Shoulder Dystocia:Analysis from a Risk

Management Perspective

Barrett NA, Ryan HM, Mc Millan HM, Geary MP

Rotunda Hospital, Dublin, Ireland.

• Definition• Background

•Incidence• Risk Factors•Clinical Manifestations

• Aims of Study• Methods• Results•Conclusions

Shoulder Dystocia

Definition

– A delivery that requires additional manoeuvres to release the shoulders after gentle downward traction has failed. (RCOG Dec 2005)

Definition

– “Vertex delivery in which gentle lateral head traction and normal maternal pushing efforts fail to deliver the shoulders, in the absence of other causes of dystocia or slow progress” (Piper & McDonald, 1994)

– “Further progress toward delivery is prevented by impaction of the fetal shoulder within or above the maternal pelvis” (Seeds, 1991 quoted by Hall, 1997)

Background-Incidence

• 0.6 % in Europe and North America• Variation in definitions and incomplete

documentation (Simpson, 1999)

Background-Risk Factors

• Macrosomia• Maternal Diabetes• Hx of macrosomia/shoulder dystocia• Labour abnormalities• Instrumental deliveries• Post term• Increasing maternal age• Maternal obesity• Male fetus

Background-Clinical Manifestations

• Prolonged head-to-body delivery time

• Turtle neck sign

• Routine manoeuvres for delivery ineffective in delivery of shoulders

BackgroundRisk management

• Obstetric emergency potential for risk and litigation

• Risk Management involves– Risk Identification– Risk analysis and monitoring– Risk evaluation– Risk treatment– Risk control(ROCG Clinical Governance Advice 2005

Improving patient safety in Obstetrics & Gynaecology)

Aims

• To determine local incidence

• To review management

• To review documentation

• To review clinical neonatal outcomes

• To improve risk management

Methods

• 2 year review of deliveries – January 2005 -December 2006

• Computerised records / birth register incident forms / neonatal register

• Manual chart documentation review of individual cases

Results

• 80 cases• No of deliveries during this period =

14,129 • Incidence = 0.56 %• 44% (35/80)

– associated with instrumental deliveries

• 65% (52/80)– out of office hours

Results of documentation review

Results of documentation review

Results- Neonatal outcomes

*100% documentation

pH < 7.10pH >7.10pH not done

Results-Neonatal outcomesCord pH results

Results-Neonatal Outcome

Adverse events

• 4 cases of Erb’s palsy.

• 1 case of clavicular fracture

Conclusions• Poor documentation of management

• Incomplete de-briefing after an incident

• Review of management limited by documentation

Conclusions

• Reduce risk by • Improving identification of clinical risk

factors• Education of staff of risk factors• Improve documentation of risk factors

Conclusions

• Monitor risk by audit cycle

Shoulder DystociaAddressograph

Date__________ Form completed by__________________

Delivery of head Spontaneous Instrumental LSCSCall for HELPEmergency Bleep TimeArrival Time Name

Registrar/ spr/ cons doc y/n doc y/n Senior Midwife doc y/n doc y/n

Paediatrician doc y/n doc y/n Anaethesist doc y/n doc y/n

PROCEDURE USED TO ASSIST DELIVERY OF SHOULDERS

Sequence Time Performed by Evaluate for EpisiotomyEpisiotomyMcRoberts’ position Directed Supra pubic pressure rocking/continuous

Enter manoeuvresUnspecified manouevres

Woods ScrewDelivery of posterior armRoll mother onto all fours position Time delivery of head ________ Head facing: Left: Right: not documented

Time delivery of body _________ Cord pH and BE Arterial __________Cord pH and BE Venous __________

Apgar Score 1 minute 5 minute NICU Y/NExplanation to parents post event Yes NoFollow up after discharge Yes No Advice for next pregnancy D Y/N LSCS/SVDRisk factors/NDweight

Conclusions

• Control risk by• A standardised proforma

• Improve documentation • Improve awareness of

clinical pathway for follow-up

• Staff training fire-drills• Feedback sessions

Thank you

Royal College ofObstetricians andGynaecologists

Setting standards to improve women’s health

Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting

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