N Massiah, V Bamigboye
N Massiah, V Bamigboye. Shoulder dystocia at water birth. The Internet Journal of Gynecology and Obstetrics. 2007 Volume 9 Number 1.
Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia. Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes
A 33 year old, para 1 lady presented in active labour at 40 weeks gestation. The abdominal findings were fundal height 39 cm, longitudinal lie and cephalic presentation. Vaginal examination revealed cervical dilatation of 5 cm, occipito-anterior position of the foetal head at station minus two. The membranes were intact. The booking investigations, dating and anomaly scans were found to be normal. The current pregnancy was uncomplicated. The first pregnancy and vaginal delivery were uneventful.
The pool was requested for labour and delivery. The labour progressed well to full dilatation. There was good descent of the head with active pushing. After delivery of the head, the shoulders were impacted. Mc Robert's manoeuvre and suprapubic pressure were attempted without success. The patient was moved from the birthing pool to the bed. Mc Robert's manoeuvre, suprapubic pressure and downward traction of the head led to delivery of the anterior shoulder followed by the remainder of the body. The time interval between the delivery of head and body was 3 minutes. The estimated blood loss was 350 mls. The neonate had a birth weight of 4200g with an Apgar score of 8, 9 and 10. Paediatric examination of the neonate was normal.
The incidence of shoulder dystocia at water birth is 0.16%1. This case highlights that it is vital to be prepared for emergencies even with low risk women. They may occur in unfamiliar situations. Since the patient was wet, her safety whilst being moved to the bed was of great concern. This was done carefully but quickly. It is estimated that the umbilical cord pH falls by 0.04 unit/min after delivery of the head2. A delay in delivery of the shoulders may result in cerebral hypoxia, cerebral palsy or death. Forty seven percent of deaths from shoulder dystocia were within 5 minutes of delivery of the head3. The principles of management were widening of the pelvic diameters and repositioning the foetal shoulders into the oblique pelvic diameter to facilitate delivery4.
Health professionals providing obstetric care should be familiar with guidelines for shoulder dystocia. Regular drills are fundamental to the improvement of team work, enhancing communication skills and essential for good outcomes5. Obstetric birthing simulators should be considered since they significantly improve competence in the management of shoulder dystocia6,7. Learning and teaching are continuous processes in our practice. Optimal training is required to minimize morbidity and mortality of this obstetric complication.