Episode 102 Shoulder Dystocia

This episode looks at the emergency situation that is Shoulder Dystocia when there is difficulty with the birth of the baby's shouders after the head has been born.

Want to know more?
https://www.youtube.com/watch?v=UTz2eIiZOL8
https://www.rcog.org.uk/media/ewgpnmio/gtg_42.pdf
https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/shoulder-dystocia-patient-information-leaflet/
https://www.erbspalsygroup.co.uk/

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Transcript

Shoulder Dystocia

Florence: [00:00:00] Episode 1 0 2 Shoulder dystocia. So after some more reflective topics and conversations with others, I thought this week I'd return to a bog standard clinical topic, partly because in my brief Twitter poll that I did for my hundredth episode, many of you said you like clinical topics. Today I'm going to talk about shoulder dystocia

it's one of those emergencies that I mentioned in episode 79 help. It's one of the things that we might pull that emergency buzzer for and we all might rush to try and resolve. So let's start. What is shoulder dystocia? Its definition is that we may need to do additional maneuvers to help the woman birth her baby

there may be a delay [00:01:00] between the birth of the head and the birth of the shoulders. This can be harder to define than you might think, because with any baby's birth, the head delivers and then before the shoulders can come through the pelvis, the shoulders have got to rotate and what we call. External rotation and restitution.

I talked about it a bit in one of my early episodes. Balance shoulder dystocia happens because the anterior shoulder that is the shoulder that's at the front of the woman's pelvis gets wedged behind her pelvic bone or the pubic symphysis. If we understand this, then we can can understand a bit. How to treat it.

Part of the problem with shoulder dystocia is it can be a bit unpredictable. [00:02:00] There are things, it's true that make the chance of shoulder dystocia more common. One of the major things we think about is having a big baby, and particularly a big baby in the context of maternal diabetes of pregnancy, and I've talked about.

In my episode, big Baby. Often, however, it's unpredicted. We don't know the baby's going to be big, or the baby isn't particularly big, but there's something about the labor itself that means it's more likely to happen. Some of the factors that make a higher chance of shoulder dystasia, such as having an assisted vaginal birth

or a slow second stage that is the pushing phase. Once the cervix has fully dilated, are so common [00:03:00] that it's very difficult to anticipate the problem because whilst these factors are very common, shoulder dystasia actually only occurs in around 0.7% of vaginal birth. . So how can we pick out which births?

It might be a problem from those where it isn't, but some of those other factors are present. Why is it important and what delay is important? If the baby's head has been born and the shoulders are wedged behind the pelvic symphysis? , the rest of the baby can't be born. The baby can't properly expand its chest and start breathing and adapting to life outside the womb, but equally, it's not [00:04:00] getting the blood supply through the umbilical cord that it was when it was in the womb because the umbilical cord is compressed between the body and the woman's pelvis.

Therefore, one of the risks of a shoulder dystocia. A shortage of oxygen or hypoxia, how many minutes we have to get the baby out will depend on what condition the baby was in to start with. If this baby had coped well with labor and was in good condition before the birth of the head, then actually we've got quite a few minutes.

Whereas if this baby was already compromised, already struggling, it's starting from a lower baseline. A shoulder dystocia in this situation could result in significant damage to the baby, and the damage we are worried about if we're not doing something to help the baby birth [00:05:00] is damage to the baby's brain.

Aside from the baby being distressed and the hypoxia shortage of oxygen babies with shoulder dystocia can experience other injuries. The one we really hope to avoid is something called a brachial plexus injury, or B P I. This occurs because there is stretching of the nerves in the brachial plexus. The brachial plexus is the bunch of nerves that come out to the baby's neck and supply the arm

stretching of these nerves excessively sometimes due to us as practitioners, perhaps pulling on the baby's head to try and release that shoulder can result in damage. Fortunately, most of the time this damage is short-lived and may be easily corrected with physiotherapy, but in some [00:06:00] cases this damage can be permanent.

The other complication that can sometimes occur for a baby is a fracture of a bone, a fractured arm, or a fractured collarbone. And again, babies are very resilient. Little things, this will usually heal very well. The baby will be given some painkillers, some physiotherapy, and some follow up. Mothers can also experience complications and problems from shoulder Dystocia, one of the most common problems being a bad tear.

and therefore excessive blood loss. I hope that these descriptions haven't scared you too much because what I'm going to talk about next is how we treat shoulder dystocia. We are well aware that for both mother and baby, this is an emergency situation where time is of the essence and we need to be

careful in doing the right [00:07:00] things to relieve the situation and free that shoulder so that we don't cause more harm than good in our actions. Sometimes we can anticipate a shoulder dystocia might be going to happen. Maybe we know it's a particularly big baby, or as the head is born, we get what's called a turtleneck sign so the head comes out, but.

Not completely. Maybe the chin doesn't come out and emerge properly, and therefore it looks like the baby's wearing a polo neck or turtle neck sweater. If we anticipate this problem, we may start doing some of the things that might help relieve the shoulder dystocia before we've even decided if it's going to happen, taking preventative measures as it were

training for shoulder dystocia is something we do on a regular [00:08:00] basis. It's a key component of our annual mandatory training update. As obstetricians and midwives, we can click into exactly what we need to be doing.

and we have a little mnemonic to help us on our way. Help remind us what are the steps we should be doing and the mnemonic is helper. So let's start with h. H stands for help. We need help. We need to pull the emergency buzzer if we haven't got lots of people there to. . If we have got plenty of people, we might be calling the pediatricians If they're not already present help.

We need more pairs of hands. Essentially, we'll be pulling that emergency buzzer and we may be [00:09:00] putting out the 2 22 2 obstetric emergency bleep. We will probably say to the woman, We are just going to get in some extra people to help with the birth of your baby, and we're going to move you into some different positions to try and help your baby come out safely.

There'll be a flurry of activity for people coming into the room. The next thing is e evaluate. For an episiotomy, it's actually not easy to make and do an episiotomy once the baby's head has already been born. And given that we said the shoulder is actually stuck behind the pelvic bone, making a cut in itself is not going to release the shoulder.

But it might give us space to safely do some of the other maneuvers that we may need to do to assist the baby out [00:10:00] without. , too much damage to the woman's pelvic floor and perineum. So E stands for evaluate a episiotomy. Next, we have l. L stands for legs. The first thing we're going to do is put the woman in what we call McRoberts position.

This will involve two members of. staff And we'll tell the woman what we're going to do as we're doing it. We're going to lie her flat, so put the back of the bed down, extend her legs out long, and then bend them and bring them up so that her knees are coming towards her shoulders. This is called Mc Robert's position.

It will help open up the pelvic outlet and give the baby a bit more [00:11:00] space . If this doesn't work, we move on to P. This one's a little bit of a gimmick because it stands for supra pubic pressure. Whoever is helping with the birth will identify which side the baby's back is, and then another assistant midwife or doctor will apply supra pubic pressure from behind the baby's shoulder.

This is a bit like doing C P R that you see in the movies when someone has a cardiac arrest. It's the same sort of hand position, and we can either apply it constantly for 60 seconds or often what you'll see us do is exactly like C P R Rock for 60 seconds, and what we're trying to do is get the baby's shoulder to rotate and dip under.

The pubic symphysis under that bone that's blocking it, coming down the birth [00:12:00] canal. To a woman, this may feel quite traumatic. We've suddenly flung her legs back in the air. There's lots of people in the room, and then someone is pounding on her abdomen just above her pubic bone. Although this sounds very dramatic.

most shoulder dystocia will actually resolve with these two measures, more than 80% of cases, this will free the baby. So if we can communicate and explain to the woman and her birth partner what we're doing, why we're doing it in a calm quick manner we're going to ask some extra people to come in and give us some help, and we're going to change your position and move you around quite a bit and press on your tummy to help release your baby and help your baby on its way.

