CRITICAL INCIDENT REPORTING OF SHOULDER DYSTOCIA
CRITICAL INCIDENT REPORTING OF SHOULDER DYSTOCIA
This essay is a critical analysis of an incident that occurred in the author's place of practice. The issues identified in the client's care will be discussed and the management implemented will be reflected on using current researched evidence.
The rationale for choosing this incident is because it inspired me to reflect on my practise and develop my clinical competences.
According to Miller (1999) reflective thinking have been regarded as an important tool both as a learning process and directing future clinical practice. This can only be achieved by being honest with ourselves and our performance, ask for help from our colleagues if necessary and ensure our practice is based on up- to- date relevant research.
This have been also highlighted by Glenn (1993)who stated that the development of critical thinking is essential to sound professional practice and is the hallmark of the effective practitioner".
Burnard (1990) suggested that successful reflective thought enhances the individual's ability to :
Generate opinions
See possibilities
Discriminate intelligently
Be creative
Identify new ideas
The incident is a reflection of the author's management of shoulder dystocia in her practice area. This piece of essay will be discussed into different themes that emerged from the client's case study, using relevant evidence.
WHAT IS SHOULDER DYSTOCIA?
Shoulder dystocia is defined as a delivery that requires additional obstetrics manoeuvres to release the shoulders after gentle downward traction have failed (Resnick 1980). It is said to occur when either the anterior or less commonly the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory (RCOG 2005).
Frazer and Cooper (2003) further stated that, shoulder dystocia is a rare complication, whereby the fetal shoulders failed to rotate, descend and deliver with a subsequent perinatal morbidity and mortality. It is regarded as an obstetric emergency.
Statistics
The overall incidence of shoulder dystocia varies based on fetal weight, occurring in 0.6% to 1.4% of infants with a birth weight of 2500 to 4000 grams and increasing to 5% to 7% in fetuses weighing 4000 to 4500grams born to mothers without diabetes (Berku, et al 1999). Over 50% of shoulder dystocia occurs in the normal birth weight infants and is unanticipated.
It occurs with equal frequency in primigravid and multigravid women, although it is more common in infants born to mothers with diabetes (Al Hadi, M. et al 2001).
According to the RCOG (2005) shoulder dystocia can be a high perinatal morbidity and mortality associated with the condition, even when it is managed appropriately.
Maternal morbidity is also increased particularly postpartum haemorrhage (11%) and third and fourth degree lacerations (3.8%) and their incidence remains unchanged by the manoeuvres required to effect delivery. Other maternal complications are: rectovaginal fistula, uterine rupture and symphyseal separation or diathesis.
Among the most common fetal complications are brachial plexus palsies injuries occurring in 4% to 16% of infants(Gherman 2002). This is when the nerves in a baby's neck are temporarily or permanently damaged. The nerves of the brachial plexus control the function of arm and hand.
Injury to the upper part of the brachial plexus is called ERBS palsy while to the lower nerves is called KLUMPKE palsy.
Other documented fetal complications have also been highlighted such as :fractured clavicle, fetal hypoxia with or without permanent neurological damage, fracture humerus and fetal death.
In this piece of work the author have adhere to an ethical standard therefore all names and identity features have been changed to maintain confidentiality(NMC2004). Mrs. Kargbo is a forty years old, African woman. G2 P1, who is 41/40 pregnant.
She is gestational diabetic, diet controlled and her antenatal period have been uneventful.
In her previous pregnancy, she also had GDM diet controlled. She laboured spontaneously at 39/40 and had a spontaneous vaginal delivery.
Baby weighed 3.830grams and postnatal period was also uneventful.
She was transferred to the delivery suite in established labour from the antenatal ward following induction of labour for post date pregnancy.
On abdominal palpation, fundal height was 42cm, fetal lie was longitudinal, presentation was cephalic and it was 3/5 palpable above the pelvic brim. Mrs. Kargbo is 158cm tall as documented in hand held maternity note.
