AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements related to the safe management of a delivery complicated by a shoulder dystocia. The key elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) staff responsible for managing a delivery complicated by shoulder dystocia.
How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to determine how elements will be implemented on your L&D unit. Consider any existing facility policies or processes related to shoulder dystocia. Consider using standing orders, preprinted checklists, and staff simulation training to support implementation. A sample of how some of these key perinatal safety elements can be incorporated into a unit approach to shoulder dystocia is provided in the Appendix of this tool.
Key Perinatal Safety Elements
| Standardize When Possible (CUSP Science of Safety) | |
|---|---|
| Key Perinatal Safety Elements | Examples |
| Use a predetermined approach to management of a shoulder dystocia approved by unit leadership. |
|
| Standardize communication of information during episode. |
|
| Create Independent Checks (CUSP Element) | |
| Use cognitive aids such as checklists, algorithms, or protocols to guide a systematic approach to management and documentation of shoulder dystocia. |
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| Learn From Defects (CUSP Element) | |
| Debrief and analyze near misses and adverse events related to shoulder dystocia. |
|
| Have a process in place to review severe maternal or neonatal morbidity and mortality events. |
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| Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning. | Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally. |
| Simulation (SPPC Program Pillar) | |
Sample scenario:
|
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| Teamwork Training (TeamSTEPPS®) | |
| Have situational awareness. | Situational awareness refers to all staff caring for the patient—
In the context of shoulder dystocia, this includes risk awareness for all patients, timely recognition of a shoulder dystocia diagnosis, awareness and monitoring of time since diagnosis, and discussing next steps if sequential maneuvers are not successful. |
| Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques. | Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of shoulder dystocia use, these techniques are particularly useful—
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| Communicate during transitions of care. | Use of transition communication techniques assures a shared mental model of plan of care and perceived risks between shifts, between units. |
Have high-reliability teams:
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Team members protect each other from work overload and place requests or offers for assistance in the context of patient safety. It is expected that assistance will be actively sought and offered.
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| Patient and Family Engagement (CUSP Module) | |
| Communicate with patient and family during episode. |
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| Disclose any unintended outcomes. | Unit-established process for disclosing unintended outcomes. This may include the following:
|
References
- Sokol RJ, Blackwell SC, American College of O Obstetricians and Gynecologists, et al. ACOG practice bulletin: Shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). Int J Gynaecol Obstet. 2003 Jan;80(1):87-92. PMID: 12578001.
- Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998 May;43(5):439-43. PMID: 9610468.
- Patient safety checklist No. 6: documenting shoulder dystocia. Obstet Gynecol 2012 Aug;120(2 Pt 1):430-1. PMID: 22825113.
- Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs 2008 Sep-Oct;37(5):510-5. PMID: 18761565.
- Stitely ML, Gherman RB. Shoulder dystocia: management and documentation. Semin Perinatol 2014 Jun;38(4):194-200. PMID: 24863024.
- Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011 Apr;204(4):322 e1-6. PMID: 21349495.
- Deering SH, Tobler K, Cypher R. Improvement in documentation using an electronic checklist for shoulder dystocia deliveries. Obstet Gynecol 2010 Jul;116(1):63-6. PMID: 20567169.
- Kwek K, Yeo GS. Shoulder dystocia and injuries: prevention and management. Curr Opin Obstet Gynecol 2006 Apr;18(2):123-8. PMID: 16601471.
- Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008 Oct;112(4):906-12. PMID: 18827135.
- Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008 Jul;112(1):14-20. PMID: 18591302.
Appendix
Every effort was made to ensure the accuracy and completeness of this resource. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
Sample Process for Shoulder Dystocia Management
___ Step 1. Identify shoulder dystocia
___ Failure to deliver the infant with gentle traction.
___ The "turtle sign" with retraction of the fetal chin and head to the maternal perineum.
___ Failure of restitution.
| ___ Call out time of identification of shoulder dystocia (hh:mm:ss) ___ : ___ : ___ |
___ Step 2. Call for help/activate emergency response
___ Call for additional nurses, maternity care provider, and anesthesiology.
___ Call for pediatric provider at delivery (if not already present).
___ Assign staff responsible for communication with patient and family.
___ Assign staff responsible for recording.
___ Step 3. Maneuver patient’s buttocks to edge of the birthing bed
[Call time] hh:mm:ss) ___ : ___ : ___
___ Step 4. McRoberts maneuver used concurrently with suprapubic pressure
[Call time] hh:mm:ss) ___ : ___ : ___
___ Step 5. Primary maneuvers [Call time for each maneuver]
Move sequentially through the primary maneuvers (rotational procedures, posterior arm delivery, all fours) in an efficient manner. No more than 30 seconds should be used with an individual maneuver before attempting the next one. Discuss the plan for delivery if primary maneuvers do not work.
