SHOULDER DYSTOCIA PROTOCOL
This condition is an emergency and the best strategy is to have in place a defined shoulder dystocia protocol to help health care professionals cope with the condition. The HELPERR mnemonic is one of such clinical tools.
H – Call for help
This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labour and delivery unit.
E – Evaluate for episiotomy
Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation manoeuvres are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder. Because most cases of shoulder dystocia can be relieved with the McRoberts manoeuvre and suprapubic pressure, many women can be spared a surgical incision.
L – Legs (the McRoberts manoeuvre)
This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. Nurses and family members present at the delivery can provide assistance for this manoeuvre.
P – Suprapubic pressure
The hand of an assistant should be placed suprapubically over the foetal anterior shoulder applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the foetal shoulder. This manoeuvre should be attempted while continuing downward traction. When this manoeuvres is successful, the foetus should be delivered with normal traction.
E – Enter manoeuvre (internal rotation)
These manoeuvres attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. These manoeuvres can be difficult to perform when the anterior shoulder is wedged beneath the symphysis. At times, it is necessary to push the foetus up into the pelvis slightly to accomplish the manoeuvres. The manoeuvres include the Rubin II, the Woods corkscrew and the Reverse Woods corkscrew manoeuvres.
R – Remove the posterior arm
Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the foetus to drop into the sacral hollow, freeing the impaction. The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall. Grasping and pulling directly on the foetal arm may fracture the humerus.
R – Roll the patient
The patient rolls from her existing position to the all-fours position. Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction. In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the foetal shoulders.
If the manoeuvres described in the HELPERR shoulder dystocia protocol mnemonic are unsuccessful, several techniques have been described as ‘last-resort’ manoeuvres. They include –
Deliberate clavicle fracture
Direct upward pressure on the mid-portion of the foetal clavicle; reduces the shoulder-to-shoulder distance.
Cephalic replacement followed by cesarean delivery; involves rotating the foetal head into a direct occiput anterior position, then flexing and pushing the vertex back into the birth canal while holding continuous upward pressure until cesarean delivery is accomplished. An operating team, anesthesiologist, and physicians capable of performing a cesarean delivery must be present, and this manoeuvre should never be attempted if a nuchal cord previously has been clamped out and cut.
Musculoskeletal or uterine relaxation with halothane or another general anesthetic may bring about enough uterine relaxation to affect delivery. Oral or intravenous nitroglycerin may be used as an alternative to general anesthesia.
Abdominal surgery with hysterotomy
General anesthesia is induced and cesarean incision is performed, after which the surgeon rotates the infant transabdominally through the hysterectomy incision, allowing the shoulder to rotate, much like a Woods corkscrew manoeuvre. Vaginal extraction is then accomplished by another physician.
Intentional division of the fibrous cartilage of the pubic symphysis under local anesthesia has been used more widely in developing countries. It should be used only when all other manoeuvres have failed and capability of cesarean delivery is unavailable.
Following the successful delivery of the baby after inplementation of a shoulder dystocia protocol, proper documentation is necessary for two reasons. The first is because the documentation would prove useful in developing better techniques to deal with the condition; secondly because shoulder dystocia is an important reason for initiating medico-legal action.
- Fully document events in terms of description and sequence of manoeuvres including times from delivery of head to complete delivery.
- Who was called to help and record time.
- Take paired cord samples and record pH levels.
- Baby is assessed by staff grade pediatrician.
- Complete audit form and clinical incidence form.
- Details of information given to parents.
Figure: A representation of the shoulder dystocia.