Mrs. Kargbo laboured rapidly and went to full dilation within three and half hours. She commenced active pushing half an hour since becoming fully dilated. She continued pushing for another hour. During the subsequent contractions the vertex descended and was delivered.
No umbilical cord was felt or visible around the fetal neck.
No restitution of vertex was seen and there ...
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On abdominal palpation, fundal height was 42cm, fetal lie was longitudinal, presentation was cephalic and it was 3/5 palpable above the pelvic brim. Mrs. Kargbo is 158cm tall as documented in hand held maternity note.
Mrs. Kargbo laboured rapidly and went to full dilation within three and half hours. She commenced active pushing half an hour since becoming fully dilated. She continued pushing for another hour. During the subsequent contractions the vertex descended and was delivered.
No umbilical cord was felt or visible around the fetal neck.
No restitution of vertex was seen and there was a gasped by the baby at the perineum.
I quickly explain to Mrs. Kargbo the need to implement a Mac Roberts manoeuvre and summoning assistance. I asked Mrs. Kargbo's birth support to activate the emergency call bell and hyper flex Mrs. Kargbo's thighs .
About five staff including the labour ward co-ordinator and the obstetric registrar arrived in the room and helped with positioning Mrs. Kargbo for the delivery.
Mac Robert manoeuvre with supra pubic pressure aided the delivery of a live female infant, weighing 4320grams.Apgars were 4@1, 6@5 and 8@10. No birth injury was sustained by the baby after being examined by the neonatal senior house officer.
Mrs. Kargbo sustained a second degree tear, that was sutured well.
After the incident, the author documented in the notes in retrospect as there was no chance for contemporaneous documentation as recommended by the NMC (2004).
An incident reporting form was filled and a shoulder dystocia pro-forma was also completed as required by the trust/ maternity unit guideline.
Mrs. Kargbo was debrief about the incident by the obstetric registrar and the author. All her questions were answered and reassured that the baby has not sustained any birth injury which was her prime concern.
In Mrs. Kargbo's scenario the author identified the risk factors she presented with during her pregnancy that predicted her to be at risk of shoulder dystocia. These will be listed but for the purpose of this essay three will be discussed/ analysed into theme using evidence base information.
Risk Assessment:
Gestational diabetic diet controlled
Post term pregnancy/ Induction of Labour
Previous big baby
Suspected big baby (high fundal height)
Macrosomic baby (BWT 4320gm)
Mrs. Kargbo is forty years old (maternal age).
The above were the issues identified during Mrs. Kargbo's case study, as already mentioned earlier, the author will discuss the complications of gestational diabetes, post- date pregnancy and macrosomic baby during pregnancy and the postparturm periods.
Mrs. Kargbo have been found to be gestational diabetic during this pregnancy and also at the previous pregnancy. This have predicted her to be classified at high risk of shoulder dystocia, therefore, a good surveillance of her fetus's size was of paramount importance.
Gestational diabetes mellitus is defined as a carbohydrate intolerance of varying degree of severity with onset or first recognition during pregnancy (Metzger & Couston 1998). This includes women with pre-existing diabetes only diagnosed in pregnancy. A wide range of complications is associated with the disorder. For the mother, gestational diabetes increases the risk of pre-eclampsia, caesarean section and future type 2 diabetes. In the fetus or neonate, the disorder is associated with higher rates of perinatal mortality, macrosomia, birth trauma, hyperbilirubinemia and reactive hypoglycaemia at birth(Turok et al 2003). This condition complicates about 2% of pregnancies in Denmark (Jensen et al 2000) while in the Irish population, the prevalence of gestational diabetes is 2.7%.
In the United Kingdom, 3/100 people are affected by diabetes and 3/4 have type two diabetes mellitus and approximately one million undiagnosed (Diabetes U.K. 2000).
Gestational diabetes mellitus is prevalence to type 2 diabetes mellitus and is highest in areas with a high proportion of ethnic groups (Hutchinson 2001). This has also been identified in the author's practice area, where in the highest population of the maternity service users are of Asian origin. In the United States of America, the African- American population is affected by gestational diabetes compared to their Caucasian and Filipino counterparts (Griffen et al 2000).