Don't be frightened. This [00:13:00] is something we all train to do. So those two measures are our go-to. I'm going to pause here a moment because. If you're at a home birth or a birth on the midwifery lead unit where a woman isn't necessarily lying down, often what we'll do is actually get the woman to roll over onto all fours because that will often dynamically change her pelvis and release the baby.

Or if she's in a birthing pool, actually moving her hips apart to step out of the birthing pool can also often help release the baby. So although these steps come further down, the helper mnemonic that we're traditionally taught, the order in which you do some of these maneuvers may not follow that exact script.

It will depend on whether you've got a woman [00:14:00] who's completely mobile or whether you've got a woman who's bed bound with an epidural and heavy legs. Now we've got to e.

This is about trying to do internal rotational maneuvers. So we've tried suprapubic pressure pressing on the woman's abdomen to dislodge that shoulder. Now we're going to put our hands in the vagina and press either side of the baby's shoulders to try and do internal rotation. Again, we're trying to rotate that shoulder away from the bone that it's stuck.

This can be very difficult to do. It's very tight. There isn't a lot of room to get your fingers in the vagina alongside the baby. The maneuvers are done in two different ways. One is called Ruben two. This is putting the [00:15:00] fingertips behind the anterior shoulder and trying to rotate it forwards towards the baby's chest.

This is so-called Ruben. Because Ruben one is the super pubic pressure. This is an internal version of the same maneuver trying to push the anterior shoulder forwards. Woodscrew maneuver is using the fingers of the opposite hand, approaching the posterior shoulder, so that's the shoulder at the back from the front of the fetus

aiming to rotate that shoulder up towards the pubic bone. The symphysis again, we're trying to push the baby's shoulders through 180 degrees, like a thread on a screw, and thereby release the anterior shoulder, which is the one that is causing the trouble. Reverse wood screw is the opposite. . [00:16:00] So you place your fingers on the posterior shoulder from behind and try and rotate in the opposite direction.

So all these internal rotational maneuvers can be tried. As I said before, the strict order in which you practice maneuvers once you've done the super pubic pressure and McRoberts position depends on the individual doctor or midwife. How they feel most confident at managing the situation, and also how mobile is the woman and what position she's in.

The final bit of helper is a little bit of a trick because it's r r two Rs at the end. The first R is to roll the woman over, roll over onto all fours. And I've mentioned this. because midwives will often use this much [00:17:00] earlier in proceedings if they're at a home birth or the woman's very mobile. If you imagine, this immediately flips everything upside down.

So the anterior shoulder, which is stuck, is now at the bottom and the posterior shoulder is at the top, and gravity, as well as a change in the diameters of the pelvis with this movement may allow the baby to be born. , the other R stands for remove the posterior arm. So if you can get your hands into the vagina, you have to feel your way up towards the elbow of the arm that's at the back.

And this is because there's more space in the pelvis at the back than there is at the front where the shoulder is stuck on the symphysis. You feel your way up to the. bend or flex the forearm and sweep it down across the baby's chest. That releases the [00:18:00] posterior arm, brings the posterior arm down through the vagina, and then that in turn releases the anterior shoulder and unders the blockage as it were.

This maneuver can be very successful at delivering the baby, but this is the maneuver where if done with difficulty. . This can result in fractures, particularly of the baby's humorous. That's the upper arm bone or the clavicle. The collarbone. But for many shoulder dystocias difficult ones, removing the posterior arm actually results successfully in the birth of the baby.

What if none of these maneuvers work? As I've said, the clocks tick. Time is moving on, and we are worried about the lack of oxygen for the baby. So if we've gone through all these maneuvers, we [00:19:00] will go back to the beginning and start them all over again. But there are some other extreme moves that are written about in the textbooks that most of us obstetricians have never performed or seen perform.

They simply aren't practical or have significant consequences. The first is something called the Zavinelli Maneuver. This has the idea of trying to reverse the progress of birth. Flexing the baby's head and trying to push it back up the vagina into the womb so that we can perform a cesarean section. This is fraught with difficulty.

