
BJ:
This is Shoulder Dystocia and is an obstetric emergency where extra help is needed from senior Obstetrician, Anaesthetist, neonatal resuscitative team and more midwifery assistance. Maternal pushing should be discouraged as this may lead to further impaction of the shoulders thereby exacerbating the condition. The woman should be manoeuvred to bring her buttocks to the edge of the bed. Fundal pressure should not be applied as it is associated with unacceptably high neonatal complication rate and may result in uterine rupture. Consideration for episiotomy should be individualised. The Mc Roberts manoeuvre should be used first as it has high success rate of 90% and a low complication rate. Flexion and abduction of maternal hips and positioning the maternal thighs on her abdomen straightens lumbosacral angle, rotates maternal pelvis cephalad and is associated with an increased uterine pressure and amplitude of the uterine contractions. Suprapubic prsessure can be employed together with Mc Roberts manoeuvre to improve success rate. This pressure is applied in downward and lateral direction on the posterior aspect of anterior shoulder either continuously or in a rocking fashion for 30 seconds. It reduces the bisacromial diameter and rotes the shoulder in oblique pelvic diameter. This frees the shoulder to slip underneath symphysis pubis with the aid of routine traction. If these simple measures fail then there is a choice between internal advanced manoeuvres and rolling on all fours which should be individualised. There is no advantage between delivery of posterior shoulder and internal manoeuvres and therefore clinical judgement and experience can be used to decide their order. Delivery may be facilitated by rotating the shoulder in oblique pelvic diameter by Rubin’s two, Woodscrew and Reverse Woodscrew manoeuvres. Delivery can also be facilitated by delivery of posterior arm, though there is a slightly higher complication rate. There is no conclusive data on the recommendation of time limit for the management of shoulder Dystocia. Third line methods are recommended in cases resistant to simple measures though there is a higher maternal and perinatal morbidity. These include Cleidotomy(bending the clavicle with a finger or surgical division), symphysiotomy(dividing the symphyseal ligament) and the Zavanelli manoeuvre. Latter involves cephalic replacement and delivery by caesarean section. Following shoulder dystocia there is a high risk of complications like postpartum haemorrhage and perineal trauma which should be looked out for. Proper documentation, debriefing and risk management form should be done following the emergency.


b)
The notes should be available prior to debriefing her of the events during the management of shoulder dystocia. Exclude medical conditions like Diabetes mellitus and BMI(>30). Other risk factors (induction and augmentation of labour, poor progress in first or second stage of labour and use of instrumental delivery) should be identified and discussed with the woman as possible causes. She should be told that Shoulder dystocia is not preventable and in large majority of cases it occurs in women with no risk factors. Recurrence rate varies from 1-15%. In her case (assuming no Diabetes and BMI<30) there is no requirement to advise her elective caesarean section routinely. She should be offered a choice between vaginal delivery and elective caesarean section between 39-40 weeks. If BMI>30, advise on lifestyle modification to reduce weight is given. If Diabetes then appropriate referral to Diabetologist should be made.
Posted by Chitra.s M.
sorry.sent incomplete ans .
A. shoulder dystocia is an obstetric emergency with increased perinatal morbidity/mortality & maternal morbidity. Additional help is called for-senior obstetrician,anaesthesiologist,midwife & paediatric resuscitation team.The time of delivery of head is noted.A member of the team( midwife/resident) is asked to document the time & sequence of events.The situation has to be handled efficiently to avoid hypoxia & acidosis and carefully to prevent unnecessary trauma.The mother is briefed quickly that there is some difficulty in delivering the baby\'s shoulders.She is asked to stop bearing down efforts.Mc roberts manoeuvre is performed.The lady is manoeuvred to bring the buttocks to the edge of the table.Her thighs are flexed on to the abdomen flexing & abducting her hips.This straightens the sacrum relative to the lumbar spine & rotates the pelvis cephalad.The shoulder can slip under pubic symphysis & delivered by routine traction.This manouvre can be aided by suprapubic pressure applied by an assistant in downward & lateral direction.This pushes the posterior aspect of anterior shoulder towards the fetal chest & helps disimpact it.Fundal pressure should not be applied as it worsens shoulder impaction.
If mcroberts manoeuvre with suprapubic pressure does not free the shoulder in about 30 seconds, second line manoeuvres are employed.They include \'all fours \' position or internal manouvres.All four positions is employed if the woman does not have epidural analgesia ,has a normal BMI & when senior help has not yet arrived.In a less mobile woman with epidural analgesia & in the presence of senior obstetrician, internel maoeuvres are employed.The order of these is determined by the clinical situation, expertise & unit protocols.There is no advantage between rotational manouvres & delivery of posterior arm.To deliver the posterior arm ,hand is introduced along the posterior arm & pressure exerted at the antecubital fossa.This flexes the fetal forearm which is then swept over the chest & deliverd.This has a higher rate of fracture of the fetal humerus.The rotational manouvres are Woods corkscrew & rubin\'s manoeuvre.In woods manouvre pressure is applied to anterior surface of the posterior shoulder in an attempt to abduct & disimpact it.In Rubin\'s manoeuvre pressure is applied to the posterior aspect of the most accesible shoulder to adduct & disimpact it.Each manouvre is tried for about 30s & if unsuccessful, moved on to the next one.Continuous fetal monitoring is done.An episiotomy, though not mandataory ,is considered to facilitate the preformance of these manoeuvres.
Persistent failure of first & second line manoeuvres warrants careful consideration of third line manouvres-cleidotomy,symphysiotomy & Zavanelli manouvres.These are associated with increased maternal morbidity.Zavanelli manoeuvre involves flexing the fetal head & replacing it into the vagina & delivery completed by LSCS.Cleidotomy involves deliberate fracture of clavicle by applying finger pressure on midclavicle.This is technically difficult to perform,associated with greater trauma to the underlying fetal neural & pulmonary structures.Symphysiotomy is dividing the symphyseal ligament.Choice of the procedure depends upon the fetal condition & expertise avilable.
Following delivery active management of 3rd stage of labour is done .The team is alert for the possibility of PPH.Third & fourth degree perineal tears are likely & looked out for.The baby is assessed for fractures(humerus,clavicle),brachial plexus injury.
The documentation should include the timing of delivery of head,the timing & sequence of manoeuvres, arrival of various staff,apgar scores & umbilical cord ph measurements.Incident form is filled up.Postnatally the couple are counselled.

