Previous Shoulder Dystocia

How I Practice Video Series
Tamika Auguste, MD, FACOG

HIP: Previous Shoulder Dystocia from ACOG on Vimeo.

Transcript:

When I have a patient that presents to me for prenatal care that has had a previous vaginal delivery complicated by shoulder dystocia, I address that complication in the very first prenatal visit. I have a very lengthy discussion with her about her previous pregnancy, if there were any complications like diabetes, and then I talk to her about her delivery. Very rarely will the patient say “I had a shoulder dystocia.” It’s more along the lines of “My baby got stuck,” and when I hear that my “spidey-senses” start tingling and I know the questions to ask. I tell her to describe to me what happened in the last delivery. I ask her did her previous physician tell her anything about future pregnancies and were there any lasting sequelae with the baby. I take that all into consideration and determine whether or not she truly had a shoulder dystocia.

If I think that she has, then we start some lengthy conversations. I assess her weight and current Body Mass Index or BMI, and if she is obese I will screen her for diabetes and I do that with an early 1 hour acola (check spelling?). And then we have a conversation about proper nutrition and exercise in order to maintain a healthy weight during this pregnancy. Then we talk about her upcoming delivery and her risk of having a shoulder dystocia. I explain to her that because she’s had a previous shoulder dystocia, or where the baby got stuck, her risk for that happening again is high. I then take the time to listen to what she has to say and how she feels. I assess her anxiety about the upcoming delivery and I assure her that together we’ll make the best plan for her delivery. Later in the pregnancy, in the third trimester, I again have a discussion about her delivery. I review how her prenatal course has been to date, if there’s been any complications, how she’s feeling, her anxiety level, and I assess the fetal weight of the baby.

Taking all of this into consideration, I then offer her either a caesarian delivery or a vaginal delivery. I think it’s important for a patient who’s had a previous shoulder dystocia to be involved in the decision making and share the responsibility for the plan for her future delivery. If the patient chooses a vaginal delivery, and she shows up in Labor and Delivery in labor, I make sure that the entire Labor and Delivery care team from the primary nurse to the charge nurse to the OB providers, the anesthesia team and the neonatology or pediatrics team are all aware, on board and on the same page with what her history has been involving the shoulder dystocia.

When it comes time for delivery, I make sure the room is set. I make sure that we have enough help in there, both on the nursing side and the provider side, that we have a stepstool in the room in case we need to give superpubic pressure and then I also take the time and talk to the patient what maneuvers and what the room will look like in case there is another shoulder dystocia. I do all of this to make sure that myself, the labor and delivery care team, and the patient are all on the same page and prepared in case there is another shoulder dystocia. In managing a patient that has had a previous shoulder dystocia, the conversation needs to start early, it needs to happen frequently, and your patient needs to be involved in her subsequent plan for delivery.

This is how I practice.

   

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