PP.63 Shoulder Dystocia – A Risk Management Point of View

Abstract

Background: Shoulder dystocia occurs when additional manoeuvre is needed to deliver an impacted fetal shoulder. The RCOG Shoulder Dystocia Guideline (2005) recommends auditing all cases of shoulder dystocia to improve training and patient care. The UK CMACE Report (2006-2008), Top Ten Recommendations highlighted Clinical & Drills Training and Learning from Serious Incidents. Aim: This study reviewed all cases of shoulder dystocia from July 1, 2008 - Dec 31, 2010 at a large University Teaching Hospital NHS Trust in London, UK (10,000 deliveries per year). Materials: Data from the computer system. Methods: This retrospective study reviewed maternal and fetal complications in all cases of shoulder dystocia. Cases were collected from the Operating Theatre, Special Care Baby Unit, Delivery Suite and Risk Management Registries. Results: There were 292 cases of shoulder dystocia, consisting primigravida (n = 100), and multiparous (n = 192). The overall total [Group 1] (n = 292 mean birth-weight 3.979 kg ±0.475; the instrumental delivery [Group 2] (n = 94) mean birth-weight 3.937 kg ±0.486; and the Instrumental Delivery in Theatre [Group 3] (n = 28) mean birth-weight 4.036 kg ±0.577. In group 3, a Consultant was present in theatre 19/28 = 67.86%. The Trust used the HELPERR mnemonic and the RCOG Shoulder Dystocia Proforma for standardization of documentation. Fetal complications: SCBU Admission (n = 17) - 5.82% Macrosomia >4.5 kg (n = 33) - 11.30% Erbs Palsy & Bone Fracture (n = 6) - 2.05% Stillbirth (n = 1) [Forceps delivery - 4.6 kg, delivered in 7 mins]. Maternal complications: Postpartum Haemorrhage >1000 mls (n = 20) - 6.85% 3rd Degree Tear (n = 22) - 7.53% & [4th degree Tear (n = 1)] Severe Shoulder Dystocia Delivery head-to-body interval ≥5mins (n = 12) - 4.10% Delivery Required ≥3 Manoeuvres (n = 34) - 11.64%. Conclusions: 1. Risk Management and Education Teams: The teams had a robust proforma system to identify, investigate (Serious Incident Reporting), and follow up all cases of shoulder dystocia. The trust has monthly Skills & Drills teachings. 2. Significant Maternal and Fetal Complications: 1 case stillbirth (0.34%) and Erbs palsy/fractures (2.05%) 1 case 4th degree tear (0.34%) and head-to-body-delivery ≥5mins = 4.1%. 3. High Risk Population: There were 292 cases of shoulder dystocia (∼1%); about 40% of the population are high-risk. Since this audit, the trust increased the Labour ward Consultant cover to 96 hrs/week. Re-audit will be done in preparation for CNST inspection November 2012.