When I first read the recent article in the May issue of BJM on ‘Managing shoulder dystocia: understanding and applying the RCOG guidance’ (Jenkins, 2014), I was immediately engaged and interested in the identified problem and the innovative approach taken to resolve it. I wanted to know what this author, Louise Jenkins had to say on the subject. It was, in my view, an exemplar as to how a midwife teacher in this case, could take a subject that her students were finding difficult and de-construct it in a manner which drew on recent authoritative guidance (Royal College of Obstetricians and Gynaecologists (RCOG), 2012), ending up with a modification that not only highlighted important aspects of the initial HELPERR mnemonic based approach (Baxley and Gobbo, 2004), but broadened general understanding and insight in to what can be a terrifying and devastating event. In placing this in the context of her student's learning, she provided a comprehensive overview of the professional advice available, the process of managing a shoulder dystocia, and the impact and long term implications for both mother and baby. Overall, a brilliant and well-written professional article, which I have no doubts will enhance not only the learning of Louise's students, but midwives in general.
However, a few aspects of the article caused me concern, and I initially thought of writing a letter to point these out, raise awareness and enable further consideration of some of the salient points that had been identified. Sadly, such questions can be misconstrued and one of our principal weaknesses as midwives is a failure to establish and engage in a well-intentioned, open, professional dialogue. In my own experience as a clinician and a teacher, asking questions or raising a point of interest with students and qualified midwives in practice can result in the ‘shutter going up’ and responses that attempt to deters ‘further inquiry’. This may result from the way the question is framed, but in general, is more likely because of a fear of ‘not knowing’ or ‘feeling challenged’. While the first point is in itself an opportunity for learning, the second should in the first instance be considered as a reasonable inquiry, seeking to clarify what is happening or an appeal to better understand the situation. In doing so, reflective practitioners not only bring additional knowledge and experience to the problem at hand, but also help create a constructive and positive collegiate relationship, which is vital to good team work.
‘Accurate diagnosis and management is not just essential it is imperative; and substandard performance can, without doubt, contribute to the increase in morbidity and mortality associated with shoulder dystocia’
Consequently, instead of writing a letter I decided that a short article might better fulfil my wish to open a broader discourse on the important clinical issue of shoulder dystocia, but equally help to clarify the role Advance Life Support in Obstetrics (ALSO) (UK) has played and continues to play in our awareness, understanding, and management of the condition. In doing so, I do not seek to diminish in anyway, what I believe to be one of the best articles I have read on this subject for many years. So where do I begin?
Although in the distant past, I vividly recall as a pupil midwife, the instructions given as to how I should manage a shoulder dystocia—call for help, turn the woman into the left lateral position, and pull hard. Little mention was given to the adverse impact such action might cause, and apart from Cleidotomy, that is cutting or breaking the baby's clavicle(s), there was little structure as to what should be done next if initial action failed. Sadly, even after many years of clinical practice and advanced studies, the only real change to my approach was the recognition that hyperflexion of the woman's legs onto her abdomen and internal manoeuvres to disimpact and rotate the baby's shoulder may be of benefit. All this changed in June 1996, when I attended the first ALSO course in the UK; a systematic, mnemonics-based programme in the management of obstetric emergencies. I avidly read my manual and spent two exciting and energising days listening and learning the ALSO way to manage maternity urgencies and emergencies, which included the much used HELPERR mnemonic (ALSO, 1993). As early as 1997, these courses rapidly expanded and gathered momentum, with the HELPERR mnemonic and other ALSO approaches being introduced and applied in NHS hospitals as well as being taught on British University midwifery programmes (Lewis, 1996; Lewis and Dodd, 1997).
Since these early days, ALSO (UK) has trained more than 12 000 midwives and over 5000 doctors and this number is still rising. As a part of a global network, 70 000 maternity care providers have been trained in the United States alone and more than 160 000 practitioners worldwide (American Academy of Family Physicians (AAFP), 2014). In promoting safety through taught, standardised, mnemonic-based approaches to maternity urgencies and emergency situations, ALSO's multiprofessional programmes have directly led to, and stimulated, the development of other similar structured programmes such as PROMPT (PRactical Obstetric Multi-Professional Training) (PROMPT Maternity Foundation, 2014), and MOET (Managing Obstetric Emergencies and Trauma) (Advanced Life Support Group, 2014). So what does this mean in terms on my own learning and experience, and how does this compare and contrast with the brilliant article by Louise Jenkins?