B.The woman is encouraged to express her views & concerns regarding the present delivery & any queries answered.She is informed that previous shoulder dystocia is a risk factor for shoulder dystocia in the next pregnancy.however the recurrence rates vary(1-16%) .The choice of delivering by elective ceserean or vaginally depends upon the mother\'s wishes & conditions prevailing in the next pregnancy.Her notes are reviewed & if she is diabetic ,advice is given regarding good glycemic control preconceptionally & antenatally to optimse the pregnancy outcome.She is booked in a consultant led obstetric unit to manage her next pregnancy & labour.Serial growth scans are offered from 24 weeks to detect macrosomia.In the presence of macrosomia & diabetes elective ceserean is offerd to prevent maternal & neonatal morbidity associated with shoulder dystocia.If she is nondiabetic with suspected fetal macrosomia, the choice of mode of delivery is according to the maternal wishes & estimated fetal weight.Routine induction of labour is not offered as it it does not prevent shoulder dystocia or improve maternal & fetal outcome.
Posted by drvimaladkm@yah K.
I would attend the delivering woman immediately as shoulder dystocia is an obstetrical emergency which may result in fetal perinatal mortality or morbidity (like Brachial plexus injury or fracture of humerus, clavicle). Judicious and effective intervention may reduce this complication.
I would assess the position of the fetal head , viability, whether anterior (above pubic symphysis) or posterior (rare, above sacral promontory) or both shoulders are impacted. I would ask for help of a senior midwife for my assistance & paediatrician for the neonatal resuscitation. Patient is orally informed about the problem & further managed.
The patient is brought down to the edge of the table. She is given Mc Robert’s position with hyperflexion and abduction at both hip joints in order to straighten the lumbosacral curve and for the pelvic cephaloid tilt. This position enhances the descent of the shoulder. I would ask the assistant to give suprapubic pressure with downward & lateral direction which helps in the disimpaction of the shoulder. At the same time, with slight downward traction the foetal body is delivered . If not delivered I would go for 180 degree rotation of the fetal trunk so that posterior shoulder rotates to the anterior. 90% of cases are successfully delivered by giving this position. The fundal pressure should not be given as it may further impact the shoulder or may go for uterine rupture.
Sometimes yet the baby may not be delivered & further manoeuvers are required. I would ask for further help of the senior obstetrician & anaesthetist for there may be need of anaesthesia for further management. Meanwhile I would go for episiotomy for easier manipulation with extra space. The posterior arm is delivered out and then the fetal trunk is rotated in a screw manner(wood screw) for 180 degree and the fetal body slips out with mild traction. Posterior arm is under sacral promontory & at a lower level than pubic symphysis & more easily reachable. But delivery of the arm may cause fracture humerus . The delivery has to be as early as possible within 5 mins as severe hypoxia & acidosis may occur.
Inspite of all these maneuver if delivery is not possible options left out are Cleidotomy, Zavanellie’s technique or Symphysiotomy. Cleidotomy is to divide the clavicle by using finger or by surgical division. Zavanellie’s technique is to replace the fetal head back in the vagina and to deliver the baby by caesarean as early as possible. This technique may be required in bilateral shoulder dystocia. Symphysiotomy is a surgical separation of pubic symphysis by dividing the anterior & posterior ligaments. It is associated with severe maternal morbidity like injury to the bladder or urethra , haemorrhage & sepsis.
Baby is further assessed by paediatrician.Delivery may be followed by complications like postpartum haemorrhage(PPH) or by perineal tears(3rd or 4Th degree.)PPH is prevented by following active management of 3rd stage using prophylactic oxytocin & controlled cord traction. Perineal tears are carefully sutured in the OT under anaesthesia with suturing of rectal mucosal tear or sphincteric tear if present.
Detailed documentation has to be done in the proforma with time of delivery of the head and body,direction of the head after restitution, maneouvere s done ,fetal condition at birth, & complications if occured & people involved. This will help if there is litigation. Details of events of delivery has to be explained to the patient & to her close relatives once there is a stable situation.
Regarding subsequent pregnancy the mother is told that there is risk of recurrence of shoulder dystocia in about 1 to 16%. Fetal weight alone may not be responsible for shoulder dystocia. (Maternal propulsive forces may also contribute for the dystocia). Sometimes, brachial plexus injury may occur even after an elective caesarean section. (2345 caesarean sections may have to be done to prevent 1 brachial plexus surgery which is not feasible -Decesion analysis model by US).She may decide about the vaginal or caesarean delivery considering the fetal weight and the severity of the shoulder dystocia in the future pregnancy. Usually caesarean section is adviced if expected fetal weight is more than 5 Kg at term or more than 4.5 kg with Diabetes mellitus.
VDKM
Posted by AFSHEEN M.
You are called urgently to attend a spontaneous vaginal delivery because of difficulties delivering the shoulders. (a) Discuss and justify your management [15 marks]. (b) The woman attends for post-natal review 6 weeks later and there are no complications. The birth weight was 4600g. How would you counsel her about the management of a subsequent pregnancy? [5 marks]


A)I will call for help from senior midwife and quickly obtain a brief history from the attending midwife, about the duration of shoulder dystocia,any manouvres already performed and any risk factors such as maternal diabetes or prolonged second stage of labour.I will ask one of the midwives to record the timings.I will assess the condition of the baby including color and examine the perineum and perform a right mediolateral episiotomy ,which may help while performing manouvres.I will position the mother in Mc Roberts position with her head flat on the bed,thighs flexed onto her abdomen and abducted ,which can provide some space.I will asess the descent of the head by gentle traction. If no progress, I will ask a senior midwife to apply suprapubic pressure, after assessing which side is the fetal back.It can be applied in a continuous or rocking fashion ,in order to help reduce the anteropsterior diameter of the shoulders.I will assess the descent with gentle traction,after applying every manouvre for approxiamtely 30 seconds.If no progress, I will apply a Wood csrew or a reverse wood screw method, in order to flex the anterior shoulder, to reduce the AP diameter to facilitate delivery.If no success, I will attempt to remove the posterior arm or roll the mother over on all fours. If there is still no success, I will repeat the drill again with suprapubic pressure, woodscrew method or attempting to remove posterior arm.Second line methods include breaking one of the clavicles to reduce AP diameter, or symphisiotomy.If no success,last method is to reduce the head into the vagina and perform a caesarean section.
Once the bay is delivered,I will examine the perineum for lacerations and suture them appropriately.There is inceased isk of PPH, which will be managed according to the unit guidelines.The baby should be reviewed by the peadiatrician and a thorough examination performed. If there are any fractures of clavicles or humerus, paeds orthopaediac referral may be necessary.I will prescribe analgesia and appropriate thromboprophylaxis for the mother and complete an incident form.I will also debrief the events around the delivery to the parents, before discharge home and arrange a follow up appointment.


b)I will assess her physical and psychological well being and identify any predisposing risk factors such as maternal BMI >30,diabetes mellitus, previous history of shoulder dystocia or prolonged first/second stage of labour .I will inform her that the risk of should dystocia may be increased in the subsequent pregnancy and advise her to book under consultant led care.She will need sceening for diabetes mellitus at 24-28 weeks gestation and treated accordingly, if positive. I will advise her about life style changes such as reducing weight if BMI >30.During labour, she will be examined regularly and progress plotted on a partogram to avoid prolonged labour. I will ensure that unit protocols are up to date and staff are well reheaesed with the shoulder dystocia drill.Senior obstetrician,midwife and anesthetist should be available on the delivery suite to attend the delivery.I will provide her with written information about shoulder dystocia.
Posted by ASB -.
ASB
(a) I would call for help from senior obstetrician , midwifes and neonatologist. Discourage maternal pushing and bring the patient buttocks to the edge of the table . Mc Robert manouvre refers to hyperflexion of maternal thighs towards her abdomen. It flatten the lumbosacral curve and leesen any obstruction caused by sacral promontary and displaces the symphysis pubis cephalad.It is effective in the majority of cases . Suprapubic pressure by an assisstant should be downward and oblique to move the shoulder to the wider oblique diameter of the pelvic inlet . Fundal pressure should be avoided . simultaneous gentle traction of the fetal head in a neutral position avoiding excessive lateral movement of the head .

If these measures fail , generous episiotomy is required to facilitate interventions . I would try to rotate the anterior shoulder to the oblique diameter as it is wider than the anteroposterior diameter of the pelvic inlet . If this fail , I would try woodscrew manouvre . It refers to rotation of the posterior shoulder 180 degree anteriorly . This simultaneusly combined with by a degree of traction would bring the shoulder under the symphysis pubis . Alternatively , delivery of posterior arm could be tried .

If these measures fail , I would repeat them again in the same sequence . If this fails again or both shoulders are above the pelvic inlet , I would try a more difficult intervention . Cleidotomy is intended fracture of fetal clavicle to reduce the bisacromial diameter . symphysiotomy refers to separation of symphysis pubis . Zavanelli refers to cephalic replacement and delivery by seasarean section .

Following delivery , maternal assessment for cervical and vaginal lacerations . baby to be reviewed by neonatologists . complete documentation of events .

