Managing shoulder dystocia

Vol. 15 no. 3 - September 2007

Although the course of her second pregnancy had been uncomplicated, Mrs P, a 32-year old teacher, had
some anxieties about labour. In her first pregnancy there had been suggestions of gestational diabetes but a
glucose tolerance test was not done, and she had a normal delivery of a healthy baby girl weighing 4000g.
This time, she felt the baby was bigger than her first and relatives had commented on the size of her
abdomen. Fundal height measurements taken in the third trimester were on the 90th centile.
Two days after the estimated due date, Mrs P was admitted to the delivery suite in spontaneous labour. On
palpating the abdomen the admitting midwife remarked that this was a big baby. Mrs P had strong, regular
uterine contractions and progressed from 3cm cervical dilatation on admission to 9cm six hours later. It took
three more hours before the cervix was fully dilated.
Progress was also slow in the second stage of labour and Dr A, locum consultant, was called after Mrs P
had been pushing for 45 minutes. Having assessed the pelvis, he proceeded to ventouse delivery of the
baby. The head was delivered easily, but it immediately retracted, with the babys chin abutting on the
perineum (the turtle sign). Dr A applied traction to deliver the rest of the baby but this was unsuccessful
and it became clear that there was shoulder dystocia.
Dr A cut an episiotomy, then applied further traction but could not deliver the shoulders. A click was heard as
he tried unsuccessfully to deliver the posterior arm. Meanwhile the midwife tried to assist by applying fundal
pressure but this was not successful. Mrs Ps legs were then removed from the stirrups and McRoberts
manoeuvre was applied. This was successful in disimpacting the anterior shoulder and the baby boy G was
delivered. G had Apgar scores of 6 and 9 at one and five minutes respectively, and weighed 4300 g. He had
a fracture of the left humerus and was found to have a brachial plexus injury of the right side involving C5,
C6 and C7 nerve roots (Erbs palsy). Mrs P suffered a third degree perineal tear, postpartum haemorrhage
and symphysis pubis dysfunction. She suffered post-traumatic stress disorder because of the delivery.

Expert opinion
The expert witnesses were critical of the management of shoulder dystocia. Once the turtle neck sign was
observed, any lateral traction on the babys head carried the risk of causing brachial plexus injury and
should have been avoided. The hospital had a protocol for the management of shoulder dystocia which
outlined the type and sequence of manoeuvres that should be employed. Dr A knew of this protocol but had
not read it.
The application of fundal, rather than suprapubic, pressure could not be supported by a reasonable body of
medical opinion. Indeed, this practice was considered to be potentially dangerous, as it pushes the impacted
shoulder against the pubic bone and could cause uterine rupture.
Expert opinion was also critical of the technique employed by Dr A in an attempt to deliver the posterior arm.
The case was settled for a substantial sum.

Learning points

When working as a locum, or in any post, familiarise yourself with the protocols that are in place. If you
dont follow the local protocol then you must be able to show that this departure was based on good
clinical grounds, valid evidence, and safe practice.
An important aspect of the management of shoulder dystocia is contemporaneous documentation, and
the hospitals protocol stated that the type, duration and sequence of manoeuvres used in managing

each case should be documented. Although Dr A wrote an operation note for the ventouse delivery,
these details regarding the management of shoulder dystocia were not documented.
Events in previous pregnancies should be taken into account in performing a risk assessment in the
index pregnancy.
Although shoulder dystocia is largely an unpredictable emergency, there were risk factors in this case
which made the diagnosis foreseeable: a suggestion of possible impaired glucose tolerance,
macrosomia, prolonged labour and mid-cavity instrumental delivery. These should have alerted the staff
to anticipate shoulder dystocia and rehearse the shoulder dystocia drill. If shoulder dystocia is
appropriately managed, it is more likely than not that the outcome for the baby will be good.
Consider the entire clinical picture when contemplating an intervention. In this case the slow progress
towards end of the first stage of labour, taken with the past obstetric history and macrosomia, should
have rung alarm bells.
Simulation training (fire drills) for uncommon emergencies help to hone skills in readiness for actual
cases.

Shoulder dystocia is a birth emergency that occurs in approximately 1% of all births. Shoulder
dystocia can be followed by broken clavicle or humerus, brachial plexus injury, fetal hypoxia, or
death. Although risk factors for shoulder dystocia include previous birth complicated by
shoulder dystocia, maternal obesity, excessive prenatal weight gain, fetal macrosomia,
gestational diabetes, and instrumental delivery, shoulder dystocia is not predictable. Perinatal
nurses can reduce the risk for shoulder dystocia by teaching mothers about optimal weight gain
in pregnancy and assisting mothers with diabetes to prevent hyperglycemia through diet
management and medication use. During childbirth preparation or early labor, nurses can
educate mothers about position changes and maneuvers used for shoulder dystocia. Nurses play
a vital role in obtaining assistance during a shoulder dystocia, keeping time, assisting with
maneuvers such as suprapubic pressure, and documenting the dystocia management. Nurses
can assist mothers and families to review the shoulder dystocia and any newborn injuries in the
postpartum period, thereby reducing confusion and anxiety.