Shoulder dystocia is impaction of either the fetal anterior shoulder on the maternal symphysis pubis or the posterior shoulder on the sacral promontory after spontaneous or assisted delivery of the fetal head. This complication, occurring in 0.2% to 3.0% of deliveries, is unpredictable and unpreventable and may result in permanent neonatal injury (brachial plexus palsy and hypoxic encephalopathy) and significant maternal morbidity (pelvic lacerations and obstetric hemorrhage).[1] The prompt recognition of shoulder dystocia and performance of essential obstetric maneuvers to accomplish delivery in a team setting are critical to achieving optimal outcomes. OB/GYN hospitalists are in a unique position to emergently assist in these deliveries and to foster a culture of safety by leading shoulder dystocia skills drills and team-training simulations.

Knowledge

OB/GYN hospitalists should be able to:

• Define shoulder dystocia.
• Explain the mechanical pathophysiology resulting in shoulder dystocia.
• List prenatal and intrapartum risk factors for shoulder dystocia.
• Describe the possible neonatal and maternal injuries associated with shoulder dystocia.
• Outline the sequential maneuvers used to manage shoulder dystocia.
• Explain the role of episiotomy in the management of shoulder dystocia.
• Describe the possible neonatal and maternal injuries associated with maneuvers used to reduce shoulder dystocia.

Skills

OB/GYN hospitalists should be able to:

• Promptly recognize shoulder dystocia.
• Identify patients at risk for shoulder dystocia.
• Assemble and coordinate a team to effectively and rapidly manage shoulder dystocia.
• Act as a consultant for other obstetric providers encountering shoulder dystocia.
• Demonstrate proper technique and skill in performing obstetric maneuvers for management of shoulder dystocia.
• Assess both mother and baby for possible injury following a delivery complicated by shoulder dystocia.
• Communicate with patients and families regarding the outcome of a delivery complicated by shoulder dystocia.
• Convey to patients and families the risk of shoulder dystocia and injury in subsequent pregnancies.
• Counsel patients with significant prenatal risk for shoulder dystocia regarding primary cesarean delivery as an alternative to vaginal delivery.
• Document the details of the delivery complicated by shoulder dystocia in collaboration with nursing and pediatric providers, preferably using a template such as that suggested by the American College of Obstetricians and Gynecologists.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Maintain proficiency in essential obstetric skills required for managing shoulder dystocia, such as rotation, posterior arm delivery, posterior axillary sling traction, and cephalic replacement by participating in regular and frequent simulation exercises.
• Develop and maintain a unit-based coordinated team approach to shoulder dystocia management by leading team simulations emphasizing communication, situational awareness, and mutual support.
• Recognize that the patient and family should be included as members of the team with prompt communication during the delivery and continued support and communication after the delivery, especially in the event of an adverse outcome.
• Seek self-support when an adverse event occurs.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead team debriefings after shoulder dystocia events.
• Establish a standard format for documenting shoulder dystocia on labor and delivery units.
• Encourage all providers to participate in shoulder dystocia simulation training.
• Lead efforts to review shoulder dystocia cases with adverse neonatal outcomes with the goal to improve through enhanced team strategies.
• Recognize and mitigate the emotional impact of an unexpected emergency and provide support for the “second victim” in the event of an untoward outcome.

References