Shoulder Dystocia: A Primer for Successful Team Response


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Shoulder Dystocia: A primer for successful team response
Compiled by Cheryl Raab, MSN, CNL, RNC-OB, C-EFM 2019

TABLE OF CONTENTS
SECTION 1
BACKGROUND .................................................................................................................................. 1 Definition .................................................................................................................................. 1 Prevalence................................................................................................................................. 1 Risk Factors ............................................................................................................................... 1 Recognition…………………………………………………………………………………………………………..……………..1 Complications ........................................................................................................................... 2
SECTION 2
MANAGEMENT ................................................................................................................................. 3 Initial steps ………………………………………………………………………………………………………………………....3 Maneuvers ………………………………………………………………………………………………………………………....4 McRoberts ............................................................................................................................. 4 Suprapubic pressure .............................................................................................................. 4 Episiotomy ............................................................................................................................. 4 Delivery of the posterior arm ................................................................................................ 4 Rubins .................................................................................................................................... 5 Woods corkscrew ................................................................................................................. 5 Gaskin.................................................................................................................................... 6 Fracture of clavicle ................................................................................................................ 7 Zavanelli ................................................................................................................................ 7 Abdominal rescue...................................................................................................................7
SECTION 3
TEAMWORK & COMMUNICATION ........................................................................................................ 8 Simulation training ................................................................................................................... 8 Team training............................................................................................................................ 8 Debriefing ................................................................................................................................. 9 Documentation ....................................................................................................................... 10
SECTION 4
TEST YOURSELF ............................................................................................................................... 11 Shoulder Dystocia Crossword Puzzle ...................................................................................... 11 Multiple Choice Questions ................................................................................................ ……12
REFERENCES ……………………………………………………………………………………………………………….……………… 15

BACKGROUND
Shoulder dystocia is the nightmare of many obstetric providers and nurses. Shoulder dystocia during a delivery can rapidly change a happy, anxiously awaited event to one of anxiety, fear and concern as it can culminate in injury, death and litigation. Complicating this is the fact that shoulder dystocia is both unpredictable and unpreventable. But the situation is not hopeless. Instead knowledge, communication and team preparation can produce positive outcomes.
 DEFINITION – ACOG defines shoulder dystocia as delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. Others have defined shoulder dystocia as a head-to-body delivery time exceeding 60 seconds or the need for ancillary obstetric maneuvers. Ultimately the definition is a subjective one and only the delivering provider can make the call.
 PREVALENCE – Because of the use of various definitions, it is difficult to be certain as to the exact prevalence of shoulder dystocia. Additionally, severe cases of shoulder dystocia are easily identified but mild cases may be over or under diagnosed. Reported incidence is anywhere between 0.2 to 3.0% of all vaginal deliveries in vertex presentation.
 RISK FACTORS – Risk factors exist in the antepartum and intrapartum periods.  Antepartum risk factors – o Diabetes o Maternal obesity (>200 lbs. / BMI >30) o Excessive weight gain o Multiparity o Post term gestation o Macrosomia o History of a previous shoulder dystocia o Abnormal pelvic anatomy o Short maternal stature (< 5 feet tall)  Intrapartum risk factors – o Prolonged active phase of labor o Failure or arrest of descent o Midpelvis operative vaginal delivery o Precipitous delivery  Women without identified risk factors may experience a shoulder dystocia
 RECOGNITION & DIAGNOSIS – Despite the list of risk factors, shoulder dystocia is difficult to predict. Scenarios that may foreshadow shoulder dystocia include:  Prolonged second stage  Difficulty or failure to accomplish external rotation of the head after it has passed the perineum  Turtle sign – after its delivery, retraction of the fetal head against the maternal perineum creating the appearance of a double chin.
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 Resistance to the delivery of the anterior shoulder with the usual gentle downward traction applied to the fetal head
 COMPLICATIONS - Shoulder dystocia places both the mother and fetus at high risk for birth-related injury  Maternal Complications o Uterine atony / Postpartum hemorrhage o 3rd or 4th degree laceration / rectovaginal fistula o Uterine rupture  Fetal Complications – a minority of shoulder dystocia’s result in neonatal injury; reported rates are 4-40% o Brachial plexus palsy – may be temporary or permanent o Fractured clavicle / humerus o Hypoxic ischemic encephalopathy o Neonatal death
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MANAGEMENT
Shoulder dystocia is an obstetric emergency. A systematic, step by step approach to the management of a shoulder dystocia is a key primary risk reduction strategy. Further information related to the steps listed below can be found in the subsequent pages.
Step 1 – Planning
 Think about shoulder dystocia before every delivery but remember that there is no way to conclusively predict it in a given patient.
 In the setting of suspicion for shoulder dystocia, all team members should be made aware of the possibility. A shared mental model is key to teamwork.
 Nursing staff should assure the presence of one or two step stools in the room. Step 2 – Announce the situation
 Obstetric Provider: Announce the presence of a shoulder dystocia  Nurse: Utilizing the intercom system, inform the BA and charge nurse of the shoulder
dystocia  BA: Make an overhead page of “Shoulder dystocia, Rm ___”.
Step 3 – Communicate
 The nurse will discontinue Pitocin infusion, if one is infusing. It can be started again following resolution of the dystocia
 The obstetric provider and nurse should calmly communicate the occurrence of the shoulder dystocia to the patient and family
 Instruct the mother not to push while maneuvers are implemented
Step 4 – Maneuvers
 Maneuvers are sometimes referred to as First Line, Second Line and Extraordinary/Desperation Maneuvers
 McRobert’s and suprapubic pressure may be performed by nursing staff at the request of the delivering provider. All other maneuvers are the responsibility of the MD/CNM provider
Step 5 – Debrief
 Following completion of the delivery, staff should debrief the events of the shoulder dystocia
Step 6 – Documentation
 It is important that documentation be accurate and comprehensive to demonstrate appropriate standard of care in the event of litigation.
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Maneuvers Knowledge of the use and application of various obstetric maneuvers is key to the intrapartum management of
shoulder dystocia. There are no randomized trials that demonstrate the superiority of some maneuvers over others for resolving shoulder dystocia once it is identified. Both nursing and medical providers should have a basic understanding of all maneuvers and their role in utilizing them.
First Line Maneuvers:  McRobert’s maneuver – requires 2 assistants sharply flexing the patient’s legs against the abdomen. This results in straightening the sacrum relative to the lumbar vertebrae.  Suprapubic pressure – an assistant applies pressure downward and laterally against the posterior aspect of the anterior shoulder. This is usually done in conjunction with McRobert’s. Do not apply fundal pressure.
UpToDate
Second Line Maneuvers:  Episiotomy – does not help to release the shoulder dystocia but may be helpful in providing room prior to performing the following maneuvers. Episiotomy does increase the incidence of perineal trauma.  Delivery of the posterior arm – should be considered following McRobert’s maneuver and suprapubic pressure as an appropriate next maneuver. o Best performed with adequate anesthesia o Introduce a hand into the vagina to identify the posterior shoulder and arm o If the elbow is flexed, grab the forearm and hand and pull the arm out of the vagina o If the elbow is extended, apply pressure to the antecubital fossa, which causes the elbow to flex and proceed as above 4

