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For use in: Maternity Care By: Midwives and Medical Staff For: Management of shoulder dystocia Division responsible for document: Womens and Children’s Key words:
Shoulder dystocia; brachial plexus injury
(BPI); risk factors; management
Name of document author: Julie Mansfield Job title of document author: Practice Development Midwife Name of document author’s Line Manager: Anna Haestier Job title of author’s Line Manager: Chief of Maternity Services Supported by: Mr David Fraser, Mr Alastair McKelvey Assessed and approved by the: Maternity Guidelines Committee (MGC) If approved by committee or Governance Lead Chair’s Action; tick here Date of approval: 08 July 2021 Ratified by or reported as approved to (if applicable) : Clinical Safety and Effectiveness Sub-Board To be reviewed before: This document remains current after this date but will be under review 08 July 2024 To be reviewed by: Julie Mansfield Reference and / or Trust Docs ID No: IO31 – ID No: 888 Version No: 6 Compliance links: (is there any NICE related to guidance) RCOG Green Top Guideline 42 https://www.rcog.org.uk/en/guidelines-research- services/guidelines/gtg42/ If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Compliant with RCOG Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Version and Document Control: Version Number Date of Update Change Description Authors 6 08/07/ Line Manager amended and RCOG links replaced. Julie Mansfield Anna Haestier This is a Controlled Document Printed copies of this document may not be up to date. Please check the hospital intranet for the latest version and destroy all previous versions. Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Objective To provide clear guidance on the effective management of shoulder dystocia based on current available evidence. Rationale Shoulder dystocia is diagnosed when the shoulders fail to deliver by gentle downward traction following the birth of the head .Shoulder dystocia occurs when the fetal shoulders fail to rotate into a transverse position - the problem is at the pelvic inlet rather than at the outlet. It is an uncommon occurrence but potentially a serious complication of vaginal delivery. It occurs 1% of vaginal births. In the most severe cases it may be associated with stillbirth or neonatal death or long-term morbidity from birth asphyxia or to brachial plexus injury (BPI). Guidance on risk factors and standards for management and record keeping are therefore imperative. A high level of awareness and training is also required for those attending births. Broad recommendations Risk factors associated with shoulder dystocia A number of antenatal and intrapartum risk factors have been associated with shoulder dystocia but even a combination of these is poorly predictive. Obstetric medical staff and midwives should therefore be alert to the possibility of shoulder dystocia in all vaginal births. However, when significant antepartum risk factors are identified, these should be highlighted to the on-call obstetric team and coordinating midwife, and an experienced obstetrician, of at least SpR level (ST3 or above), would be expected to available on Delivery Suite in the second stage prepared for any shoulder dystocia that may arise. RISK FACTORS FOR SHOULDER DYSTOCIA Antenatal Intrapartum Previous shoulder dystocia Prolonged first stage Macrosomia >4.5kg Secondary arrest Maternal diabetes mellitus Prolonged second stage Maternal BMI > 30 Oxytocin augmentation Induction of labour Assisted vaginal delivery Obstetric medical staff and midwives must be familiar with the procedure for summoning help, the manoeuvres to be employed in the event of shoulder dystocia (summarized in the quick reference guideline) and the standards for record keeping (see Record keeping chart – appendix ). Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Macrosomia as a risk factor Acker et al. (1985) reviewed 14,721 births in non-diabetic mothers and reported the following rates of shoulder dystocia. Birthweight Incidence of shoulder dystocia < 4000g 1% 4000-4499g 10% 4500 or more
However, macrosomia remains only a weak predictor as the large majority of infants with a birth weight of > 4500g do not develop shoulder dystocia and in addition up to 50% of shoulder dystocia occurs in infants weighing < 4000g (Naef and Martin, 1995, Baskett and Allen, 1995). This is further compounded by difficulty in detecting macrosomia by ultrasound scans. Rouse and Owen (1999), reported a 10% margin for error of birth weight and failure to detect 40% of infants over 4500g. Maternal diabetes is a risk factor. Maternal Diabetes increases the risk of shoulder dystocia (Nesbit et al, 1998). Infants of diabetic mothers were three to four times more likely to experience shoulder dystocia compared with infants of the same birth weight born to non-diabetic mothers. (Acker et al.1985). Induction of labour can reduce the incidence of shoulder dystocia in women with gestational diabetes. Elective caesarean section should be considered to reduce the potential morbidity for pregnancies complicated by pre-existing or gestational diabetes, regardless of treatment, with an estimated fetal weight of >4.5kg Signs of shoulder dystocia All birth attendants routinely look for signs of shoulder dystocia and include: - Difficulty with delivery of the face and chin The head tightly applied to the vulva or retracting i.e. the ' turtle neck sign Failure of restitution of the fetal head Failure of the shoulders to descend SYSTEMATIC EMERGENCY MANAGEMENT OF SHOULDER DYSTOCIA Don’t panic. There is plenty of time - serial scalp pH between delivery of the head and trunk falls relatively slowly (0.2 unit/5 minutes) provided the baby is not compromised. Excessive traction may cause BPI and any fundal pressure further impacts the shoulders. Get help immediately! Call 2222 - State ‘ Obstetric Emergency’ and ‘Shoulder Dystocia‘, and give location. You need the most experienced midwife and obstetrician immediately available and a neonatologist for resuscitation. Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Delivering the posterior arm will reduce the diameter of the shoulders by an arm width, providing enough space to resolve the dystocia, allowing delivery to be completed by moderate traction. If the wrist is not immediately accessible the arm can be flexed by placing a thumb in the antecubital fossa and gentle grasping the elbow. Pulling on the upper arm is associated with humeral fracture Ask patient to get onto all fours. Change of position may free the shoulders. Start again If the above manoeuvres have failed to allow birth. Failure of first and second line manoeuvres: what measures should be taken? Third-line manoeuvres should be considered very carefully to avoid unnecessary maternal morbidity. There is no time limit to suggest, but there appears to be a very low rate of hypoxic brain injury up to five minutes. Third line manoeuvres include:- Zavenelli manoeuvre- vaginal replacement of the head and then delivery by caesarean section. Cleidotomy- surgical division of the clavicle or bending with a finger. Symphysiotomy- dividing the anterior fibres of the symphyseal ligament. Postnatal management Cord gases should be taken for acid-base analysis. Post-partum haemorrhage should be anticipated, with steps taken to avoid this such as active management of the third stage and a low threshold for post-partum syntocinon infusion and other oxytocic drugs. The maternal perineum should be thoroughly assessed to check the extent of perineal trauma (in some cases this may require regional anaesthesia and/or assessment in theatre prior to commencing suturing). All women whose delivery is complicated by shoulder dystocia should be debriefed about the course of events. Process for follow up of the newborn All babies delivered following shoulder dystocia should be carefully examined by an ex- perienced neonatologist before discharge. Follow up of the newborn where there is actu- al or suspected brachial plexus injuries will be arranged by the neonatologists prior to discharge who will also refer to tertiary specialist services, if required. Brachial plexus in- jury complicated 2.3 -16% of cases of shoulder dystocia. Other injuries the accoucheur should be aware of include fractures to the clavicle and humerus, pneumothoraces and hypoxic brain damage. Future deliveries Either caesarean section or vaginal delivery can be appropriate after a previous shoulder dystocia. The decision should be made jointly by the woman and her health care profes- sionals. Standards for record keeping Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Comprehensive and accurate record keeping is essential in all cases of shoulder dysto- cia. Details of the emergency must be recorded in the maternal notes. Ensure you re- cord clearly who was present (and who was called), the time they attended, the man- oeuvres performed, whether it was the left or right shoulder which was impacted, delivery time of the head and the completed delivery, Apgar scores and cord pHs. The Shoulder dystocia proforma (Appendix 1). The chart should be filed in the maternal health records and an electronic incident report made. Maternity services expectations for staff training. Refer to maternity Training Needs Analysis (TNA). Clinical audit standards The Maternity Services are committed to the philosophy of clinical audit, as part of its Clinical Governance programme. This standards contained in this clinical guideline will be subject to continuous audit, with multidisciplinary review of the audit results at one of the monthly departmental Clinical Governance meetings. The results will also be summarised and a list of recommendations formed into an action plan, with a commitment to re-audit within three years, resources permitting. Auditable standards derived from this guideline: Shoulder dystocia proforma (appendix 1) to be used in all cases of shoulder dystocia (Standard 100%, exceptions – none). All midwives and Medical Staff in training should have attended a skills/drills session on shoulder dystocia within the previous year (Standard 100%, exceptions – none). The Risk Management Team to be informed urgently of all cases of suspected or actual BPI (Standard 100%, exceptions – none). Incident reporting of all shoulder dystocias. Summary of development and consultation process undertaken before registration and dissemination The authors listed above drafted this guideline on behalf of the Maternity Guidelines Committee who has agreed the final content. Distribution list / dissemination method Trust Intranet Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
position at delivery of head tick Mode of delivery of head Spontaneous Instrumental – vacuum forceps Time of delivery of head 24 hour clock Time of delivery of baby 24 hour clock Head-to-body delivery interval: 24 hour clock Fetal position during dystocia: Head facing maternal Left fetal shoulder anterior Head facing maternal Right fetal shoulder anterior Procedures used to assist delivery Performed by Print name Time 24 hour clock Order Details or tick as appropriate Subsequent attempts by Print name McRoberts’ position: Suprapubic pressure: From maternal Left Right Consider Episiotomy: Enough access Tear present Already performed Delivery of posterior arm: Right arm Left arm Internal rotation manoeuvre: Description of rotation: Description of traction: Routine axial (as in normal vaginal delivery) Other: detail Reason if not routine axial: Other manoeuvres used: detail
Shoulder Dystocia Proforma
Date^ Patient Identifier Label dd/mm/yyyy T ime 24 hours clock Consultant Person completing form (scribe) Print name Signature Designation Date dd/mm/yyyy Birth Birth weight Kg Apgars @ (^) 1 min: 5 min: 10 min: Cord gases: Arterial pH: Arterial BE: Venous pH: Venous BE: Parents Tick when actioned^ Time actioned as appropriate 24 hour clock Explanation to parents Explanation by -print name and designation Incident form Tick as appropriate Time actioned as appropriate 24 hour clock Incident form completed (^) Yes No If yes - Datix reference Neonatologist called Tick when actioned^ Time actioned as appropriate 24 hour clock Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
Neonatologist called Print name of the Neonatologist who attended and time of arrival If Neonatologist not called or did not arrive - give reason: Baby assessment after birth (may be done by RM): Tick^ as appropriate Any sign of arm weakness? Yes No If ‘yes’ to any of these questions: - for review and follow up by Consultant Neonatologist. Any sign of potential bony fracture? Yes No Baby admitted to Neonatal Intensive Care unit? Yes No Person completing Assessment Print name Signature Designation Date dd/mm/yyyy Time 24 hours clock Clinical Guideline for: The Management of Shoulder Dystocia Author/s: J. Mansfield Author/s title: Practice Development Midwifent Approved by: MGC Date approved: 08/07/2021 Review date: 08/07/
