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Similarly, symphysiotomy has been suggested as a potentially useful procedure, both in thedeveloping 74,75and developed world.76However, there is a high incidence of serious maternalmorbidity and poor neonatal outcome.77Serious consideration should be given to these facts,particularly where practitioners are not trained in the technique.

Other techniques, including the use of a posterior axillary sling, have been recently reported butthere are few data available.78,79Evidence level 4

6.4What is the optimal management of the woman and baby after shoulder dystocia?

Birth attendants should be alert to the possibility of postpartum haemorrhage and severe perineal tears.Evidence

level 2+

and

Evidence level 3There is significant maternal morbidity associated with shoulder dystocia, particularly postpartumhaemorrhage (11%) and third and fourth degree perineal tears (3.8%).11Other reportedcomplications include vaginal lacerations,80cervical tears, bladder rupture, uterine rupture,symphyseal separation, sacroiliac joint dislocation and lateral femoral cutaneous neuropathy.81,82

The baby should be examined for injury by a neonatal clinician.BPI is one of the most important complications of shoulder dystocia, complicating 2.3% to 16% of suchdeliveries. 7,11,13,14

Other reported fetal injuries associated with shoulder dystocia include fractures of the humerusand clavicle, pneumothoraces and hypoxic brain damage.15,83,84

An explanation of the delivery should be given to the parents (see section 9).Evidence level 3

7. Risk management

7.1Training

7.1.1What are the recommendations for training?

All maternity staff should participate in shoulder dystocia training at least annually. Grade D

Evidence level 4The fifth CESDI report recommended that a ‘high level of awareness and training for all birthattendants’ should be observed.50Annual ‘skill drills’, including shoulder dystocia, are recommendedjointly by both the Royal College of Midwives and the RCOG85and are one of the requirements in

the Clinical Negligence Scheme for Trusts (CNST) maternity standards.86

Where training has been associated with improvements in neonatal outcome, all staff receivedannual training.14

One study looked at retention of skill for up to one year following training using simulation. If staffhad the ability to manage a severe shoulder dystocia immediately following training, the ability todeliver tended to be maintained at one year.87

7.1.2What is the evidence for the effectiveness of shoulder dystocia training?

Practical shoulder dystocia training has been shown to improve knowledge,88confidence 89and management of simulated shoulder dystocia.90–93Training has also been shown to improve the actor-patients’ perception of their care during simulated shoulder dystocia.

Evidence level 3Evidence level 2-Evidence level 1-

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●●●●●●●

manoeuvres performed, their timing and sequence maternal perineal and vaginal examinationestimated blood loss

staff in attendance and the time they arrived general condition of the baby (Apgar score) umbilical cord blood acid-base measurementsneonatal assessment of the baby.104,106

It is particularly important to document the position of the fetal head at delivery as this facilitatesidentification of the anterior and posterior shoulder during the delivery.

●●●●●●●●

Suggested audit topics

incident reporting of shoulder dystocia (CNST standard)

critical analysis of manoeuvres used in the management of shoulder dystocianeonatal team called at diagnosis of shoulder dystocia documentation of the event (see above)performance of cord blood gas analysis

monitoring neonatal injury (BPI bony fractures) following shoulder dystocia staff attendance at annual trainingdiscussion of events with parents.

9. Support

An information leaflet for parents ‘A difficult birth: what is shoulder dystocia?’ produced by the RCOG isavailable online (http://www.rcog.org.uk/womens-health/clinical-guidance/difficult-birth-what-shoulder-dystocia).

The Erb’s Palsy Group (www.erbspalsygroup.co.uk) provides an excellent support network for children andfamilies affected by BPI.

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Figure 1. The McRoberts' manoeuvre (from the SaFE study)

Figure 2

Suprapubic pressure (from SaFE study)

Figure 3 Delivery of the posterior arm (from the SaFE study)

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APPENDIX 4

Clinical guidelines are ‘systematically developed statements which assist clinicians and women in makingdecisions about appropriate treatment for specific conditions’. Each guideline is systematically developedusing a standardised methodology. Exact details of this process can be found in Clinical Governance Advice No.1: Development of RCOG Green-top Guidelines (available on the RCOG website athttp://www.rcog.org.uk/guidelines). These recommendations are not intended to dictate an exclusivecourse of management or treatment. They must be evaluated with reference to individual patient needs,resources and limitations unique to the institution and variations in local populations. It is hoped that thisprocess of local ownership will help to incorporate these guidelines into routine practice. Attention isdrawn to areas of clinical uncertainty where further research might be indicated.

The evidence used in this guideline was graded using the scheme below and the recommendationsformulated in a similar fashion with a standardised grading scheme.

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