(b) I would review delivery notes to determine risk factors for shoulder dystocia like diabetes , obesity , prolonged first or second stage . If she is diabetic , approriate glycemic control preconceptually and antenatally reduces the risk of fetal macrosomia and consequently shoulder dystocia . If not diabetic , screening for diabetes using glucose tolerance test at 28 weeks . assessment of fetal weight clinically and by ultrasound rocognising that both methods are poor predictors of fetal weight . offer elective caesarean section for diabetic women with suspected macrosomia . Otherwise patient is offered chance to choose between vaginal delivery and elective CS .
Posted by M E.
SAM
a) Shoulder dystocia is diagnosed after routine traction is applied in an axial direction. Once diagnosed i will call for help from senior obstetricain, pediatric resuscitation team, anaesthetic team and midwife. Accurate documention should be commenced by a member of the team to record events, manoeuvres and time. Blood investigations such as FBC and blood for GXM should be taken simultaneously.
Mother should be informed of the situation and pushing should be stopped, since this may further impact the fetal head. Mother should be repositioned to bring the buttocks to the edge of the bed.
Mc Roberts manoeuvre, where there is flexion and abduction of the maternal hip and the thighs brought to the mothers chest. This straightens the sacrum relative to the lumbar spine, causes cephalic rotation of the pelvis which can help free the impacted shoulder. It has a success rate of 90%. It can be used in conjuction with suprapubic pressure applied in a downward and lateral direction. This reduces the biacromial diameter and pushes the anterior shoulder beneath the symphysis pubis. Fundal pressure should not be given.
If these maneouves fail, an episiotomy may be given to facilitate room for maneouveres such as delivery of the posterior arm or internal rotation of the shoulders. It also reduces the incidence of severe lacerations.
Internal maneouvres should be performed to deliver the posterior arm and shoulder. The fetal trunk may follow or the arm can be used to rotate the fetal trunk to aid delivery. It is associated with the risk of humeral fractures.
If these fail, the patient can be placed in the all fours position, since this increases the anterioposterior diameter and facilitatees other maneouvres.
Extreme measures such as Zavanelli manoeuvre and symphysiotomy should only be performed as a last resort. It associated with severe perinatal hypoxia and fetal death.
Upon delivery the baby should be handed to the pediatric resuscitation team. Active management of the third stage should be performed, since she is at risk of PPH. The perineum should be systematically examined for 3rd and 4th degree laceration. Parents should be debriefed of the preceeding events. Reporting form should be fulled out after delivery.

b) Patient should be counselled that she has a 1 - 16% chance of recurrence of shoulder dystocia in her future pregnancies. She should be avised about weight reduction if obese since this is a risk factor for shoulder dystocia.
She should be advised that her antenatal care in her future pregnancies should be in a consultant lead unit, so a plan for delivery can be constructed. Elective caesarean section should not be offered to reduce the risk of shoulder dystocia. Screening should be performed for diabetes in her next pregnancy. SErial ultrasound should be performed after 24weeks to evaluate fetal growth.
Written information about shoulder dytocia should be given to patient and counselling documented in mother\'s notes
Posted by Ulduz A.
UA
a)It is an obstetric emergency.We have to call for help senior obstetrician,neonatologist and senior anaestetist.Time when head delivered asked and fixed in the notes.Shoulder distocia should be managed systematically.MacRoberts manoeuvre is the single most effective intervention and should be performed first.Need for episiotomy will be assessed.MacRobert\'s manoeuvre is flexion and abduction of the maternal hips which straightenes the lumbo-sacral angle and rotates rhe pelvis cephalad.It is the single most effective intervention with success rate of 90%.
Suprapubic pressure should be employed together with MacRobert\'s manoeuvre.Suprapubic pressure reduces the bisacrominal diameter and rotates the anterior shoulder into the oblique pelvic diameter.It is advised that this is applied for 30 seconds.
If primary manoeuvres fails,secundary manoeuvres should be tried.If women is slim and no epidural anaesthesia the-all-fours position is appropriate, which has 83% success rate.For less mobile woman with epidural internal manoeuvres will be more appropriate.
Rotation of fetal shoulders into an oblique diameter or by a full 180-degree rotation of the fetal trunk is tried.
Delivery of the posterior arm can facilitate delivery of fetal trunk but has high complication rate.
If first and second line manoeuvres fails, third line manoeuvres may tried, but they are acossiated with maternal mortality and morbidity.Cleidotomy is bending the clavicle with a finger or surgical division,symphysiotomy is dividing the symphyseal ligament and the Zavanelli manoeuvre is cephalic replacement of the head.It should be remembered that at this stage most of the fetuses are irreversibly acidotic.
After delivery of the baby active management of third stage should be carried out to reduce of risk of PPH.Careful inspection of cervix,vagina and perineun carried out to reveal 3rd and 4th degree tears and proper repairing.
Risk management form should be filled up.Proper notes written with corect timing and signed.Records should include when baby delivered,Apgar score,cord blood gases and staff present.It is important to determine which shoulder was anterior because damage to the posterior shoulder plexus is not due to shoulder dystocia.Patient and partner debriefed and questions answered.
b)Woman should be informed thatthere is relationship between fetal weight and shoulder dystocia, but around 48% of shoulder dystocia occurs in infants with birth weight less than 4000 grams.Woman should know that shoulder dystocia is unpredictable and unpreventible event.She should be informed that if she has no diabetes,routine ionduction of labour will not prevent risk of shoulder dystocia.If she found to be diabetic,tight diabetic control and 2-weekly growth scans starting from 24 weeks can predict fetal macrosomia.Planned caesarean section should be considered to reduce the potential morbidity if fetal macrosomia accosiated with maternal DM.Written information should be provided.
Posted by Ulduz A.
UA
a)It is an obstetric emergency.We have to call for help senior obstetrician,neonatologist and senior anaestetist.Time when head delivered asked and fixed in the notes.Shoulder distocia should be managed systematically.MacRoberts manoeuvre is the single most effective intervention and should be performed first.Need for episiotomy will be assessed.MacRobert\'s manoeuvre is flexion and abduction of the maternal hips which straightenes the lumbo-sacral angle and rotates rhe pelvis cephalad.It is the single most effective intervention with success rate of 90%.
Suprapubic pressure should be employed together with MacRobert\'s manoeuvre.Suprapubic pressure reduces the bisacrominal diameter and rotates the anterior shoulder into the oblique pelvic diameter.It is advised that this is applied for 30 seconds.
If primary manoeuvres fails,secundary manoeuvres should be tried.If women is slim and no epidural anaesthesia the-all-fours position is appropriate, which has 83% success rate.For less mobile woman with epidural internal manoeuvres will be more appropriate.
Rotation of fetal shoulders into an oblique diameter or by a full 180-degree rotation of the fetal trunk is tried.
Delivery of the posterior arm can facilitate delivery of fetal trunk but has high complication rate.
If first and second line manoeuvres fails, third line manoeuvres may tried, but they are acossiated with maternal mortality and morbidity.Cleidotomy is bending the clavicle with a finger or surgical division,symphysiotomy is dividing the symphyseal ligament and the Zavanelli manoeuvre is cephalic replacement of the head.It should be remembered that at this stage most of the fetuses are irreversibly acidotic.
After delivery of the baby active management of third stage should be carried out to reduce of risk of PPH.Careful inspection of cervix,vagina and perineun carried out to reveal 3rd and 4th degree tears and proper repairing.
Risk management form should be filled up.Proper notes written with corect timing and signed.Records should include when baby delivered,Apgar score,cord blood gases and staff present.It is important to determine which shoulder was anterior because damage to the posterior shoulder plexus is not due to shoulder dystocia.Patient and partner debriefed and questions answered.
b)Woman should be informed thatthere is relationship between fetal weight and shoulder dystocia, but around 48% of shoulder dystocia occurs in infants with birth weight less than 4000 grams.Woman should know that shoulder dystocia is unpredictable and unpreventible event.She should be informed that if she has no diabetes,routine ionduction of labour will not prevent risk of shoulder dystocia.If she found to be diabetic,tight diabetic control and 2-weekly growth scans starting from 24 weeks can predict fetal macrosomia.Planned caesarean section should be considered to reduce the potential morbidity if fetal macrosomia accosiated with maternal DM.Written information should be provided.
Posted by Bee N.
(Bee)


