Shoulder Dystocia: Analysis from a Risk Management Perspective

2. Shoulder Dystocia:Analysis from a Risk Management Perspective Barrett NA, Ryan HM, Mc Millan HM, Geary MP Rotunda Hospital, Dublin, Ireland.

3. Shoulder Dystocia • Definition • Background • Incidence • Risk Factors • Clinical Manifestations • Aims of Study • Methods • Results • Conclusions

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

5. 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)

6. Background-Incidence • 0.6 % in Europe and North America • Variation in definitions and incomplete documentation (Simpson, 1999)

7. Background-Risk Factors • Macrosomia • Maternal Diabetes • Hx of macrosomia/shoulder dystocia • Labour abnormalities • Instrumental deliveries • Post term • Increasing maternal age • Maternal obesity • Male fetus

8. Background-Clinical Manifestations • Prolonged head-to-body delivery time • Turtle neck sign • Routine manoeuvres for delivery ineffective in delivery of shoulders

9. 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)

10. Aims • To determine local incidence • To review management • To review documentation • To review clinical neonatal outcomes • To improve risk management

11. 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

12. 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

13. Results of documentation review

14. Results of documentation review

15. Results- Neonatal outcomes *100% documentation

16. Results- Neonatal outcomes Cord pH results

17. Results-Neonatal OutcomeAdverse events • 4 cases of Erb’s palsy. • 1 case of clavicular fracture

18. Conclusions • Poor documentation of management • Incomplete de-briefing after an incident • Review of management limited by documentation

19. Conclusions • Reduce risk by • Improving identification of clinical risk factors • Education of staff of risk factors • Improve documentation of risk factors

20. Conclusions • Monitor risk by audit cycle

21. Shoulder Dystocia • Addressograph • Date__________ Form completed by__________________ • Delivery of head Spontaneous Instrumental LSCS • Call for HELP • Emergency Bleep Time • Arrival 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 Episiotomy • Episiotomy • McRoberts’ position • Directed Supra pubic pressure • rocking/continuous • Enter manoeuvres • Unspecified manouevres • Woods Screw • Delivery of posterior arm • Roll 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/N • Explanation to parents post event Yes No • Follow up after discharge Yes No • Advice for next pregnancy D Y/N LSCS/SVD • Risk factors/ND • weight

22. Conclusions • Control risk by • A standardised proforma • Improve documentation • Improve awareness of clinical pathway for follow-up • Staff training fire-drills • Feedback sessions

23. Thank you

24. Setting standards to improve women’s health Royal College ofObstetricians andGynaecologists Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers