Eight of the 22 mothers with babies weighing more than 4,000g at birth were not identified as having an LGA baby by USS prior to birth. Diabetes can pre-exist a pregnancy or develop during a mothers pregnancy. National Institute for Health and Care Excellence. The team did not have access to the case notes or individual interviews and based their findings on the completed reports. <>/Metadata 638 0 R/ViewerPreferences 639 0 R>>
In the cases of 10 of the 14 mothers who had a suspected LGA baby based on USS there was no evidence of a discussion with the mother regarding the increased risk of shoulder dystocia or what this may mean for the labour and birth. The options of IOL and expectant management should be discussed with the parents. NICE (2015) also does not offer guidance for maternal GDM testing if a baby is suspected to be LGA in the current pregnancy. 0000001092 00000 n
While shoulder dystocia can occur during any birth, regardless of the babys birthweight, babies that are larger than average are at an increased risk of a birth injury, brain damage or, very rarely, death, because their shoulders get stuck during birth (National Institute for Health and Care Excellence, 2019). An individualised discussion about risks, benefits, and choices to enable mothers to make decisions is enabled by the identification of an LGA baby, particularly when combined with other factors such as GDM. It was agreed for the mother to have a CS at 40+2 weeks due to the LGA. %
There was no discussion with the Mother regarding birth choices., Examples of findings from HSIB maternity investigation reports, 2 Screening for gestational diabetes mellitus (GDM). Royal College of Obstetricians and Gynaecologists (2016) Legal Patient consent [Online]. The Trust to ensure that a birth plan is developed as early as possible and that this includes place of birth, mode and timing of birth and staff who need to be present, as well as any specific care requirements. The BRAIN acronym is a mnemonic that healthcare professionals can use to engage antenatal and intrapartum discussions.
This guideline relates to mothers already in labour rather than those during the antenatal period. stream The reported incidence of shoulder dystocia varies between 0.58% and 0.70% of births (Royal College of Obstetricians and Gynaecologists, 2012). (2008b) Inducing labour. Several antenatal (pregnancy) and intrapartum (labour and birth) characteristics have been reported to be associated with shoulder dystocia. In 3 of the 31 cases the baby died: 2 were intrapartum stillbirths related to the shoulder dystocia and 1 was a neonatal (newborn) death which was not attributed to the shoulder dystocia as there were other health concerns present. (2015) Diabetes in pregnancy: management from preconception to the postnatal period. stream endobj A mother was admitted to a co-located birth centre in spontaneous labour at 39+5 weeks. The Cochrane review recommends that further trials of IOL for LGA babies are needed in order to determine what the possible management options might be to reduce harm such as fractures and hypoxic injury (signs of babies not receiving enough oxygen during birth). The Trust to ensure all mothers with an identified increased risk of shoulder dystocia receive counselling regarding the risks and benefits associated with a vaginal birth and alternative options for care. Diabetes can also cause a baby to grow bigger and extra growth surveillance is recommended during the pregnancy (National Institute for Health and Care Excellence, 2015). All but one of the cases involved a shoulder dystocia of more than 6 minutes (durations ranged from 2 to 14 minutes). During pregnancy it was noted that the SFH was measuring very large, this was plotted on a population based SFH chart. 127 0 obj <> endobj xref 0000008855 00000 n This plan is to be made available to the maternity team and to the family. HSIB has considered the Cochrane review (Boulvain et al, 2016) regarding IOL at or near term for suspected fetal macrosomia (another term for a larger baby) and considers this a useful tool for trusts to adopt to inform discussions with mothers to enable shared decision making.See Appendix A. HSIB has reviewed two further tools that may be of benefit for trusts to support discussions with mothers. 0000001263 00000 n (2020) IDECIDE a new consent tool is on its way [Online]. National guidance recommends intrapartum care should be transferred to obstetric-led care if an LGA baby is suspected during pregnancy or on assessment in labour. A recent large literature review (Moraitis et al, 2020) found that third trimester USS screening reliably predicted delivery of an LGA baby. Boulvain, M., Irion, O., Dowswell, T. and Thornton, J. G. (2016) Induction of labour at or near term for suspected fetal macrosomia. 0000003445 00000 n The head to body interval was 13 minutes. The rationale supporting the use of customised charts compared to population- based centile charts (which show national average size) is that individual factors relating to a mother, for example her weight, height, ethnicity, and parity (number of previous births) are taken into consideration. This is expected to be piloted in 2021 and will be supported by a training package. Mrs Montgomery had expressed concerns about her ability to deliver her baby safely and indicated that, had she been advised of the risks, she would have chosen a caesarean section. Where we consider this requires national change, we have suggested a HSIB safety recommendation. When a shoulder dystocia was recognised there was not always an emergency call made. The clinicians adopted a confirmatory strategy to deal with the issues of time focus and perception.