Mrs. Kargbo had risk factors of developing gestational diabetes mellitus: Previous GDM, over forty years old, African and high body mass index. All these features have been found in various studies by different authors i.e. Griffen et al 2000, Hutchinson 2001, DOH 2001 & Jensen et al 2000.
During pregnancy, metabolic changes occur to optimise fetal growth. Therefore, insulin secretion need to increase throughout pregnancy to maintain material glucose control (Hutchinson 2001).
The management of gestational diabetes in pregnancy is to optimise glycaemic control, which reduces the risk of congenital malformation, intrauterine death, neonatal hypoglycaemia and respiratory distress syndrome (Dang et al 2000). Women should aim to maintain blood glucose as near to non- diabetic range as possible without risk of hypoglycaemia. This means targeting levels within the range of 4 and 7 mmol/l.
According to the Turok et al (2003),it is imperative for diabetic women to be referred to a multidisciplinary team led by a named obstetrician and physician for the provision of maternity care. Diabetes specialist midwives should educate and teach women in home blood glucose monitoring and dietary advice given where Mrs. Kargbo have been cared for throughout her pregnancy. This have also been the common practice in the author's practice area. Hutchinson (2001) further highlighted the need for regular antenatal follow- up, growth scans, regular exercise and fetal cardiology if GDM diagnose prior to 16 weeks gestation.
The next issue/ theme to be discussed in Mrs. Kargbo's care was that of macrosomia. Mrs. Kargbo's baby was 4320gm at birth and this led to shoulder dystocia during delivery.
Fetal macrosomia is defined as a birth weight of above 4.000gm and it complicate more than 10% of pregnancies (Schwart & Teramo 1999).
Zamorski and Biggs (2001) thought that the term "macrosomic fetus" is misleading as birth weight is never known with certainty until after delivery.
Frequently, a distinction has been made between macrosomia in non diabetic mothers. In babies born to non diabetic mothers 5% to 7% will weigh more than 4000gm and 1% will go beyond 4500gm.
Fetal macrosomia affects neonatal and maternal morbidity and mortality (Ferber 2000). It is the most significant risk factor for shoulder dystocia. Further more, macrosomia have been the most researched and most often proposed as the potential target to control in hopes of decreasing the number of shoulder dystocia deliveries (Hall 1996).
Prediction of fetal weight and diagnosis of macrosomia is being based on three strategies: clinical risk factors, clinical estimation by Leopold's manoeuvres and ultrasonogrphy, Gherman (2002) & Berkus et al (1999).
The risk factors identified in Mrs. Kargbo's care have already been discussed earlier and these have been very significant in planning her care especially during delivery. However, Zamorski & Biggs (2001) mentioned that even when two or more risk factors are present, the risk of macrosomia is only 32% while 34% of macrosomic infants are born to mothers without any risk factor and 38% of pregnant women have at least one risk factor.
Gherman (2002) states that, most of the preconceptions and prenatal risk factors have severely poor positive predictive values and do not allow obstetricians to accurately and reliably predict the occurrence of shoulder dystocia. This have been shared by authors like Resnick (1980), Lewis (1998) and Romoff (2000).
Clinical estimation of fetal weight has been estimated by uterine height and by Leopold manoeuvres . It is the name given to palpation of the maternal abdominal wall a series of four specific steps in order to determine fetal position, fetal presentation and an estimation of the size of the fetus (ALSO 2003).According to Simpson (1999) the volume of amniotic fluid, the size and configuration of the uterus and maternal body habitus complicates estimation or the size of fetus by palpation through the abdominal wall. Several studies have documented mean errors of about 300g.
Ultrasound is the most commonly used and widely studied method for fetal estimation. A number of formulas to estimate fetal weight have been developed to determine fetal size. Most use fetal biparietal diameter(BPD), abdominal circumference(AC) and femur length(FL).
Each of this data-derived formulas works well for the specific population from which the method was developed, but further application of them uniformly produce errors of 7-10%. This means that only approximately two thirds of estimations are within 10% of actual birth weight.
