Managing shoulder dystocia: Understanding and applying RCOG guidance
Shoulder dystocia occurs in less than 1% of births but can have severe consequences for both the mother and baby. It is also the third most common cause of litigation in the UK. A structured approach to management has been shown to help practitioners provide effective care, and since 2000 many Trusts have implemented the HELPERR mnemonic developed by the Advanced Life Support in Obstetrics group (ALSO) as a basis for care. In 2012, the Royal College of Obstetricians and Gynaecologists (RCOG) updated guidance on managing shoulder dystocia and moved away from the use of the mnemonic HELPERR; however, our midwifery students reported that they felt daunted by the RCOG algorithm and preferred to use a mnemonic to help them provide systematic care. This article sets out a modified approach and adapted version of the HELPERR mnemonic for use in practice that incorporates the latest RCOG guidance for use in the management of shoulder dystocia.
Shoulder dystocia is a relatively common phenomenon that most midwives will encounter as they care for women in labour. Evidence suggests that the incidence rate varies between 0.58 and 0.7% (Royal College of Obstetricians and Gynaecologists (RCOG), 2012) and can result in significant neonatal mortality and morbidity. Therefore, all health professionals involved in caring for women during labour and birth should be prepared to manage this obstetric emergency. For the purposes of this article, the term midwife will be used to describe the primary care giver, although this role could apply to midwives, doctors or paramedics.
The RCOG adapted Resnick's (1980) definition and state that shoulder dystocia is defined as ‘vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed’ (RCOG, 2012: 2). Despite this clear definition being accepted for many years, shoulder dystocia is under-reported. When discussing management of shoulder dystocia, students anecdotally report that midwives often refer to ‘difficult delivery of the shoulders’ that resolves with the use of the McRoberts position, and are often reluctant to make the diagnosis of shoulder dystocia. However, in order to provide safe and effective care in future pregnancies, and minimise potentially expensive compensation claims, it is essential that accurate diagnosis and documentation occurs. If care is based on the definition proposed by RCOG, then any additional manoeuvres that are used to facilitate delivery of the shoulders (including the use of McRoberts position) mean that a shoulder dystocia has occurred. Compensation claims to the NHS Litigation Authority (NHSLA) between 1 April 2000 and the 3 March 2010 included 250 claims for shoulder dystocia with a combined value in payments of £103 520 832 (NHSLA, 2012). Therefore it is important for women, their babies and families and employing NHS Trusts that shoulder dystocia is effectively managed.
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