Subject: Shoulder Dystocia       

POLICY: Shoulder dystocia is defined as cephalic presentation with birth of the fetal head completed but the shoulder cannot be delivered by normal mechanisms of labor. Shoulder dystocia is an obstetric emergency event.  The incidence is less than 1%. In babies over 4000g the incidence is 1.6%.

RISK FACTORS:

·         maternal obesity

·         pendulous abdomen

·         excessive weight gain

·         macrosomic infants

·         history of large siblings

·         prolonged 1st or 2nd stage of labor

·         arrested labor

·         post dates fetus

·         maternal diabetes

·         50% of shoulder dystocia cases occur without any risk factors

POSSIBLE COMPLICATIONS:

·         Fetal

o   Brachial plexus damage

o   Fractured Clavicle

o   Fractured Humerus

o   Brain damage

o   Death

·         Maternal

o   Extensive tears

o   Hemorrhage

o   Shock

o   Post Partum infection

o   Emotional Distress

GUIDELINES: 1. If shoulder dystocia is anticipated with adequate safe transport time available, client will be transferred to the hospital for birth.

2. Because shoulder dystocia can rarely be anticipated, health care providers will be trained to facilitate birth when a shoulder dystocia occurs.

PROCEDURE:  1. REMAIN CALM and act quickly

2. Birth Assistant will count out in 30 second increments total time elapsed after the birth of the fetal head.

3. REMEMBER, if there are no fetal anomalies then if the head is born the body can be born.

4. Rule out short or tight cord by sweeping around neck and shoulders of baby with finger.

·         If there is not adequate cord to birth baby the cord is to be double clamped and cut between the clamps. Do not clamp the cord if there is adequate cord length.

5. Rule out compound presentation when the finger is sweeping for cord.

·         If there is a compound presentation the presenting arm may be swept gently across the chest and over the head to relieve excess pressure.

6.  Change maternal position to hands and knees (Gaskin maneuver), McRoberts maneuver, or other hyperflexed positions.

7. Have birth assistant apply suprapubic pressure (do not use fundal pressure).

8. Perform the Woods’s screw or Rubin’s screw maneuver, rotating the fetal shoulders to the widest diameter of the pelvis (usually oblique diameter).

9. Grasp hand and posterior shoulder and sweep gently across the chest and under pubic arch.

10. Birth anterior shoulder after birth of posterior shoulder

If baby has not been delivered repeat steps 6-10 until 3-5 minutes have elapsed.

11. Birth assistant will call for transport to hospital from room phone anticipating newborn resuscitation and/or maternal hemorrhage.

12. If necessary, fracture fetal clavicle

13. Consider episiotomy if it will give more room to work

14. Consider catheterizing the bladder if overfull

15. Consider Symphysiotomy if no other method will result in the birth of the baby within a safe time period.

Be prepared for neonatal resuscitation and postpartum hemorrhage

After the baby is born:

·         Transport if indicated

·         Check for brachial plexus injury, fractured clavicle and humerus

·         Consider vitamin K injection

·         Recommend prompt follow up with pediatrician

Grade of shoulder dystocia

Treatment of shoulder dystocia

Mild shoulder dystocia

·         Gaskin maneuver

·         Maternal position change

·         Gentle traction

Moderate shoulder dystocia

·         McRoberts maneuver

·         Suprapubic pressure, which can be directed either posteriorly or to one side.

·         Wood maneuver.

·         Rubin maneuver (reverse of the Wood maneuver)

·         Attempt delivery of posterior shoulder.

Severe shoulder dystocia

·         All of the above

·         Fracture fetal clavicle

·         Symphysiotomy

·         All of the above

Undeliverable

·         Cephalic replacement