Delivery of the Posterior Arm
Clinical Procedures in Emergency Medicine  Rotational maneuvers – may be helpful in facilitating release of the shoulder dystocia
o Rubin maneuver –insert a hand into the vagina and place it on the back surface of the posterior fetal shoulder and rotate it towards the fetal face
Rubin Maneuver
UpToDate o Woods corkscrew maneuver – place a hand into the vagina on the anterior, clavicular
surface of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis
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Woods corkscrew Maneuver
UpToDate  Gaskin maneuver – is done by placing the patient in the all fours position allowing further
descent of the posterior shoulder past the sacral promontory; this position facilitates rotational maneuvers or delivery of the posterior arm
o Due to the change in maternal position it is important to re-orient yourself regarding the application of further maneuvers
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Extraordinary / Desperation Maneuvers:  Intentional fracture of the clavicle- Unintentional fracture of the clavicle is a not uncommon occurrence in the setting of a shoulder dystocia. Intentional fracture of the clavicle has been utilized to enable delivery by collapsing the shoulder girdle and freeing the impacted shoulder. o Accomplished by hooking the fingers behind the midpoint of the clavicle and exerting pressure up and out.
 Zavanelli maneuver – cephalic replacement through reversal of the cardinal movements of labor: rotation of the fetal head to pre-restitution position; flexion of the fetal head; application of pressure to return the head into the vagina; followed by cesarean delivery
 Abdominal rescue – vaginal delivery utilizing direct pressure on the fetal shoulder either through an abdominal incision with an intact uterus or through a low transverse uterine incision
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TEAMWORK AND COMMUNICATION
Recognition of a shoulder dystocia and facilitating proper interventions and timely delivery of the infant are the goals of the care delivery team. Communicating effectively as interdisciplinary teams is essential to meeting these goals. Strategies to develop teamwork and communication include: simulation training and team training.
 Simulation Training – a recreation of real world situations that allow for learning in an interactive manner without exposing caregivers or patients to harm; utilized to develop effective communication, within and between teams o Simulation and shoulder dystocia in the literature  Crofts et al. (2015) – 0 cases of brachial plexus injury lasting >12 months in 562 cases of shoulder dystocia one decade after simulation training introduced  Deering, Weeks & Benedetti (2011) – gender, body habitus and provider experience were not predictive of how much force a provider applies on the fetal head during a simulated shoulder dystocia  Crofts et al. (2006) – training with mannequins improved the management of shoulder dystocia; training on high-fidelity mannequins including force monitoring, offered additional benefits  Goffman, Heo, Pardanani, Merkatz & Bernstein (2008) - Shoulder dystocia simulation training improved communication skills among resident and attending physicians
 Team Training – a comprehensive program that includes strategies and tools to facilitate teamwork behaviors. o Key Principles:  Team structure – “The ratio of We’s to I’s is the best indicator of the development of a team”, Lewis B. Ergen  Clearly defined team  Infrastructure for decision-making, care delivery & communication  Identification of Team roles during a shoulder dystocia: 1. Delivery provider – Team leader; identify the situation; focused on performing delivery maneuvers 2. Delivery nurse – Vigilance; alerts the team and mobilizes resources; assigns roles to other team members 3. Recorder – Maintains situational awareness for the team; documents team actions and time of action; timekeeper – call out time intervals to maintain situational awareness of team 4. Anesthesia personnel – Appropriate pain control to allow maneuvers 5. Neonatal personnel –Stabilization and assessment of the newborn; resuscitation as required  Leadership – “Leadership: the art of getting someone else to do something you want done because he wants to do it.:, Dwight D. Eisenhower  Effective leaders create the climate that allows teamwork to flourish
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Shoulder Dystocia: A Primer for Successful Team Response