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Managing Shoulder Dystocia: Preventing Brain Damage and Nerve Injury all over the world

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    This blog describes why Shoulder Dystocia occurs; how it should be managed correctly; and the complications that can arise when it is not. It also reports how a group of doctors and midwives have got together and through training and education have improved the lives of many children who would otherwise have suffered the complications of Shoulder Dystocia.

    By Abigail Ringer

Shoulder Dystocia is a potentially life threatening complication of child birth. It arises when the baby’s body is prevented from delivering after the head, because the baby’s shoulder is obstructed by the mother’s pelvis.

Once the obstruction occurs, correct management is crucial: The clock starts ticking because a healthy baby will only compensate for a finite amount of time yet trying to deliver the baby by pulling too much on the baby’s head can result in nerve damage to the baby’s arm. With training and education, doctors and midwives can manage Shoulder Dystocia correctly, to avoid complications and assist in the delivery of healthy, happy babies all over the world.

PROMPT symposium

Earlier this spring, I went along to the Assembly Rooms in Bath where I had the pleasure of mingling with over a hundred midwives and doctors who had come from dozens of different countries, from Australia to Abu Dhabi, to take part in the PROMPT Maternity Foundation (PMF) symposium. The PMF is made up of a group of doctors and midwives who strive to make childbirth safer through training and education all over the globe.

While I was there I discovered that Shoulder Dystocia complicates around one in fifty vaginal deliveries, which seemed like quite a lot to me and was delighted to learn how, with correct training, the outcomes for children affected by Shoulder Dystocia have been hugely improved.

What is Shoulder Dystocia?

Shoulder Dystocia is an acute and potentially life threatening event that arises when the baby’s body is prevented from delivering after the head, because one of the baby’s shoulders is obstructed by the mother’s pubic symphysis (the nobbly joint at the front of the pelvis). It is often described as like driving a lorry under a low bridge: the cab passes under but the cargo gets stuck.

What are the risk factors for Shoulder Dystocia?

A number of risk factors are associated with Shoulder Dystocia, including a large baby or a mother with diabetes or obesity.

How should Shoulder Dystocia be managed?

Once Shoulder Dystocia is identified and further assistance is called for, the mother is normally placed on her back with her knees up towards her ears. This is known as the McRoberts’ position. The McRoberts’ position increases the ‘front to back’ diameter of the pelvis.

If the obstruction of the shoulder is not released by the McRoberts’ position, the doctor or midwife will apply “supra pubic” pressure to the base of the mother’s abdomen. The pressure is aimed at reducing the diameter of the baby’s shoulders, enabling the trapped shoulder to pass freely underneath the pelvis.

If the McRoberts’ position and pressure are ineffectual, the doctor may deliver the arm which is not trapped. This will reduce the diameter of the shoulders and may provide enough room to enable delivery of the body. Alternatively, the baby can be rotated so that its shoulders lie in line with the widest point of the mother’s pelvis, resolving the Shoulder Dystocia.

Possible Complications of Shoulder Dystocia

Shoulder Dystocia is a potentially life threatening event and it is important to get the baby out quickly. Although a healthy baby will compensate for a short time, prolonged entrapment may lead to the baby’s brain being starved of oxygen, resulting in brain damage.

When the baby is trapped, there is a temptation to pull the baby’s head, yet excessive pulling can cause injury to the network of nerves that supply the arm and damage to these nerves can result in weakness in the arm, otherwise known as a brachial plexus nerve injury or Erb’s Palsy.

At the PROMPT symposium I was informed that through training and education, the outcomes for babies who have suffered from Shoulder Dystocia have improved enormously. Between 2009 and 2012, Southmead Hospital in Bristol enjoyed the lowest injury rate following shoulder dystocia in the world and there have been no permanent nerve injuries caused from Shoulder Dystocia in more than 17,000 vaginal births since 2009!

As a lawyer acting for children who have suffered injuries as a result of the mismanagement of shoulder dystocia and seeing the lifelong effects of such injuries, I hope that the successes at Southmead Hospital can be replicated at all hospitals in the UK to reduce the incidences of these injuries.

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