The other issue identified in Mrs. Kargbo's care was that of induction of labour. She was induced at 41 weeks gestation as her glucose level have been well controlled during the pregnancy with diet only.
According to the Royal College of Obstetrics and Gynaecology (RCOG 2004) , induction of labour is an intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix and birth of the baby. This includes both women with intact membranes and women with spontaneous rupture of membranes but not in labour.
As with any interventions, induction of labour may have unwanted effects It should be indicated only when the benefit of early delivery outweighs a healthy outcome for both mother and fetus than if delayed.
In Mrs. Kargbo's case the estimated fetal weight was 3900 at 37 weeks gestation. However, her first child's BWT was 3830gm, had a spontaneous labour and an uncomplicated vaginal delivery therefore the obstetrician were not worried about the estimated fetal weight as her metabolic glucose was well controlled.
The actual BWT of this baby was 4320gm. This have proved that there are errors in ultrasound measurement of EFW and that the fetal macrosomia can only be diagnose post delivery (Zamorski & Biggs 2001).
Some authors and clinician support elective induction of labour for suspected macrosomia in order to prevent further fetal growth, excessive caesarean sections and reduce shoulder dystocia however, Baxley and Gobbo (2004) stated that, induction of labour for macrosomia without diabetes did not lower the rate of shoulder dystocia or the rate of caesarean section. They further highlighted that, induction of labour for gestational diabetic women requiring insulin reduce the risk of macrosomia and shoulder dystocia but the risk of maternal or neonatal injury is not modified. On the contrary, RCOG (2005) stated that there is a small decrease in the number of deliveries complicated by shoulder dystocia.
In addition to the above, the possibility that diagnosis of gestational diabetes may lead to increase obstetric interventions including induction of labour and caesarean section is a concern. Delivery before full term is not indicated unless there is evidence of macrosomia, polyhyramnois, poor metabolic control or other obstetric complications i.e. pre-eclampsia or intra uterine growth restriction (Conway & Langer 1998).
Continuation of pregnancy in uncomplicated GDM to ten days beyond term, as in Mrs. Kargbo's case, is acceptable provided that indications from fetal monitoring are reassuring (RCOG 2005)
Reflection
Shoulder dystocia is a rare but potentially serious obstetric emergencies 50% of cases have no identifiable risk factors and there can be a high mortality and morbidity associated with the condition, even when managed appropriately(Gherman 2002).
Looking at Mrs. Kargbo's antenatal predisposing risk factors, I was able to anticipate and prepare myself for the management of shoulder dystocia in case it happens. Although, several authors have mentioned in their studies about the insufficiency of predictive risk assessment in the prevention of the large majority of cases(RCOG2005).
Secondly, the author was able to institute the HELLPER Mnemonic of shoulder dystocia by summoning help and requesting for the appropriate personnel at the delivery. In so doing the author was exercising her professional accountability as recommended by the midwives rules and code of practice (NMC2004), CEMACH(2004) and also the NICE guidelines(2004).
Implication for midwifery practice
All birth attendants should be trained in the management of shoulder dystocia to enable us to fulfil our duty of care to both mother and babies(NMC 2004 & Carr2004).Gould et al (2004) also mention the value of continuous professional development in order to meet the needs of the health service and its users.
A high level of awareness and training have also been recommended by the fifth CESDI report. The Royal College of Midwives and the RCOG have jointly recommended annual skill drills for birth attendants.
Incident reporting and debriefing of a critical incident of any obstetric emergency will enable personnel involved to reflect on the actions, learn and also share experience with colleagues.
Auditing the number of cases by keeping a register of all cases of shoulder dystocia and outcome of mother and baby.
Accurate documentation of events by the use of a pro forma will reduce the successful litigation after a shoulder dystocia (Carr2004, NMC2004, RCM 2000, RCOG 2005).
On reflection, the whole scenario have been a learning curve for the author not only the care and management implemented during the incident but writing this critical report have enabled me to generate new ideas from the research/ evidence read.
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H. Sesay