You are called urgently to attend a spontaneous vaginal delivery because of difficulties delivering the shoulders. (a) Discuss and justify your management [15 marks]. (b) The woman attends for post-natal review 6 weeks later and there are no complications. The birth weight was 4600g. How would you counsel her about the management of a subsequent pregnancy? [5 marks]

A)I will call for senior obstetric attendance as well as peadiatricians because shoulder dystocia is assoiciated with high rate of fetal morbidity (erbs palsy and neurological damage) and mortality and would need experienced accoucher. I will inform midwife or a colleague to arrange for cross matching of blood at least 4 units due to risk of PPH. I will appoint a time keeper to ensure time is not unduely wasted in any particular manauvre. Mortality rate after 5 minutes is between 40 -50%. Each manuavre should last 30 - 45 sec. I will then ask patient to stop pushing and ensure no further fundal pressure is exerted as ths can cause injury to baby who is suffering from a bony impaction. I will place patient in lithotomy and fully flex the hip and knees with adbuction of the hips (McRobert\'s position.) This alone usually disimpacts about 80% of all shoulder dystocia. If this does not work I will go on to ask an assistant to apply sustained or rocking suprapubic pressure while I attempt delivery. Next I will try to adduct the anterior shoulder after which I will attempt adduction of the anterior shoulder and rotation of posterior shoulder. Episiotomy may be needed to allow easy access for manauvering. If this still doesnt work, I will place woman on all fours before attempting surgical measures. Surgical measures will include trying to place head back into the pelvis and proceding to a ceasarean section(Zavenelli manauvre), fracturing of the clavicle or symphysiotomy and then delivery. After delivery I will consider use of oxytosics such as oxytocin infusion 40IU for 4 - 6hours and if need be consider transfusion if blood loss warrants it. There should be accurate documentation of all procedure carried out and an incident form filled. Patient will be debriefed after the procedure in the ward to inform of what happened, associated risk factors and prognosis for future pregnancy.

B)I will ask for her concerns and approach her in a sympathetic and sensitive manner.I will inform her that increased birth weight is an associated risk factor for shoulder dystocia despite the fact that most people with macrosomic babies will still deliver vaginally wthout shoulder dystocia. I will inform her that history of shoulder dystocia further puts her at risk. However in the absence of maternal complications and fetal complications there is no indication for ceasarean section as benefits of vaginal delivery still out weighs that of a section even with macrosomic babies. I will inform her that this will change if she is found to be diabetic in or outwith pregnancy(in such situations ceasarean section is adviced if baby is found to be macrosomic). If the baby has any morbidity(such as erb\'s palsy,neurological damage) or mortality, then ceasarean section will be available for her in future pregnancies. Ultimately, the choice is her\'s as to mode of delivery in future pregnancy. If she feels traumatised by the whole event, I will ask if she would like a psychiatric specialist referral.
Posted by Ida I.
I.

a).
She is having shoulder dystocia after routine traction in axial direction has failed, and this is an obstetric emergency. A call for help should be done immediately, and the team should include the senior obstetrician, senior midwife, paediatrician for resuscitation and the anaesthetist. Her buttocks has to be brought to the edge of the bed, and fundal pressure avoided, as this can increase the risk of uterine rupture. Evaluate the need for episiotomy, as it does not improve the risk of maternal or fetal morbidity and mortality. However, episiotomy can be useful in facilitating enter manouevers.
She has to be positioned in the McRobert\'s position, which is to pull the legs towards the abdomen in flexion and abduction. This will straighten the lumbosacral angle and rotate the maternal pelvis cephalad, thus increasing the diameter of the pelvic outlet. This can be the single most effective method with a high success rate of more than 90%. Suprapubic pressure can be emplyoed together with McRobert\'s position to improve success rate. Pushing the fetus towards the fetal chest will reduce the bisacromial diameter, and turning the baby to the oblique pelvic diameter.
If these two manouevers fail, internal rotation of the fetal trunk can be done, either by rotating the fetus to the oblique diameter or turning the baby a full 180 degrees. This will free the impacted anterior shoulder from the symphysis pubis. Delivery of the posterior arm can also facilitate delivery, whereby the arm can be used to rotate the trunk or the trunk may follow directly when traction is applied. However, delivery of the posterior arm is associated with risk of humerus fracture.
The patient can also be rolled into the all-fours position to facilitate delivery. This position has been reported to have an 83% success rate. However, it is more effective in a slim, mobile woman without epidural. In an obese woman with epidural, internal rotation would be more appropriate.
Third line manouevers need careful assessment by the senior obstetrician. They are rarely required, and are associated with higher risk of maternal and fetal morbidity. Third line manouevers include cleidotomy (bending of the fetal clavicle with a finger), symphysiotomy ( division of the symphysis ligament) or the Zavanelli procedure (pushing back the baby into the abdomen and proceed for caesarean section).

b)
She has to be advised to lose weight if she is obese, and has to be screened for diabetes in her next pregnancy. She also needs to be counselled that shoulder dystocia cannot be predicted, and can recur in her next pregnancy. She can be offered either a vaginal delivery or a caesarean section in her next pregnancy. Although elective caesarean section is not routinely offered, the decision has to be made between the woman and her carers. Fetal size and maternal preferance will also be taken into consideration in deciding on the mode of delivery in her future pregnancy.
Posted by Dr Dyslexia V.
X
a) Shoulder dystocia is an obstetric emergency which complicates about 1% delivery and should be recognized for its effect of morbidity, mortality and litigation impact on the healthcare. The emergency shoulder dystocia protocol should be initiated in regards to alerting the consultant obstetrician, the neonatologist, additional mid wifery staff and anesthetist. After taking a quick history in regards to the time of delivery of the head, maneuvers done and the fetal heart rate, then I would proceed with basic maneuvers. With the assistant of the mid wifery team I would do the McRobert’s maneuver which is hyperflexion and abduction and of the maternal hips to straighten the sacral curve the facilitate the delivery of the anterior shoulder. Additionally suprapubic pressure which should be applied by an assistance with McRobert’s maneuver with gentle traction to the head coordinated with the contraction will be helpful. Supra pubic pressure should be applied in a oblique direction to the posterior aspect of the anterior arm to dislodge it. Usually this basic maneuvers could successfully deliver about 60% of dystocia deliveries.

Advance maneuvers should be undertaken when the basic maneuvers fail. This involves internal manipulation and episiotomy should be considered for this purpose. The maneuvers include the internal rotation of the shoulders by rotating it into an oblique diameter or by rotating it by a full 180 degrees rotation of the fetal trunk to facilitate delivery. Otherwise attempt to deliver the posterior arm of the fetus by placing the fingers at the posterior aspect of the fetus and subsequently reaching the posterior arm and sweeping it across the anterior aspect of the fetus and delivering it. This maneuver is associated with significant fetal complication such as humeral fracture.

If this second line maneuvers fail and if fetal is still alive, maneuver such as Zavenelli should be attempted. It involves replacing the fetal head back into the pelvis and delivery by an emergency caesarean section. Other methods also include Cleidotomy in which the fetal clavicular bone is bended deliberately to facilitate delivery and it’s obvious association with clavicular fracture. Other methods include, Symphisiotomy in which the symphisial ligamen is divided after placing a urinary catheter in situ and pushing it to the side to facilitate delivery. This procedure involves significant pelvic maternal morbidity. After the delivery the presence of an extended tear which include a 3rd or 4th degree tear should be vigilantly looked for. There is also risk of PPH(post partum haermorage) in such deliveries and adequate measure should be taken.