Everything the womb and the baby have been doing up to this point and the contractions are moving in the [00:20:00] opposite direction. So potentially we can traumatize not only the baby with fractures of the skull. But also the womb. We can tear or traumatize the vagina and we can cause a rupture of the womb causing a woman to lose significant amount of blood.

Most of us as obstetricians know, even when the baby's head is low in the pelvis and has not been born, it's very difficult for us to perform a cesarean at that late stage of labor. And I think this is why, although it's reported in the literature, the Zavinelli maneuver is something most of us have heard of, but wouldn't dream of actually trying to do in practice.

Extremely difficult. and likely to cause complications. The other very drastic [00:21:00] option is something called a symphysiotomy and this works on the principle that the pelvis just isn't quite wide enough, and that if we actively could cut the pubic symphysis, the joint in the front of the pelvis and just open up.

That joint that would help the baby to pass. Again, this is something I have never done in my career or seen my colleagues do, but it is something we are taught in simulation to give local anesthetic and cut the joint in that bone. It's something that used to be done much more frequently before the era of

much higher cesarean section rates and much safer anesthetics. For cesareans, [00:22:00] having these extremely rare, drastic treatments listed in textbooks can cause problems. for me, shoulder dystocia has always been absolutely imprinted in my mind because of what happened when I was taking my membership exams of the Royal College of Obstetricians and Gynecologists.

I went on a very well respected part two revision course. and part of our exams is to do something called OSCES. These are simulated clinical exams, and in my practice, in my part two revision course, I had a mock OSCE, a simulation of shoulder Dystocia. , I did all the normal maneuvers. This was with a mannequin and a doll.

I was talking through to the examiner about what I was [00:23:00] doing and why. At the end of the scenario, I was quite aggressively questioned. What else would I like to do? What else? I got the feeling that I'd left something out and I couldn't think what it was they wanted me to talk about. . I hadn't mentioned the zavinelli maneuver, but surely, surely they didn't expect me to do that.

Although this was a very good revision course. I must admit that this particular event was a little bit teaching by humiliation. I was up in front of the whole group that were on the course on the. and being chastised and taken through exactly what I should have done for shoulder dystocia and how I should have mentioned and discussed the Zavinelli maneuver and symphysiotomy.[00:24:00] 

I was actually really quite upset. I didn't feel it was realistic treatment. And why would you say an exam something that you would never do. , but I took my medicine as it were, and I went home and I revised shoulder dystocia and I thought long and hard about what I should say. Imagine the dry mouth moment in my real part two exam a month or two later when lo and behold what was my actual real, genuine OSCE situation.

shoulder dystocia. My heart sank. I absolutely knew it inside out, but there was that doubt in my mind. Oh my God. Do [00:25:00] I, do I mention the Zavinelli maneuver? Do I not? Do I discuss it? What do I do? I confidently launched into the shoulder dystocia, and actually the examiners were much more friendly and much more encouraging than my mock OSCE had been.

And I got through to the end and discussed everything, and I did briefly mention the zavinelli maneuver, at which point the examiner slightly laughed, and I did have a reasonable explanation and conversation about how of course this was an option, but that there were pros and cons and that it is rarely if ever performed.

So I felt in the actual exam, I had been able to put it in the correct context, but that experience means for me, shoulder dystocia absolutely drummed [00:26:00] into. , unbelievably never to be forgotten. So I don't know if that's good contributes to my skillset and experience or bad. It can be debated. . As I mentioned earlier, one of the key things when the baby's head has been born and we're experiencing difficulty with the shoulders is the importance of not pulling too hard on the baby's head and stretching those nerves that brachi your plexus of nerves that supply the arm because it's that pulling and stretching without release.

the blockage of the shoulder that causes those brachial plexus injuries, which happen in one in 10 babies with a shoulder dystocia. For this reason, we practice shoulder [00:27:00] dystocia in our training year in, year out, and at one point we did have a mannequin to practice on that actually had a strain gauge, so it measured when you were pulling on the baby's head.

how much pressure you were putting and therefore how much pressure you might be putting on that brachi plexus on those important nerves so that you could understand how much pulling was safe because you do need a little bit of traction pulling to release the baby, but not excessive force. . So with a shoulder dystocia, we practice every year, year in, year out.