Shoulder dystocia is an uncommon and unpredictable obstetric emergency, and there is no dispute that it is associated with an increased risk of maternal and fetal morbidity and mortality (Gherman 1998). There is, however, a wide variation in the reported incidence, which varies between 0.5 and 0.7% (Gherman, 2002); and is known to increase with increasing fetal weight in spite of the fact that the majority of babies who suffer this event, are of normal birth weight. The RCOG Green-top guidelines (RCOG, 2012) cite the above incidence rate, drawing on a range of publications between 1994 and 2005. Yet in spite of this, it is often described as a relatively common phenomenon that most midwives encounter (Jenkins, 2014); but perhaps this says more about how we perceived and define shoulder dystocia than its actual occurrence? Indeed, an incidence of 0.5% is similar to that of scar dehiscence in vaginal births after caesareans (VBACs), and how many midwives regularly come across this as part of their every day work?
While the RCOG shoulder dystocia guideline draws on Resnick's (1980) definition, it should also be recognised that the primary factor that results in delay, dystocia and additional manoeuvres to assist the birth of the baby, once the head had been born, is impaction of the anterior shoulder above the symphysis pubis. In such situations, as Jenkin's (2014) points out, accurate diagnosis and management is not just essential it is imperative; and substandard performance can, without doubt, contribute to the increase in morbidity and mortality associated with shoulder dystocia. As early as 1996, the Confidential Enquiry into Stillbirths and Deaths in Infancy 5th Annual Report (1998) identified that one of the principle causes of such devastating outcomes in shoulder dystocia, was the failure of the practitioner to move from one manoeuvre to the next when it had failed to result in movement and birth of the baby.
‘What ALSO (UK) teaches in respect of shoulder dystocia, goes well beyond the use of a defined mnemonic and looks at the wider context of care, and adaptation of approach as the situation demands’
Clearly, having the necessary understanding of the dynamics and process of shoulder dystocia, and the skills to effectively manage this when it occurs, is vital to safe and effective management. Although identified risk factors have poor predictive value (Lewis et al, 1998), education and training has been shown to reduce the incidence of adverse outcomes. It is in such taught approaches however, that allegiances and bias can be formed, and this can and does result in determining and possibly limiting the full repertoire of interventions that might assist in the resolution of the problem. As such, Jenkin's (2014) modification of the ALSO HELPERR mnemonic and adaptation of the RCOG's algorithm is an innovative way to include two different, but not mutually exclusive approaches into one, and sensitively draws on both schools of thought. Nevertheless, the evidence we use and the recommendations that we make today, may not be the evidence or recommendation that apply tomorrow.
There is also within the article, some important misunderstandings in what ALSO (UK) teaches in respect of shoulder dystocia, which goes well beyond the use of a defined mnemonic, and looks at the wider context of care and adaptation of approach as the situation demands. This is recognised in the recently updated preamble to the RGOG green top guidelines on shoulder dystocia, where they state: ‘The guideline provides guidance for skills training for the management of shoulder dystocia, but the practical manoeuvres are not described in detail. These can be found in standard textbooks and course manuals such as PROMPT, ALSO, MOET and others’ (RCOG, 2013). It is this broad view of evidence, experience, application and approach, that best reflects how practitioners should approach each individual emergency event, taking into consideration the priorities of care, the needs of the mother and child, and the context of the situation. While at the same time, bringing their own knowledge and skills to bear in a flexible and adaptable way that most readily seeks to resolve the situation. Louise's article demonstrates the beginnings of such an approach, but midwives and obstetricians need to similarly meld their skills and ways of working to optimise all possibilities.
