shoulder dystocia: analysis from a risk management perspective barrett na, ryan hm, mc millan hm,...
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Shoulder Dystocia:Analysis from a Risk
Management Perspective
Barrett NA, Ryan HM, Mc Millan HM, Geary MP
Rotunda Hospital, Dublin, Ireland.
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• Definition• Background
•Incidence• Risk Factors•Clinical Manifestations
• Aims of Study• Methods• Results•Conclusions
Shoulder Dystocia
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Definition
– A delivery that requires additional manoeuvres to release the shoulders after gentle downward traction has failed. (RCOG Dec 2005)
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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)
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Background-Incidence
• 0.6 % in Europe and North America• Variation in definitions and incomplete
documentation (Simpson, 1999)
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Background-Risk Factors
• Macrosomia• Maternal Diabetes• Hx of macrosomia/shoulder dystocia• Labour abnormalities• Instrumental deliveries• Post term• Increasing maternal age• Maternal obesity• Male fetus
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Background-Clinical Manifestations
• Prolonged head-to-body delivery time
• Turtle neck sign
• Routine manoeuvres for delivery ineffective in delivery of shoulders
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BackgroundRisk 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)
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Aims
• To determine local incidence
• To review management
• To review documentation
• To review clinical neonatal outcomes
• To improve risk management
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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
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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
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Results of documentation review
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Results of documentation review
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Results- Neonatal outcomes
*100% documentation
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pH < 7.10pH >7.10pH not done
Results-Neonatal outcomesCord pH results
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Results-Neonatal Outcome
Adverse events
• 4 cases of Erb’s palsy.
• 1 case of clavicular fracture
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Conclusions• Poor documentation of management
• Incomplete de-briefing after an incident
• Review of management limited by documentation
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Conclusions
• Reduce risk by • Improving identification of clinical risk
factors• Education of staff of risk factors• Improve documentation of risk factors
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Conclusions
• Monitor risk by audit cycle
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Shoulder DystociaAddressograph
Date__________ Form completed by__________________
Delivery of head Spontaneous Instrumental LSCSCall for HELPEmergency Bleep TimeArrival 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
Sequence Time Performed by Evaluate for EpisiotomyEpisiotomyMcRoberts’ position Directed Supra pubic pressure rocking/continuous
Enter manoeuvresUnspecified manouevres
Woods ScrewDelivery of posterior armRoll 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 Score 1 minute 5 minute NICU Y/NExplanation to parents post event Yes NoFollow up after discharge Yes No Advice for next pregnancy D Y/N LSCS/SVDRisk factors/NDweight
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Conclusions
• Control risk by• A standardised proforma
• Improve documentation • Improve awareness of
clinical pathway for follow-up
• Staff training fire-drills• Feedback sessions
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Thank you
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Royal College ofObstetricians andGynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting
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