Rapid Recap is distributed each month using suggested topics or topics on trend (seasonal/disease trends). NWAS-wide clinicians, irrespective of grade, are invited to contribute towards writing content in future issues in a supportive process. Please get in touch with rapid.recap@nwas.nhs.uk.
This month's Rapid Recap looks at shoulder dystocia.
A plain-text version can be found at the bottom of this page.
What?
Shoulder dystocia (SD) is a time-critical obstetric emergency that occurs when, after delivery of the baby's head, the anterior fetal shoulder becomes impacted behind the maternal pelvis, delaying the birth of the baby’s body.
SD occurs in approximately 1 in 150 (0.7%) of vaginal births. SD is often unpredictable and unpreventable, with most cases occurring in the absence of identifiable risk factors; remember, it can occur during any birth.
SD may be recognised by witnessing slow and difficult delivery of the face and chin. When the baby’s head is delivered, the chin may retract and remain tightly applied to the perineum. Documenting the time the baby’s head is born is important to understand the duration between head and body delivery; document both times within EPR.
Once the head is born, the rest of the baby’s body should follow with maternal pushing during the next contraction; if this does not happen, then management for shoulder dystocia should be started.
So What?
Request back-up to ensure adequate resources are available for safe and effective care of both patients. Remember: SD increases postpartum haemorrhage risk following birth, caused by uterine atony or trauma.
SD is a bone-on-bone mechanical obstruction (fetal shoulder on maternal pelvis). Once recognised, maternal pushing should be discouraged, as this may further impact the shoulder against the maternal pelvis. Initial management, therefore, focuses on widening the functional
dimension of the maternal pelvis (McRoberts position) and reducing the fetal shoulder diameter (Suprapubic pressure). SD can be a painful experience for the mother; consider Entonox (see JRCALC).
A recognised complication of shoulder dystocia is brachial plexus palsy. Injury to the brachial plexus is caused by excessive lateral or downward traction of the baby’s head and neck. For this reason, traction should be gentle and aligned with the baby’s spine.
Newborn Life Support may be required as SD is associated with cord compression and/or prolonged head-to-body delivery, which may result in hypoxia.
Now What?
JRCALC SD guidance includes a structured management algorithm, supported by short instructional videos and
images, demonstrating the recommended manoeuvres.
An Overview (Must see JRCALC for further detail):
For McRobert's position, the thighs are simultaneously hyperflexed towards the maternal abdomen in parallel; this may increase space by up to 2cm to help shoulder release. Communication with a team member is crucial to ensure effective and sustained positioning.
Suprapubic pressure is a continuous or rocking downward pressure for up to 30 seconds for each method, while providing gentle axial head traction.
The all fours position may also be attempted, ensuring the woman's thighs are touching her abdomen with her chest close to the ground; gentle axial head traction is applied for up to 30 seconds.
Advanced Paramedic Practitioners can perform internal manoeuvres to release the shoulder; therefore, early escalation to CIH is crucial to get the right timely support and to minimise on-scene time.
If SD remains unresolved following these manoeuvres, a time-critical transfer with a pre-alert to the nearest obstetric-led maternity unit is required. Convey in a lateral position without pressure on the baby's head