The ALSO provider approach is clearly compatible with the current RCOG guidelines, and it is important to understand that prior to any ALSO course, the teaching faculty as part of their quality assurance process, reinforce the range of repertoires for each and every emergency that is taught, but also the range of advice that accompany this. In the case of shoulder dystocia, the first expectation is for the practitioner to recognise the problem and this is defined as a delay or failure of the baby to be born after the birth of the fetal head. In most cases a midwife will apply gentle axial traction, and where there is resistance and no movement, they must immediately stop pulling, and take their hands of the baby's head. Failure to do so often results in the practitioner continuing to pull, and if the mother cannot see the practitioner's hands, they will believe that this is exactly what is happening. At the same time, the midwife should get the woman to stop pushing and immediately call for help. On the ALSO course, this involves a subsidiary mnemonic known as SOAPS (senior midwives, obstetricians, anaesthetist, paediatricians and someone to support and scribe).
Traction of the fetal head is an important issue, and the questions we should all be asking ourselves, is how hard and how long would we pull on a baby's head? In a normal birth, where the baby is birthing spontaneously, no traction may be required, in other cases traction is needed and it will vary in the length and pressure applied in each and every situation. In most cases, midwives will continue to pull throughout a contraction if the baby is moving and this could be between 60 and 90 seconds. However, where there is a shoulder dystocia, no traction should be applied once resistance and lack of movement is determined; except when applying a manoeuvre to release the shoulders. This is then usually applied for up to 30 seconds, but where resistance if felt, it is advised that the practitioner should stop pulling and move on to the next manoeuvre in the mnemonic.
There is also a misunderstanding as to what is meant by axial traction. This is no different from how midwives have been taught over many years and it is a mistake to think it is. Axial traction is gentle traction on the baby's head in line with the fetal spine. The fetal spine is directed downward in the pelvis when the head has been delivered and midwives should continue to pull in a singular, steady, gentle downward and outward movement. What they should avoid, is bending the baby's head towards it posterior shoulder, which increases the stretch and tension on the muscles and nerves of the anterior impacted shoulder and elevate the risk of possible brachial plexus injury.
Evaluation for episiotomy is the second element of the HELPERR mnemonic but the stress is on the evaluation, not the episiotomy. The practitioner should continual consider the need for, and opportunity to carry out an episiotomy, and there is no discord as to what we teach, when it is applied and why. Its use is to create space once internal manoeuvres are required, and a woman will usually be in a McRobert's position at that time, which more readily exposes the perineum, and for an episiotomy, which gives access for internal manoeuvres if needed.
The value of the McRobert's manoeuvre is well documented and in laying her flat on the bed, with one pillow, this is initially well described in the article. However, the manoeuvre itself, is a simple hyperflexion of the maternal legs onto her abdomen, and they naturally abduct because of the abdominal bump. It is not placing the legs alongside her chest towards her ears. If this is attempted, it lifts the maternal pelvis off the bed and would be extremely uncomfortable if not impossible—try it. As midwives, especially when working in the community, we would be more likely to get a woman into a deep squatting position, which is exactly the same as the McRobert's manoeuvre, but does not require two additional members of the team to apply it.
Similarly, internal manoeuvres will depend on the location and situation in which the shoulder dystocia is encountered and if a woman is already in a knee—chest position, having adopted this from an all fours position, then removal of the posterior arm might be easier and more readily available. Nevertheless, practitioners need to recognise that bony injury is greater when removing the posterior arm compared to internal rotational manoeuvres, and they will need to consider this and make a judgement in keeping with the situation, their knowledge and expertise.
With these minor but important exceptions, there is considerable agreement in the way this article represents the problem, management and professional responsibilities of midwives who encounter or are involved in the care of women and babies who experience shoulder dystocia. First, second, and third line manoeuvres provide an additional and relevant framework, but should not limit individual practitioners who may be alone or isolated to initiate the necessary skills and drills in an attempt to resolve the problem and maintain the health and wellbeing of the mother and child. The issues raised give an alternative interpretation and explanation, but it is such exceptions to the ways ‘we practice’, that should give rise to a constant and continuing discourse not only about shoulder dystocia or other urgencies and emergencies, likewise in respect of our wider practice as midwives in the development of systematic but individually appropriate, agreed approaches to care. I am grateful to Louise Jenkins for stirring my interest and motivating me to discuss our respective differences.