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

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

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. Background Risk 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

15. Results- Neonatal outcomes *100% documentation

16. Results- Neonatal outcomes Cord pH results

17. Results- Neonatal Outcome Adverse 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 BleepTime 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 SequenceTimePerformed 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 Score1 minute5 minute NICU Y/N Explanation to parents post eventYes No Follow up after dischargeYesNo 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. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers