– Do you need jaw thrust?
– Do you need a longer infl ation time?
– Do you need a second person’s help with the airway?
– Do you need to remove an obstruction in the airway using a laryngoscope and wide bore suction?
– What about an oropharyngeal (Guedel) airway?
There is no point in progressing until there is evidence that air is enter- ing the lungs.
• Chest compression. In a few cases, the cardiac function will have deteriorated so that oxygenated blood is not transferred from the aerated lungs to the heart. If the heart rate remains below 60 beats/min following effective rescue breaths, chest compres- sions will be required. The recommended method of delivering chest compressions is to grip the chest with both hands so that the two thumbs can press on the lower third of the sternum, with the fi ngers over the spine at the back. The chest should be com- pressed quickly and fi rmly by about one third of the depth at a ratio of 3 : 1 compressions to infl ations. A rate of 90–120 com- pressions/min should be aimed for. The aim is to move oxygen- ated blood from the lungs back to the heart. It is important to allow enough time during the relaxation phase of each compres- sion cycle for the heart to refi ll with blood.
• Administration of drugs (rare). In the rare event that lung infl ation and chest compressions are insuffi cient, drugs may be required to restore the circulation. The outlook for this group of babies is poor
• The Resuscitation Council (UK) (2005) states that ‘If there are no signs of life after ten minutes of continuous and adequate resuscitation efforts, then discontinuation of resuscitation may be justifi ed’. However, the midwife’s responsibility is to continue resuscitation until care is transferred to an appropriate practitioner (NMC 2004a) As in all emergency situations, it is imperative that staff with the appropriate experience are called as soon as possible, and particular attention should be made to:
• Communication with the parents
• Record keeping and documentation
The rate of progress in labour and particularly the second stage is predictive of the possibility of obstruction during the delivery.
Shoulder dystocia is one such delay.
Active childbirth encourages mothers to be upright, mobile and in control. The midwife works with the mother, engaging her trust, and this relationship is essential when faced with an emergency situation.
Defi nition: Shoulder dystocia is best defi ned as an impaction of the anterior shoulder of the fetus against the maternal symphysis pubis after the fetal head has been delivered. Any measures aimed at expediting delivery concentrate on changing the relationship between the two bony parts. Gibb (1995) described three types of shoulder dystocia, increasing in severity:
1. A tight fi t when delivering a big baby
2. A unilateral dystocia, where the anterior shoulder becomes impacted above the maternal symphysis pubis
3. A bilateral dystocia, where both the shoulders have become arrested above the pelvic brim
Incidence: The incidence of dystocia is generally agreed to be between 0.2 per cent and 0.3 per cent at term (Eden et al. 1987), increasing to 1.3 per cent by 42 weeks. These fi gures may vary due in part to midwives’ reluctance to diagnose true shoulder dystocia.
Risk factors: Although it is known that the following risk factors are predictive of shoulder dystocia, it is also acknowledged that they are of reasonably poor predictive value. Current practice encour- ages midwives and obstetricians to attempt to anticipate diffi culty using these triggers:
• Prior shoulder dystocia. This is predictive of a further risk of dys- tocia with a reoccurrence rate of 10 per cent in subsequent deliv- eries (Smith et al. 1994)
• Diabetes. With its association with larger babies, diabetes is a signifi cant risk factor for both pre-gestational and gestational diabetes
• Post-dates pregnancy. As a pregnancy continues past 40 weeks there is a correlation with larger babies
• Prolonged fi rst stage. A longer fi rst stage, or one that has been augmented, may be symptomatic of a fetus that is large in pro- portion to the mother
• Prolonged second stage. A second stage that is longer than expected, i.e. in a multiparous mother, is indicative of a larger baby
• Operative vaginal delivery. Either forceps or ventouse deliveries are associated with a higher incidence of diffi culty with the fetal shoulders
Management
The manoeuvres described here are the currently recommended management for shoulder dystocia. They are described from the simple to the more complex, but this order is not prescriptive. They can be undertaken in any order, but for midwives the simple manoeuvres are the starting point. Organisations such as ALSO recommend the use of a mnemonic HELPERR.
