The Case of Rita Oelo

Rita is a 32 year-old woman who is 39 weeks pregnant with her third child. She has been followed in the community by a midwife. She, and her midwife, are concerned about her upcoming labour, as her last child became 'stuck' during the delivery and suffered some permament neurological damage. Her midwife listens to the story and decides the cause was most likely shoulder dystocia.

Most cases of shoulder dystocia are unexpected. However, established risk factors include:

• maternal diabetes (principal risk factor)
• fetal macrosomia (maternal obesity, postdates pregnancy)
• prolonged labour, especially in second stage
• operative vaginal delivery, especially midforceps delivery
• previous shoulder dystocia
• older mother
• grand multiparity (five deliveries or more)

If you are involved in labour and delivery, always be prepared, mentally, with equipment and with a team, for the possibility of shoulder dystocia.

 

Patients should be informed of the risk of shoulder dystocia if the fetus is estimated to be over 5000 grams, or if over 4500 grams in a mother with diabetes, and discussion of elective cesarian section, if available, should be discussed.

 

Regular training drills should be practiced with labour and delivery teams.

 

 

 

Most cases of shoulder dystocia resolve without complication. The most common fetal/neonatal complication is brachial plexus injury, although most (~90%) resolve completely. Other complications include fractures (clavicle, humerus), asphyxia, and death.

 

Maternal complications can include genital tract lacerations, postpartum hemorrhage, rectovaginal fistula, symphyseal separation, uterine rupture, and psychological trauma.

Rita goes into labour and progresses well. However, as the head is delivered, the 'turtle sign' is seen by the midwife, as the head moves down with pushing, but then retracts back again.

 

3 minutes later with the next contraction, the baby is not delivered despite strong pushing efforts. 

 

 

ALARMER - Acronym for actions to address shoulder dystocia

Ensure the time of important events and actions are recorded. The following steps need not be done in this order.

 

Ask for help: ask patient to push hard, ask to drop head of bed down, and call for anesthesia and a pediatrician.

Legs: hyperflex legs (McRobert's manoeuvre) to open pelvis in AP direction (helpful in up to 40% of shoulder dystocias).

A: Disimpact the Anterior shoulder with suprapubic pressure. Can also try to rotate shoulders to oblique plane by inserting two fingers posteriorly into the vagina and pushing on the front of the posterior shoulder to move it off the midline

Release the posterior arm: find fetal forearm and hand and sweep it across the chest

Maneuver of Woods - Corkscrew maneuver

Episiotomy: not helpful to free infant, but can create more room

R: roll mother onto all fours to free impacted shoulder.

 

Avoid fundal pressure or excessive traction/twisting of the infant neck, as these maneuvers cause more harm than good.

 

Forceps are of little value once the shoulders become wedged.

 

Using a simulated pelvis and fetus, practice the ALARMER steps.