Proper documentation should be done in regards to weight of baby, apgar score, cord blood gas, and the pediatric assessment of the fetus and where the fetal head was facing for post delivery debriefing and future litigation purpose.

b) Counseling should include regarding the events that took place and the maneuvers involved in delivering the baby inspite the good outcome. If any PPH or extended tear occurred during delivery than the symptoms of anal incontinence or symptoms of anemia should be ascertain. She would be adviced to do a glucose tolerance test for the subsequent pregnancy to identify gestational diabetes mellitus. She should be reassured that she would be reassessed again the next pregnancy and she will be given option for a caesarean section in which the morbidity must be explained and her vicious are taken into accord. A more cautious and low threshold for caesarean section will be advocated for her next pregnancy. Her next delivery should be done in a consultant lead unit and attended by a senior staff with adequate training in handling shoulder dystocia. She should informed that routine caesarean section is not advocated to prevent shoulder dystocia.
Posted by Shamita S.
ANS
(A) The head to shoulder delivery interval should be about 5 mins so this situation needs urgent attention with systematic and careful management to avoid hypoxia and acidosis,foetal trauma and even neonatal death.Extra help to be called for which would include midwifery assisstance ,a senior obsterician ,a paediateric resusitation team and an anaeasthetist.Routine traction in an axial direction to diagnose dystocia ,it should not involve lateral and downward traction as it is more likely to cause nerve avulsion.A tightly applied head to the vulva and even retracting ,with failure of restitution would further suggest shoulder dystosia .
Maternal pushing to be discouragedd as it would lead to further impaction .The woman should should be brought to the edge of the table .
Mcroberts mannuvuer is the most effective intervention which involves acute flexion and abduction of maternal hips, positionig the maternal thighs on the abdomen an dhence straightening the lumbosacral angle .this has a success rate of 90%.Supra pubic pressure can be applied to improve success rate.
There is no role of fundal pressure as it is associated with increasd rate of complication.
If this fails then all four position may be considered depending on the patient profile like a thin patient without epidural anaesthesia .it is associatedd with success in about 80%.
Manoeuvers like delivery of posterior arm or internal rotation to be conducted .There is no definite advantage of one procedure over other so clinical judgement and expeirince should be used to decide on the manoeuvers
An episiotomy would help to do the manipulations ,but there is no role of a routine episiotomy in the management of shoulder dystocia .
If the baby is still undelivered the last resorts like symphysitomy and cleidotomy to be done ,but the associated maternal mortality and morbidity to be considered.
Cephalic replacement of the head and delivery by caeserean section can be an option but success rates vary .If there is fotal death by this time destrctive operations to be considered by a person trained to do this .
After delivery the possibility of PPH to be looked for cautiously .The perinium to be examined thourougly to look for perineal tears .
Appropriate documentation of a difficult and taumatic delivery to be done .It is important to record the time of delivery of head the time of delivery of baby and the apgar score of the baby.
(B)The woman should be informed that that there is a recurrence of shoulder dystocia in the next pregnancy in about 16%..So she should be asked to deliver in an obstetric unit only.S he should be informed that there is no role of routine induction of labour to prevent shoulder dystocia .since her baby has not had any trauma she can be allowed a vaginal delivery .casearean section is indicated if the woman wishes to,or her carers feel so.she should be offred a screening test for diabetes in her next pregnacy.
Posted by Harry B.
HB
You are called urgently to attend a spontaneous vaginal delivery because of difficulties delivering the shoulders. (a) Discuss and justify your management [15 marks]. (b) The woman attends for post-natal review 6 weeks later and there are no complications. The birth weight was 4600g. How would you counsel her about the management of a subsequent pregnancy? [5 marks]

A. I would ensure further help from the anaesthetist, neonatalogist, senior midwife on labour ward, two other midwives and consultant obstetrician is called for. I would ask the anaesthetist to speak to the woman and reassure her and ask one of the midwife to scribe the events. I would brief the woman of the complication and advise her against voluntary pushing. The woman will be laid flat, bottom to the edge of the table and the legs will be placed in McRobert’s position by two midwives while I attempt routine axial traction on the fetal head. McRobert\'s position involves hyperflexion and abduction at the hips which will straighten the maternal lumbosacral curvature and rotates the pelvis cephalad. This is easy and effective in delivering shoulders in about 90% shoulder dystocia. A third midwife will apply suprapubic pressure, either continuos or rocking from behind the fetal anterior shoulders for 30 seconds in an attempt to reduce the bisacromial diameter and to bring the shoulders into oblique direction which along with McRobert\'s position has a very high success rate.
If the above fail, then I would evaluate for episiotomy (perform one if required) to get more space for enter manoeuvres (Rubin II, woodscrew and reverse woodscrew) in an attempt to deliver the shoulders by rotating into oblique direction. If these fail, then I would try to remove the posterior arm to facilitate the body to follow or by rotating the body to 180 degrees. This is associated with higher risk of fracture humerus.
Third line manoeuvres would be considered when a senior help available, that include cleidotomy (bending of the clavicles), symphisiotomy or deliver by caesarean section by pelvic replacement of the fetal head (Zavenelli’s technique). These procedures are associated with high maternal morbidity and mortality with Zavenelli’s technique and will depend on the fetal condition at that stage.
Particular attention will be paid to prevent PPH by actively managing the third stage and careful assessment of the perineal tears. The documentation would include the time of delivery of the fetal head, direction of the head facing after restitution, staff involved and the time they arrived, manoeuvres attempted and their duration, time of delivery of the body and the condition of the baby at birth including blood gases for pH and base excess.
A thorough debriefing will be required before the discharge, by a senior obstetrician involved in the care and a follow up appointment for a formal debriefing.


B. I would encourage her to loose weight if she is obese. I would advise formal testing for detecting gestational diabetes mellitus by organising a glucose tolerance test between 24-28 weeks (earlier if any other indicators in future pregnancy). I would recommend an ultrasound scan for fetal growth at around 36 weeks to estimate the fetal growth so that a discussion regarding mode of delivery can be made. I would encourage her to aim for vaginal delivery (if no other contra-indications), but warn her of the poor predictability for the occurrence and increased risk of recurrence of shoulder dystocia. I would also offer her and consider an elective caesarean delivery at 39 weeks if the woman is anxious to try for a vaginal delivery provided the woman makes an informed choice after weighing the benefits and risks of vaginal delivery and caesarean section.
Posted by Seham S.
SE-SA

(a) Shoulder dystocia has increase risk of perinatal morbidity and mortality.47% of babies died after delivery of head within 5 minutes.So, managment of problem should be efficient to avoid hypoxia,acidosis and trauma.I will call for help (senior obstetrician,midwife,anaesthetist and neonatal team). I will ask woman to stop pushing as it may lead to more impaction of shoulders. Fundal pressure should not be done . McRobert manoeuvre is the single most effictive intervention.It is flexion and abduction of maternal hips.It has success rate of 90%.Suprabupic pressure can be employed together with McRobert manoeuvre to improve success rate . Pressure should be downward and lateral. It reduce bisacromial diameter and rotate the anterior shoulder into oblique pelvic diameter.It is advised for 30 seconds. If this first line manoeuvres failed , so there is choice to be made between all four position and internal manipulations.All four position is tried with 80% success rate.It can be used in slim patients without epidural anaesthesia while in less mobile patients with epidural anaesthesia and presence of senior obstetrician,internal manoeuvres are more appropriat. No advantages between delivery of posterior arm and internal rotation manoeuvres.It depend on clinical experience and judgment.In such cases episiotomy may be considered.If first and second line manoeuvres failed ,so third line manoeuvres requir careful considerations to avoid unnecessary maternal morbidity and mortality.It include cleidotomy,symphysiotomy and zavanelli manoeuvre which are rarly used.After delivery prophylactic measures should be taken againist postpartum haemorrhage.third and fourth degree perineal tear is another complication which should be looked for and managed.Immediat care of baby should be taken by neonatal team. Incident form should be filled . Accurat documentations of sequences is essential. Time of delivery of head,direction of head after restitution,the manoeuvres performed and their timing, time of delivery of body.Also, staff attendance and time they arrived. Condition of baby and umbilical cord acid-base measurment.

