Title: A reflective essay on how you would manage a shoulder dystocia as an obstetric emergency in a stand alone midwife led unit.
Undergraduate Degree Level Essay
The condition of shoulder dystocia is diagnosed when the delivery of the foetal head is prevented by the impaction of one of the foetal shoulders within the mother’s pelvis. Simple head traction or episiotomy alone will not resolve the condition
Shoulder dystocia is a complication of labour which is notoriously difficult to manage. It has a high complication rate and an increased rate of mortality. A number of studies have highlighted the fact that management is not always optimal. (Crofts, et al. 2006). Two UK studies produced similar findings that avoidable factors were identifiable in 66% of the perinatal deaths associated with shoulder dystocia. The definition of “avoidable factors” being a different management would have produced a better outcome.
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This malpresentation occurs in about 2% of vaginal deliveries and common associated morbidities include permanent brachial plexus injury, fracture of the clavicle, foetal haematoma and hypoxic brain injury. (Draycott, et al. 2008). Because the majority of cases of shoulder dystocia occur in the absence of predictable risk factors, all healthcare professionals in charge of a delivery should have an optimal plan to resolve shoulder dystocia in the safest way possible in any given circumstance.
The management of shoulder dystocia is a subject that has acquired a large literature in its own right. It is therefore not appropriate to discuss it in great detail.
Many of the studies done on the subject have identified a number of “critical tasks” in the delivery process. These include recognizing shoulder dystocia, asking for additional help, calling for paediatricians to be attend the delivery, applying gentle downward traction on the fetal head, placing the patient in McRobert’s position, and applying appropriate suprapubic pressure. (Deering, et al. 2005)
A number of mechanisms have been advised in the literature and these include rotational manoeuvre (Rubin’s or Woodscrew), episiotomy, delivery of the posterior arm, fracture of clavicle, symphysiotomy, all-fours manoeuvre, a cephalic replacement (Zavenelli) manoeuvre if other manoeuvres were not successful. (Crofts et al. 2008)
Shoulder dystocia appears to occur in cases where there are no discernable predisposing factors however, there are some conditions that appear to make it more likely. The strongest single predictor appears to be foetal macrosomia. A number of authorities have suggested that maternal obesity is an association of the condition, but the meticulous study by Robinson showed conclusively that it was only obesity in diabetic mothers (that was associated with macrosomia) that had a high incidence of shoulder dystocia. Other causes of obesity did not have this association. (Robinson, et al. 2003)
Gonen was able to report that a critical weight appeared to be 4,500 g with 33% of infants over this weight having shoulder dystocia and only 2% who were under it. (Gonen, et al. 1996)
There appears to be considerable controversy regarding the ideal birth position. The McRoberts position (with maternal hips in flexion), combined with suprapubic pressure, has been reported as resolving 50% of identified cases of shoulder dystocia (German, et al. 1997). It is thought to achieve its effect through a rotation of the symphysis pubis and flattening of the sacrum. This, together with fundal pressure, is believed to reduce the possibility of the anterior shoulder being impacted under the symphysis pubis. There are some reports of the possibility of increased maternal morbidity (Heath, et al. 1999) and lack of effect (Beall, et al. 2003)
On a personal note, I have reflected on my own practice in dealing with cases of shoulder dystocia. As a result of researching this essay I have resolved to further explore the evidence base for dealing with the situation, because critical analysis of some of the papers read have challenged some of the ideas that I had previously believed to be true.
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In particular, I note papers which have analysed the behaviour of the responsible clinician in cases of shoulder dystocia and have been concerned about the frequent lack of paediatric back up. This has been identified as a failure on the part of the lead clinician, who is often so engrossed in the management of the condition that back up is simply overlooked. I have personally experienced cases where this has occurred and believe that a high degree of assertiveness is required if I see that it has been overlooked in the future.
Beall M H, Spong C Y, Ross M G (2003) A Randomized Controlled Trial of Prophylactic Maneuvers to Reduce Head-to-Body Delivery Time in Patients at Risk for Shoulder Dystocia. Obstetrics & Gynecology 2003; 102: 31 – 35
Crofts J F, Bartlett C, Ellis D, Hunt L P, Fox R, Draycott T J (2006) Training for Shoulder Dystocia : A Trial of Simulation Using Low-Fidelity and High-Fidelity Mannequins : Obstetrics & Gynecology 2006; 108 : 1477 – 1485
Crofts J F, Bartlett C, Ellis D, Winter C, Donald F, Hunt L P, Draycott T J (2008) Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual. Saf. Health Care, February 1, 2008; 17 (1): 20 – 24.
Deering S, Satin A J (2005) Evaluation of Residents’ Delivery Notes After a Simulated Shoulder Dystocia. Obstet. Gynecol., February 1, 2005; 105 (2): 448 – 449.
Draycott T J, Crofts J F, Ash J P, Wilson L V, Yard E, Sibanda T, Whitelaw A. (2008) Improving Neonatal Outcome Through Practical Shoulder Dystocia Training. Obstet. Gynecol., July 1, 2008; 112 (1): 14 – 20.
German R B, Goodwin T M, Souter I, Neumann K, Ouzounian J G, Paul R H. The McRoberts’ maneuver for the alleviation of shoulder dystocia: How successful is it? Am J Obstet Gynecol 1997; 176 : 656 – 61.
Gonen R, Spiegel D, Abend M. Is macrosomia predictable and are shoulder dystocia and birth trauma preventable? Obstet Gynecol 1996; 88 : 526 – 9.
Heath L T, Gherman R B. Symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy associated with McRoberts’ maneuver. J Reprod Med 1999; 44 : 902 – 4
Robinson H, Tkatch S, Mayes D C, Bott N, Okun N. (2003) Is Maternal Obesity a Predictor of Shoulder Dystocia? Obstetrics & Gynecology 2003; 101 : 24 – 27
12.8.08 Word count 1,060 PDG
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