We are well versed in what we should be doing, and we know that 80% or more of shoulder dystocia will resolve with those first maneuvers, changing the women's [00:28:00] possession either to Mc Roberts or rolling over, and the suprapubic pressure. What if you've had a shoulder dystocia? . Then what? What can you expect in your next pregnancy?

Well, the first thing that's really important is for us to have your birth notes, to know the weight of the baby, what position you were in giving birth, and what factors might have contributed to it. What maneuvers did we have to do to help release the baby's arm and should. And did you or your baby sustain any injuries as a result of the shoulder dystocia?

If it was something actually very straightforward, just moving your position, release the baby's shoulder, and there was no ill effect for either of you, then usually we would probably be recommending vaginal delivery. We might organize a scan to check on the size of the baby in late pregnancy, maybe around 36 weeks.

And if [00:29:00] the baby seemed large, we may suggest induction of labor, but if the shoulder dystocia was more complicated, maybe the baby had injuries, maybe you had a bad tear or the whole experience was quite traumatic for you. Psychologically or you're expecting a much bigger baby, then we will discuss with you the alternative of cesarean section because this is the only way to absolutely guarantee that you do not have a recurrence.

So during your pregnancy, you should have discussions with staff and be offered both alternative options. , but our advice, our recommendations will very much depend on how severe or not the shoulder dystocia was and how you feel about it. Okay. What's my [00:30:00] zesty bit? My zesty bit is a little bit odd. . I've been thinking about a hundred years of progress because that was the theme of the International Day of the Midwife this week, and one of my listeners suggested that I do an episode on that, which I'm starting to plan.

So as part of my preparation for today, I looked in my 1930s Glasgow textbook of Obstetrics to see what did it say about shoulder dystocia . The result was simply astonishing. There was no mention of it. It was not mentioned in the index. It was not mentioned in the problems in labor. It wasn't mentioned in the instrumental birth section.

There's literally no mention of this and [00:31:00] I. . Why? Why? Why would that be that in the 1930s there was nothing about shoulder dystocia? I mean, did it not happen? Did it not happen because women were having their babies at home? Did it not happen because women were more mobile? Epidurals didn't exist. Did it not happen because we were doing less instrumental births?

Were babies smaller because women didn't have such good nutrition? , what is that all about? So one of the key messages, my zesty bit today is let's think about all the things we can do to avoid shoulder dystocia. So being active in labor, being up and about upright, not lying on our backs. if you're having an epidural or you are looking after a woman with an epidural, thinking about her sitting upright or birthing in left [00:32:00] lateral so that her pelvis has got the maximum flexibility and room to move.

Also, when we know a woman has a higher chance of shoulder dystocia, such as she has gestational diabetes, Let's pre-warn her. Let's talk to her about if we think this might be a possibility, we may ask extra people into the room. These are the positions we may get you into so that it is not a traumatic event for the woman.

So I guess I've got two zesty bits. One is, let's do everything we possibly can to avoid it in the first place, because is this something of our creation? . I don't know. And then secondly, when and if it does happen or if we're anticipating it happening, let's keep calm and communicate clearly with the woman and her partner exactly what is [00:33:00] happening and what we're expecting when people come into the room and why we've asked for their help.

And also communicate clearly to the team around. announcing this is shoulder dystocia and what maneuvers have you already done? For example, if I'm coming into the room, the midwife might often say, this is shoulder dystocia. We've already done Mc Roberts. We're about to start supra pubic pressure. And then I know at what point I'm starting to think about the next maneuver.

If you're a woman worried about shoulder dystocia, I've put some great links in the program notes. Maybe you've had a shoulder dystocia before, or maybe someone said your baby's a bit bigger than average. Have a read so you can make a well informed choice. But don't be frightened far and away. Most women and babies who experience a shoulder dystocia will have a very [00:34:00] good outcome