(b) woman should know that 50% of shoulder dystocia occur in babies weighing < 4000 gm so the condition is highly unpredictable and unpreventable. If her BMI is increased ,so she should be encouraged to reduce her wieght to decrease incidence of macrosomia. GTT could be done to diagnose diabetic patients and glycaemic control could be achieved early to reduce incidence of macrosomia.Induction of labour (IOL) for suspected macrosomia does not improve fetal or maternal outcome. Early IOL in diabetic patients treated with insulin may reduce the risk of fetal macrosomia and reduce shoulder dystocia.Elective c/s for suspected macrosomia in non diabetics is not recommended ,however in diabetic patients if wt. > 4.5 kg c/s is considered .
Posted by Green K.
This is an obstetric emergency. I will seek help from consultant obstetrician, consultant anesthetist and senior experienced midwife. Theatres and neonatologist would be informed due to potential need for Caesarean section and baby needing advanced neonatal support post delivery. Assessment will be made regarding need for episiotomy which would facilitate internal manoevers. Patient\'s legs would be placed in McRobert\'s position. This straightenes the maternal spine resulting in an increse in the anterior- posterior diameter of the pelvis. Suprapubic pressure would be applied over the suprapubic area of the patient to disloge the anterior shoulder from the symphysis pubis. It should be applied in a manner that the pressure is applied from posterior aspect of the anetrior fetal shoulder. Fundal pressure is avoided as it causes further impaction of the fetal shoulder on the symphysis pubis. Enter manouver will be done to delivery of the posterior arm in a sweeping motion across the baby\'s face. Wood\'s screw manouver to rotate the baby\'s body to dislodge the impacted shoulder. All manouver\'s will be attempted again if fail. Patient placed on all fours and repeat manouvers. If fail, Zavanelli\'s procedure will be done to replace baby\'s head into the vagina and deliver by caesarean section. Symphysiotomy is another option if experienced help is available but is associated with increased maternal morbidity and risk of bladder and urethral injury. Cord pH will be done to assess severity of acidemia. Neonatologist to be present to assess neonate upon delivery which woudl likely require advanced neonatal support. Incident reporting done for risk management purpose. Accurate recording of delivery events is essential for audit and in case of litigation in the future.

b) Explain to patient that shoulder dystocia is difficult to predict as majority of it occurs in fetus less than 4 kg. Increased risk if patient has gestational diabeets mellitus. Recommend fasting blood glocose 6 weeks post partum to detect underlying diabetes mellitus. Recommend oral glucose tolerance test before 12 weeks in the next pregnancy. If normal, to repeat between 24 to 28 weeks gestation to detect gestational diabetes mellitus. Offer 4 weekly growth scans from 28 weeks to detect macrosomia. Presence of macrosomia above 4.5kg would warrant delivery by Caesarean section. Advice hospital delivery due to potential need for emergency obstetric assistance, Caesarean section and advanced neonatal support. Patient information leaflet on shoulder dystocia and written information on the plan for next pregnancy provided to patient.

Posted by shmaila S.
DR.SAS
a) Routine traction in axial direction is employed to confirm the diagnosis of shoulder dystocia.This is an obstetric emergency.Woman,her partner and nursing staff should be informed that there is a difficulty in delivery of shouldres..Senior obstetrician,anaesthetist,paediatrician and midwife should be called for help.A SHO should be asked to maintain i/v access and take blood sample for FBC and group and save,as there is an increased risk of PPH and perineal injury.Maternal pushing should be discouraged,as it may lead to furthar impaction of shoulders.She should be placed in lithotomy position and manouvered to bring the buttocks to the edge of bed.Fundal pressure should not be employed as it is associated with an unacceptable high neonatal complication rate and may result in rupture uterus.A staff should be assigned to accurately document the events with time.Evaluation for episiotomy should be done,it may facilitate in internal manouvers but it is not mandatory.Mother,s hips should be flexed and abducted,thighs should be positioned on her abdomen(Mc ROBERTS manouver).It is the single most effective manouver,successfull in upto 90% caes and employed as the first line intervention.It straightens the lumbosacral angle and flattens the sacral promontory which helps in the delivery of impacted shoulder.An assistant should be asked to apply suprapubic pressure over the fetal anterior shoulder,in CPR style for 30sec.The shoulder will adduct or collapse anteriorly and pass under the symphysis.If these procedures fails then second line intervention should be employed.Rubin\'s manouver,which consists of pushing from behind the anterior fetal shoulder towards the chest.This procedure will adduct or collapse fetal shoulder girdle,reducing its diameter.If unsuccessfull,Wood\'s screw manouver should be combined with it.Posterior fetal shoulder is approached from front of fetus and rotated in the same direction as rubins.Shoulder may rotate and delivery may be successful.Delivery of the posterior arm should be attempted if above procedures does not result in delivery.Posterior arm is followed to the elbow,arm is flexed and the forearm is sweeped across the fetal chest.It is associated with a high complication rate(12% humeral fracture).If all these manouvers fails to release the impacted shoulder than the woman should be rolled to all four-position(not possible with epidural).In this the pelvic diameter increases and the fetal shoulder may dislodge.After persistent failure of first and second line manouvers,third line manouvers should be considered carefully to avoid unnecessary maternal morbidity and mortality.Consultant obstetrician and anaesthetist should be informed.Cleidotomy(bending the clavicle with finger),Symphysiotomy (deviding the ligament) or Zavanelli manouver(cephalic replacement of head and deliver by c/s) should be considered.Baby should be reviewed by the padeatricain after delivery as there is an increased risk of brachial plexus injuries and birth hypoxia.Paired cord blood samples should be taken.Third stage should be manged actively as there as an increase risk of PPH.Systematic vaginal and rectal examination should be done to exclude third/fourth degree perineal tears.Accurate documentation should be done on the pro-forma due to potential medico legal consequences.Clinical incident report form should be completed for the purpose of risk management.The woman and her partner should be de-breifed about the events of this difficult and potetially traumatic delivery.

b)She should be informed that recurrence risk of shoulder dystocia is 1-16%.Risk assessments for the prediction of shoulder dystocia is insufficient to allow prevention in majority of cases.50% of incidence of shoulder dystocia occurs in infants with birth wieght <4000gm.She should be offered screening for diabetes pre-pregnancy or at 24-28 weeks in the next pregnancy.Serial growth scans should be done to detect fetal macrosomia in subsequent pregnancy.She should be informed there is no evidence to support IOL in women without DM at term where the fetus is thought to be macrosomic.Elective c/s is not recommended for fetal macrosomia at term without DM.She should be informed that elective c/s in not recommended routinely for a previous history of shoulder dystocia.The decision for vaginal devliver or c/s will depend on her wishes.
Posted by tahira jabeen J.
tj)
a)
i will rush immediately as it is an acute obstetric emergency .as 5 min delay in dekivery can lead to fetal demise.i will call for help
of senior obstetrician ,senior midwife,anesthetist,neonatal team.
i will examine the pt abdomen to see how big baby is,vaginal examination to see if episiotomy is required,see back of baby as it will give idea which side to apply supra pubic pressure.i will explain mother about situation and advise her to stop bearing down as it may impact shoulders more.fundal pressure is not recomended.patient should be in lithtomy position & macroberts manouver with supra pubic pressure towards down & laetral.it will increase anterior posterior diameter of pelvis can help to dislodge impacted shoulder .more than 90% shoulder dystocias can be resolved with this method.if it is not sucessful then 2d line procedures like internal rotation of delivery of post. shoulder will be attemptedcan lead to humerus fracture in about 12% cases.then allfour position will be tried as it may help by delivering post shoulder first. .if still not delivered 3rd line methods which are destructive will be tried like clavicular fracture or symphysiotomy can be donein case all manouvers failed last resort is zuvenelles method to reisert head and delivery by LSCS.
baby will be delivered and handed over to paeds for resustitation and assessment of any trauma happened.cord PH will be taken.
after delivery of placenta .i will antcipate PPH will take all measures for active management of third stage.i will explore vagina ,cx & prenium to r/o any trauma as risk of preneal tear is more with shoulder dystocia.i will suture episiotomy if performed.
full documentation of event will be done.incident report i will write as part of risk management.post natal ward patient will be seen reassured about baby by paeds about baby progosis.as only 10% babies will have permenent demage after brachial plexus injury if it happened .debriefing to patient after delivery.
B)
as pt risks must have been assessed .so pt will be informed about most likely cause of shoulder dystocia.Pt will be explained about that as shoulder dystocia is unpridtable & unpreventable because it can be predicted in only in 16% cases and 48% case are low risk or normal wt babies.
routine IOL & LSCS is not routinely recomended to prevent shoulder dystocia in non diabetic women.but can reduce risk in diabetic women with macrosomic babies.
there is risk of recurrence about 1-16% so pt will be counselled about mode of delivery in subsequent pregnancy.she can be offered Lscs in next pregnancy .she should be informed if she is obese by decreasing weight risk of macrosomic baby will be rduced before next pregnancy.if she is diagnosed diabetic ,good glycemic control will also help to reduce incidence of macrosomic baby .but as baby did not have any complication she may opt for vaginal delivery with all precautions during preg and delivery to miimize risk of shoulder dystocia.
since baby is normal
Posted by Bgk H.

a. This is obstetrics emergency, appropriate and timely management needed to reduce the incident of maternal and fetal morbidity and mortality. I will call for help including senior obstetricians, midwives, SHO and neonatologist as skilled operator and enough manpower needed to position the patient, time keeping and for neonatal resuscitation. I will attend the patient, introduce myself and explain the situation. This will calm the patient and avoid unnecessary tension as patient cooperation is needed. I will discourage her to push further as this will further impact the shoulder. I will then put the patient at the edge of the bed as this will facilitate the manoeuvre of traction. I will the put her in Mc Robert position as this will flatten the sacral bone and widened the anterior posterior diameter. I will then ask someone to give a suprapubic pressure to push the anterior shoulder anteriorly and make the shoulder in oblique position and enable it to pass through a wider oblique diameter. Combination of Mc Robert and suprapubic pressure can also be perform. I will then evaluate the episiotomy to make sure there is enough room for internal manoeuvre. I will perform internal manipulation such as wood screw or reverse woodscrew to turn the baby shoulder anteriorly and posteriorly to fit the wider oblique diameter of pelvic outlet. If there is not enough manpower to position he patient and if she is thin and good mobility, all four position can be done. If still fail I will then deliver her posterior shoulder this will reduce the width of the fetal shoulder and relieve the impaction. I will then do symphysiotomy and cleidotomy to widen the diameter. If all the procedure fail, then I will perform Zavanelli manoeuvre to return the head inside and need to do caesarean section. If fetus is not alive, decaputation need to be considered. As this situation associated with higher risk of genital tract trauma, careful inspection of the perineum need to be done after the incident. Full incident reporting and documentation should be done. Debriefing of the situation should be given.

b. I will counsel her that there is increase risk of recurrence of shoulder dystocia to compare with women with previous normal delivery. However previous data recurrence for shoulder dystocia is bias. I will advice her to reduce weight if she obese and she need to be screened for diabetes for next pregnancy. if she keen for vaginal delivery her decision need to be documented and another episode of shoulder dystocia need to be anticipated.
Posted by Bgk H.

a. This is obstetrics emergency, appropriate and timely management needed to reduce the incident of maternal and fetal morbidity and mortality. I will call for help including senior obstetricians, midwives, SHO and neonatologist as skilled operator and enough manpower needed to position the patient, time keeping and for neonatal resuscitation. I will attend the patient, introduce myself and explain the situation. This will calm the patient and avoid unnecessary tension as patient cooperation is needed. I will discourage her to push further as this will further impact the shoulder. I will then put the patient at the edge of the bed as this will facilitate the manoeuvre of traction. I will the put her in Mc Robert position as this will flatten the sacral bone and widened the anterior posterior diameter. I will then ask someone to give a suprapubic pressure to push the anterior shoulder anteriorly and make the shoulder in oblique position and enable it to pass through a wider oblique diameter. Combination of Mc Robert and suprapubic pressure can also be perform. I will then evaluate the episiotomy to make sure there is enough room for internal manoeuvre. I will perform internal manipulation such as wood screw or reverse woodscrew to turn the baby shoulder anteriorly and posteriorly to fit the wider oblique diameter of pelvic outlet. If there is not enough manpower to position he patient and if she is thin and good mobility, all four position can be done. If still fail I will then deliver her posterior shoulder this will reduce the width of the fetal shoulder and relieve the impaction. I will then do symphysiotomy and cleidotomy to widen the diameter. If all the procedure fail, then I will perform Zavanelli manoeuvre to return the head inside and need to do caesarean section. If fetus is not alive, decaputation need to be considered. As this situation associated with higher risk of genital tract trauma, careful inspection of the perineum need to be done after the incident. Full incident reporting and documentation should be done. Debriefing of the situation should be given.

b. I will counsel her that there is increase risk of recurrence of shoulder dystocia to compare with women with previous normal delivery. However previous data recurrence for shoulder dystocia is bias. I will advice her to reduce weight if she obese and she need to be screened for diabetes for next pregnancy. if she keen for vaginal delivery her decision need to be documented and another episode of shoulder dystocia need to be anticipated.
Posted by fluffy F.
From Fluffy
a)Shoulder dystocia is defined as the need to deliver the babys\' shoulder with additional obstetric maneuvers when the normal down ward traction has failed to delivery the babys\' shoulders.This is a obstetric emergency. I will immediately call for help , from 2 senior midwives , a senior obstetrician , paediatrician and the anaesthetist. I will explain to the patient quickly regarding happenings and not to push as this will further worsen the condition.Bring the mothers buttocks to the edge of the bed. Perform the McRoberts manoever with the 2 senior midwives to hold the legs, flex and abduct the maternal hips . the mothers thigh should touch her abdomen.This allows the straightening of the lumbosacral angle and pushes the maternal pelvis cephalad , thus increases the uterine pressure and amplitude of contraction and is successful in 90% of cases . This is the safest and single most successful maneuver if done properly. If not successful , attempt the suprapubic pressure, the assistant applies pressure for about 30 seconds at the suprapubic area to dislodge the anterior shoulder impacted under the symphysis pubis. The pressure should be applied toward the direction the fetus is facing , forward pressure applied from the posterior aspect of the fetal back. Usually these 2 maneuvers are sufficient to deliver the fetus. If still not successful , an episiotomy can be done to facilitate performing the internal maneuvers. The woods screw maneuver , the acoucher inserts his hand into the posterior shoulder and rotates it 180 degrees to disimpact the anterior shoulder. If the acoucher is better experienced with delivery of the posterior arm , where the acoucher inserts his hand posteriorly , and identifies the posterior arm upto the babys\' wrist and rotates it in front of the babys\' chest and delivers the posterior arm.this can be attempted as well. Delivery of the posterior arm has high risk of fracture humerus , thus should be done by an experienced acoucher.If the second line fails , the third line maneuvers , cleidotomy - the clavicle of the baby is fractured to reduce the biacromial diameter to deliver the shoulders, Zavanellis\' method- pushing back the babys\' head into the mothers pelvis and deliver by an emergency caesarean section, or symphysiotomy - to assist delivery of the shoulders are the third line manoevers.The all fours method , can be attempted when the patient is not obese and not on epidural as it can be otherwise difficult to place the patient on all fours. Maternal complications -
Perineal injuries , third and fourth degree tears , post partum haemorhage are the usual complications after a shoulder dystocia and resussitation and careful evaluation of the perineum must be done after delivery. The baby must be examined by pediatrician standy for the delivery and resuscitation done as needed.
Documentation and counselling is a important aspect of management for shoulder dystocia.The babys\' arterial cord blood pH for evidence of hypoxia, Apgar score , the direction the babys\' face was facing during delivery as this can determine if the anterior or posterior shoulder was impacted .,the timing of delivery of the shoulders and subsequently the body , the doctors and nurses involved in the incident and the happenings and procedures done to deliver the baby must be clearly documented. The parents should be counselled after the event and explanation given regarding the mothers and babys\' condition.

b) Approach to counseling should be sympathetic and sensitive to the issues that worries the woman as the delivery per say is usually traumatic to the patient.Reacess the case for any risk factors ,such as maternal diabetes mellitus, previous history of shoulder dystocia,maternal body mass index more than 30, prolong 1st and second stage of labour, induction of labour, secodary arrest and augmentation which are factors usually associated with shoulder dystocia. However , these risk factors are not sufficient to allow prevention of shoulder dystocia in most cases and I will explain this to the couple.I will explain to them that shoulder dystocia is not a predicatable and preventable event.If she has diabetes mellitus with a macrosomic baby suspected in her next pregnancy , then elective caesarean section should be offered . Otherwise, there is no definitive role of prevention of shoulder dystocia by a elective caesaraen section in her next pregnancy.However the mothers choice should be considered in decision making.
Posted by SUNDAY A.
I would attend immediately bearing in mind that urgent and successful intervention will reduce perinatal morbidity and mortality. I would follow the unit’s protocol and skill drills for dealing with shoulder dystocia using the HELPPER mnemonic. I would call for help from consultant Obstetrician to attend, senior midwives and labour ward coordinator. I would introduce myself to the patient informing her of the situation and the need for intervention. I would proceed by asking for the bed to be flattened and an assistant asked to document. I would take over the delivery from the attending midwife and evaluate the need for episiotomy. I would ask my assistant to place the legs in McRobert’s position as this alone is sufficient in delivering
the anterior arm in 70% of case. It works by increasing the lumbar sacral curvature thereby creating additional space for the arm to be delivered. If unsuccessful I would proceed to gentle suprapubic pressure (rocking movement) by my assistant towards the direction of the baby’s back to dislodge the anterior arm. After 30secs if unsuccessful I would proceed to ‘enter’ manoeuvres which may involve wood screw or reverse wood screw technique. This aims to rotate the shoulder with the possibility of dislodging the anterior arm. If this fails, the next step is to try and deliver the posterior arm. An attempt is made to deliver the posterior arm which would make it possible to deliver the baby. If this fails, the mother can be placed
back on all fours or a repeat of the above steps or to attempt other manoeuvres such as symphysiotomy or Zafanelli’s procedure if there is time, expertise and baby is still alive. I would ensure baby is delivered within 6 minutes as the perinatal mortality including fetal death increases significantly afterwards. After the delivery I would document my findings, events and delivery in the notes with particular emphasis on the time I was called to attend delivery, time head was delivered, and time the shoulders and baby was delivered. I would document the position of the anterior shoulder which has a great medico legal implication if the baby developed erb’s palsy subsequently.
I would debrief the patient and the family afterwards. An incident report would be filled. Debriefing of staff would be done and lessons learnt as per unit\'s protocol.

I would reassure and advice her that there is no contraindication to vaginal delivery. This is because 50% of shoulder dystocia occur in deliveries with birth weight less than 3.5kg. I would inform her that often times it is difficult to predict but having a high index of suspicion based on the presence of risk factors would reduce the associated risk and improve neonatal outcome. I would advice for a glucose tolerance test at 28 weeks to rule out gestational diabetes which might have an impact on the pregnancy and baby’s weight. I would organise a growth scan to estimate foetal weight (EFW) at 37 weeks and elective caesarean would be offered if baby is more than 4.5kg. An early induction of labour at 39 weeks can be justified if EFW is more than 4kg. I would inform her that routine episiotomy, delivering in the upright or standing position does not seem to reduce the risk of recurrence of shoulder dystocia.
Posted by R S.
R S

a. Rapid assessment is done including duration since head delivery and general condition of the mother. MaCRobert maneuver is applied, it include hyperflextion and abduction of both thighs which can enlarge pelvic diameter and help release of impact shoulders. Suprapubic pressure is applied by assistance, it can reduce biacromial diameter of fetal shoulders. The baby is pulled in axial direction in a controlled manner. This maneuver is successful in majority of cases; however, if fail a trial of internal rotation is attempted by pressing on posterior aspect of anterior fetal shoulder or from the front of posterior shoulder, the rotation is toward the symphysis. Episiotomy is done to help for fetal manipulation.
Attempt to deliver the posterior are by flexion and sweeping of forearm in front of chest, this can help by providing space in the posterior compartment and release anterior shoulder.
These steps should be done simultaneously and avoid delay as it is associated with increase perinatal morbidity and mortality. The baby should be pulled gently and avoid forceful traction to avoid fetal injury. Roll on all four is attempted also, this can increase pelvic dimensions. If the baby not delivered, we can do cleidotomy, symphysiotomy which are invasive methods, also the head can be pushed upward and the mother is delivered by emergency CS. Cord blood should be sent for PH and base deficit measurements. The baby is resuscitated by expert resuscitator. Clear documentation and timing is essential to avoid litigation. Perineum is checked as there is increased incidence of third and forth degree perineal tears.

b. Appropriate history is taken including history of GDM in previous pregnancy, family history of DM in first degree relative. Ethnicity is also explored as there is high incidence of DM in south Asian and Middle East people.
BMI is calculated. If the woman is obese or over weight, she is advised to reduce weight before embarking on pregnancy in future as this can reduce incidence of shoulder dystocia. She will need a GTT at 26 weeks gestation to rule out GDM because her current baby is >4.5 kg which put her at increased risk of developing GDM. Serial growth scan will be needed fortnightly from 28 weeks to detect macrosomia. Vaginal delivery is not contraindicated provided that estimated fetal weight is less than 4.5 kg. Slow progress in the first or second stage of delivery should raise anticipation of shoulder dystocia as she has previous history of shoulder dystocia. If she selects to deliver by CS, her wishes should be respected.
Posted by Dr Asia  K.
Asia Khan
A-shoulder dystocia is an obstetric emergency associated with increased perinatal morbidity and mortality and maternal morbidity.I will take prompt assessment of the situation and call for help of senior obstetrician,anaesthetist,senior midwife,SHO and paediatric resuscitation team as crash call.I will follow the hospital protocols to deal with this emergency.I will ask the woman to stop bearing down .I will briefly explain to the woman about the situation.I will make sure that two wide bore intravenous canulae should be inserted .I will put her immediately start the MacRobert,s Manoeuvre which is the first single most effective intervention which is the hyperflexion of maternal hips,supra-pubic pressure and judicious traction and .I will evaluate for the episiotomy as well.If this fails,digital rotation of fetal shoulders in to oblique or transverse diameter by applying pressure on the posterior shoulder or repositioning on all fours depending on the woman,s mobility ,the availability of assistance and clinical judgement.Alternatively ,the posterior arm should be delivered.If these manoeuvres fail,the situation is extremely serious and interventions to be considered include cleidotomy,symphysiotomy or cephalic replacement and delivery by caesarean section.In the event of fetal death ,destructive procedures should be used.
Woman and her family should be debriefed.All the staff should be debriefed.Reterospective clear documentation of time taken to deliver the shoulders,manoeuvres involved,episiotomy,condition of the baby and any tears/lacerations and postpartum haemorrhage, should be done.Incident form should be completed.
B-Woman should be explained about the risk of recurrence which in her case will be 1-16%.She should be informed that if she is planning next pregnancy then she should be seen in consultant led antenatal clinic.She will be offered screening for gestationl diabetese as well.She should be informed that choice of delivery will depend on her wishes either elective caeserean section or vaginal delivery.In case of gestationl diabetese she will be having reiew by medical team and serial growth scans.However she sould be informed that induction of labour can not prevent shoulder dystocia.