Help
Evaluate for episiotomy Legs (McRoberts position) Pressure (suprapubically) Enter (for manoeuvres) Remove (the posterior arm)
Roll (the patient either into all fours or through 360 degrees) The fi rst action of the midwife is to confi dently diagnose a shoulder dystocia and call for assistance, i.e. more midwives, obstetricians and paediatric support. Once help is on its way the measures described below should be commenced. In a community setting or a midwife-led unit the measures can be undertaken in any order, commencing with simple measures such as rolling the patient onto all fours. In a birthing pool, the mother should be encouraged to stand up and place one foot on the edge of the pool to allow for delivery.
• McRoberts manoeuvre. This involves placing the mother fl at on her back and putting her knees on her chest. Once she is in this position attempts should be made to deliver the baby. It should be possible for the midwife to deliver the baby as normal. The manoeuvre is aiming to:
– Rotate the symphysis pubis anteriorly – Push the posterior shoulder over the sacrum – Open the pelvic inlet to its full capacity – Correct any maternal lordosis
– Remove the sacral promontory as an obstruction
If the manoeuvre in unsuccessful it is suggested that it is repeated before moving on to another. The McRoberts position is a rela- tively safe intervention with a good rate of success of 40–50 per cent
• All fours position. When there is the suspicion that a mother is at risk of a shoulder dystocia the midwife may suggest that the delivery is conducted with the mother on all fours. This position optimises the sacral curve and is in effective McRoberts upside down. With the mother on all fours she can be encouraged to rock, thereby mimicking the movement of the legs when put into the McRoberts position. This is therefore a useful tool when delivering in a birth centre or in the mother’s home
• Suprapubic pressure. This is aimed at displacing the anterior shoulder from the symphysis pubis to allow it to enter the pelvis.
It is also referred to as Rubins 1:
– Pressure is applied by the midwife or an assistant to the mother’s abdomen, above the baby’s back, in a downward direction towards the side of the mother that the baby is facing
– Whilst this pressure is applied the delivering midwife will continue to try to deliver the baby. The pressure should be continuous initially. If unsuccessful the assistant can be asked to provide pressure in a rocking movement
These manoeuvres have been shown to be effective in 67 per cent of cases of shoulder dystocia. (Luria et al. 1994)
• Episiotomy. It is widely accepted that in the event of a shoulder dystocia occurring, an episiotomy is desirable to prevent further damage to the mother’s pelvic fl oor and to provide space for the
‘enter’ manoeuvres. However, as routine episiotomy is not current practice it is diffi cult to know when the optimum time to perform it is. Once the baby’s head has delivered it is technically very diffi cult to ensure the procedure does not damage the baby
• Rubins 2 and the wood screw manoeuvre – the ‘enter’ manoeuvres.
These aim to rotate the shoulders into the oblique diameter and are often combined to expedite delivery. The wood screw involves the midwife inserting as much of her hand as possible into the vagina in order to apply pressure to the posterior aspect of the anterior shoulder to turn it to the oblique. During this manoeuvre the mother should be placed in the lithotomy posi- tion, or if at home, the McRoberts position. Suprapubic pressure can also be continued. The midwife can also enter her other hand to apply pressure to the anterior aspect of the posterior shoulder in order to provide better rotation. If at any time during the manoeuvre it is seen that the baby has moved, an attempt to deliver should be made. Rubins 2 concentrates on reducing the diameter of the shoulders. Working from behind the baby a shoulder is located and pushed into the oblique. These two pro- cedures can be used together in order to be of most effect
• Delivery of the posterior arm. If the previous endeavours have been unsuccessful the last of the ‘enter’ manoeuvres is when an attempt to deliver the posterior arm is made. The midwife enters in front of the baby’s body and locates the lower arm.
Pressure is exerted on the elbow to try to make the lower arm raise, this is then grasped and gently pulled across the baby’s face in a ‘cat lick’ motion thereby delivering the posterior shoulder
If the above manoeuvres are unsuccessful the whole round of pro- cedures should be performed again. It is recommended that this is undertaken by another midwife or obstetrician.
Documentation
Every obstetric emergency must be carefully documented after the event. This can be aided by using the mnemonic and writing the time each manoeuvre is performed and by whom. This will enable good debriefi ng of the parents when they are ready to talk about the event.
Risk management
With the advent of clinical governance, professionals are more accountable to the mothers and are encouraged to learn from events.
Reporting forms for all obstetric risk events are available in all units across the country. They allow for accurate audit of events and aid the planning of training programmes designed to keep professionals up to date with current practices in maternity care.