___ Episiotomy (if needed)
[Call time] hh:mm:ss) ___ : ___ : ___
Rotational maneuvers:
___ Anterior shoulder
[Call time] hh:mm:ss) ___ : ___ : ___
___ Posterior shoulder
[Call time] hh:mm:ss) ___ : ___ : ___
___ Delivery of posterior arm
[Call time] hh:mm:ss) ___ : ___ : ___
___ All fours (also known as the Gaskin maneuver)
[Call time] hh:mm:ss) ___ : ___ : ___
___ Step 6. Secondary maneuvers – ONLY IF ABOVE FAIL [Call time for each]
___ Purposeful clavicular fracture
[Call time] hh:mm:ss) ___ : ___ : ___
___ Cephalic replacement with cesarean section (also known as Zavanelli maneuver)
[Call time] hh:mm:ss) ___ : ___ : ___
___ Symphysiotomy
[Call time] hh:mm:ss) ___ : ___ : ___
___ Summary of delivery and documentation of sequence of maneuvers
Head delivered: (hh:mm:ss) ____:____:____
Shoulders delivered (hh:mm:ss) ____:____:____
Head to body delivery interval (seconds) __________
Time of birth (hh:mm:ss) ____:____:____
Anterior shoulder (left/right) Occiput left/occiput right
| ___ McRoberts maneuver | Maneuver #___ | Time spent_____________ |
| ___ Suprapubic pressure | Maneuver #___ | Time spent_____________ |
| ___ Episiotomy | Maneuver #___ | Time spent_____________ |
| ___ Rotational maneuvers ___Anterior shoulder ___Posterior shoulder |
Maneuver #___ Maneuver #___ |
Time spent_____________ Time spent_____________ |
| ___ Delivery of posterior arm | Maneuver #___ | Time spent_____________ |
| ___ All-fours position | Maneuver #___ | Time spent_____________ |
| ___ Purposeful clavicular fracture | Maneuver #___ | Time spent_____________ |
| ___ Cephalic replacement with C/S | Maneuver #___ | Time spent_____________ |
| ___ Symphysiotomy | Maneuver #___ | Time spent_____________ |
___ Providers present (include all)
Maternity care providers_________________________________________________
Nursing staff _________________________________________________________
Anesthesiology provider ________________________________________________
Pediatric provider______________________________________________________
Other _______________________________________________________________
___ Neonatal status
Birth weight (grams) _______
Outcome: ___ Deceased ___ Live birth
Apgars: _____________________________ (1 min/5 min/10 min, if applicable)
Moving both arms after delivery: ___ Yes ___No
Evidence of clavicular fracture: ___ Yes ___No
Evidence of humerus fracture: ___ Yes ___No
Blood gases: ___ Not Sent ___Sent
Arterial: pH: ________________ Base deficit: ________________
Venous: pH: ________________ Base deficit: ________________
Infant location after birth:
___ In room with mother
___ Neonatal intensive care unit
___ Newborn nursery for observation
___ Maternal status
Other comments: _______________________________________________________
Description of Procedures for Shoulder Dystocia Management
Primary Procedures
McRoberts maneuver: Mother’s legs hyperflexed back onto abdomen.
Suprapubic pressure: Using a closed fist over pubic bone, push in an inward and downward motion.
Rotational Procedures
If McRoberts and suprapubic pressure fail to relieve the obstruction, the clinician should try intravaginal procedures. Episiotomy may be necessary to allow for placement of the clinician’s hand but is not necessary if hand placement is possible. Each of the rotational maneuvers has an eponymous name; however, several authors emphasize the importance of learning the procedure and not the name.
- Anterior shoulder: The clinician’s entire hand is placed on the posterior surface of the fetal anterior shoulder, and pressure is applied toward the infant’s anterior chest to adduct and flex the anterior shoulder.
- Posterior shoulder: The clinician’s entire other hand is placed on the anterior surface of the posterior shoulder and pressure placed that is meant to abduct and extend the posterior shoulder.
Posterior Arm Delivery
Delivery of the posterior arm can be considered before or after rotational steps. The ideal approach is for the clinician to put pressure in the antecubital fossa of the posterior arm, flexing the arm and sweeping the hand and arm over the anterior fetal chest and delivering the hand through the vagina. This will flex and adduct the shoulders and should disengage the anterior shoulder to allow the body to deliver.
All Fours (also known as the Gaskin maneuver)
In a patient who is relatively mobile, the all-fours maneuver or rotating the woman to knee-hands position can help to dislodge the shoulder. This can be disorienting for the clinicians, but a systematic approach can assist in an orderly use of the previously attempted steps.
Secondary Procedures (also considered procedures of last resort)
Clavicular Fracture
Clavicular fracture is not uncommon in neonates after shoulder dystocia. Separate from this, however, is the deliberate fracture of the clavicle as a technique to relieve the shoulder dystocia by reducing the bisacromial diameter. This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated with this procedure. It is performed by applying upward (in a cephalic direction) digital pressure on the fetal clavicle, against the maternal pubic ramus.
Cephalic Replacement With Cesarean Section (also known as the Zavanelli procedure)
If the above procedures have failed to achieve a vaginal birth despite several attempts at sequential procedures and there is still a live baby with significant time passage, one could attempt a cephalic replacement procedure by applying firm, steady pressure on the flexed fetal head and then proceeding to cesarean section.
Symphysiotomy: This procedure is relatively common in patients in developing countries when safe cesarean section is not available. It involves dividing the symphysis pubis under local anesthesia.