previous LGA baby weighing 4,500g or above. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Mothers who have a higher chance of being pregnant with an SGA baby are often on a serial growth ultrasound scan (USS) pathway or a combination of SFH and indicated growth USS (NHS England, 2019). Available at https://www.england.nhs.uk/wpcontent/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf. 4 0 obj endobj When the USS found the babys EFW to be above the 90th centile the Mother was screened for GDM to enable a full discussion with the Mother about birth choices. Barel, O., Vaknin, Z., Tovbin, J., Herman, A. and Maymon, R. (2013) Assessment of the accuracy of multiple sonographic fetal weight estimation formals. (2019) Saving Babies Lives version two. It is a time-critical obstetric emergency that can result in severe brain injury or death and other injuries such as brachial plexus injuries (nerve injuries affecting the arm) or fractures to the arm or collar bone of a baby. If LGA is suspected in labour NICE advises that mothers in labour should be offered the option to continue, to augment (speed up) the labour, or to have a CS. HWnF}`ER8u-"(X+qkrIwf"Xa/x33ggrKvz%o=/WWy#3Q\q~7%7o~$5cY@|`$|2iC#| =B?4G|JyE&d$;+^IU @[4P8=::- s^D"%c! + 0000012549 00000 n The baby was born with Apgar scores of 1 at 1 minute, 6 at 5 minutes and 9 at 10 minutes. The NICE intrapartum care guideline (2014) is clear that mothers who are suspected to have an LGA baby should be under obstetric-led care and transferred to an obstetric-led unit for birth.
m .K endstream endobj 150 0 obj <>/Filter/FlateDecode/Index[37 90]/Length 22/Size 127/Type/XRef/W[1 1 1]>>stream The signs of imminent shoulder dystocia were not always recognised during birth and this led to delays in escalation for obstetric and neonatal support. By using this website, you agree to our use of cookies. The trial aims to be completed in 2022. Available Cambridge university press. HSIB Healthcare Safety Investigation Branch, NICE National Institute for Health and Care Excellence, RCOG Royal College of Obstetricians and Gynaecologists, At HSIB we welcome feedback on our investigation reports. The OGTT may not be accurate late in the third trimester and other methods are required such as home blood sugar monitoring, which is more time consuming and invasive for a mother. When a shoulder dystocia was recognised there was not always an emergency response using the national emergency 2222 call system. This did not enable staff to recognise the importance of the accelerating SFH growth trajectory and a growth USS or testing for GDM were not undertaken. The baby was born after a shoulder dystocia and was noted to be LGA.. When mothers are identified as having a suspected LGA baby some trusts test for GDM to. Available at https://www.nice.org.uk/guidance/cg62. Available at https://www.birthrights.org.uk/2020/01/30/idecide-a-newconsent-tool-is-on-its-way. A mother had concerns during the pregnancy that her baby was too big for a vaginal birth. ^|ZFnfJF~WxX k\MV}y-O{]VPhC pmed.1003190. During pregnancy, a mothers symphysis fundal height (SFH) is measured on a two to three weekly basis commencing from 24 to 26 weeks to screen for small for gestational (SGA) babies. As defined by the Royal College of Obstetricians and Gynaecologists (RCOG), shoulder dystocia is where additional manoeuvres are required to complete the birth of a baby, after routine traction has failed to release the shoulders during a vaginal birth (Royal College of Obstetricians and Gynaecologists, 2012). The Montgomery ruling makes it clear that all healthcare professionals must inform a mother of the risks and benefits of different birth options in all pregnancies, not exclusive to LGA or shoulder dystocia, so that she can make an informed choice about her care. BJOG, 2011; 118;474-9. I Identify urgencyD Details of the current situationE Exchange objective and subjective information (history, organisational context, mothers perspective, healthcare professionals expertise)C Choices available (evidence- based information will be on the tool generic at first but in time individualised)I I (the mother) confirm my understanding and seek any further clarification neededD Decision is made (by mothers) and recorded on the toolE Evaluation takes place a few days/weeks later using a recorded experience measure. Current practice for the management of suspected LGA babies in England is varied. BJOG, 123 (1), 111-118. There is no guidance in the antenatal period locally or nationally for the management of babies who are suspected to be LGA in the absence of diabetes. NICE guideline NG121 [Online]. 0000019391 00000 n
Risk factor screening for GDM appears to be in line with national guidance which does not always take into consideration previous births of an LGA baby. 3 0 obj Mothers may also undergo ultrasound scans (USS) to monitor their babys growth if risk factors are identified or if there is a concern about SFH measurements. Safety recommendation R/2021/114:It is recommended that the Royal College of Obstetricians and Gynaecologists (RCOG) takes into consideration the findings of this HSIB review when updating the RCOG Green Top shoulder dystocia guideline (No.42). The pathways include guidance on the frequency of growth USS, testing for GDM in late pregnancy (using home blood sugar monitoring) and sharing information with mothers regarding their options for timing and mode of delivery. Moraitis, A. Each of the characteristics is recognised as being poorly predictive of a shoulder dystocia occurring. 0000005846 00000 n 0000012142 00000 n The Trust to ensure that staff are supported to follow the escalation process to alert the neonatal team to attend so that skilled staff are present at a babys resuscitation. HSIB found that in the incidents it reviewed, 22 of the 31 babies (71%) weighed more than 4,000g at birth (see table 1).
Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf.
qZ6l\/rnnY,O)m8uRUVzkBl=+cCQ'WdbOmqb9y{=xI^5xCYkZ,-UV /UM& The baby is also at increased risk of shoulder dystocia and birth trauma, in particular fractures of the arms, collar bone or a brachial plexus injury. xZn8}7Tx)(,^Cmae+k)I;CmI"3938eL of|f?&[$b>v/#/~oxc4v1#*a(B*87MyP2]{An.a/xN gEA^eYrp`];QSM@1eM G%YJ;R6.k,w/([Wv!7$&DHKA5nmx grx'ifa`rf6T MD8gd'-@xM Y?^R?M%6-1Ast_lGKNJuts{Zu@=F8eCuX]vP9?bJqBfF]A Sq,s C 2gbsx!`p!u%Q[x^. HSIB investigations found that there was a wide variation in what action trusts take when there is a suspected LGA baby identified by increased SFH measurement; some trusts do not refer the mother for a growth USS whereas others do. GDM may affect up to 18% of mothers during pregnancy. This is due to the Cochrane review (Boulvain et al, 2016) which concluded that earlier induction of labour may reduce the incidence of shoulder dystocia in babies estimated to weigh more than 4,000g. The Trust to ensure mothers are advised of the risks and offered all available options when a baby is suspected of being LGA.
ISBN 978-108-43029-6.Royal College of Obstetricians and Gynaecologists. In other definitions it refers to a birthweight more than the 95th centile or a birthweight above 4,000g (Boulvain et al, 2016) or more than 4,500g (Royal College of Obstetricians and Gynaecologists, 2012; National Institute for Health and Care Excellence, 2019). NHS England.
These charts were designed to identify small for gestational age (SGA) babies or babies with suspected growth restriction. If a baby is in good condition (not hypoxic) entering the shoulder dystocia, they may be more likely to be able to withstand a longer HBI. LGA is often considered to mean a baby weighing more than the 90th birthweight centile. The RCOG (2012) shoulder dystocia guideline determines that IOL does not prevent shoulder dystocia in non-diabetic mothers with a suspected LGA baby. The mother had an USS with an EFW of greater than 90th centile. In some of these mothers there was an opportunity to offer a growth USS as the SFH was above the expected range. (2016) Prevention of brachial plexus injury-12 years of shoulder dystocia: an interrupted time-series study. Signs of a potential shoulder dystocia include slow or difficult delivery of the babys head. This is because the babies were born earlier and thus had a lower birthweight. Available at https://www.nice.org.uk/guidance/ng121/evidence/q-largeforgestationalage-baby-pdf-241806242780. 0000000016 00000 n In most babies with HIE following a shoulder dystocia this can be explained by the shoulder dystocia alone; in some babies HIE is the result of multiple factors. assisted vaginal birth (using forceps or vacuum). Royal College of Obstetricians and Gynaecologists. (2014) Intrapartum care for healthy women and babies. We use cookies to help our website run effectively. This report is based on the analysis of 31 HSIB maternity investigation reports. There were several mothers with a greater than expected SFH (greater than 90th centile) who did not have a growth USS with EFW calculation before birth. National guidance by the National Institute for Health and Care Excellence (NICE) (2019) recognises that LGA babies are at increased risk of a birth injury, brain injury or in rare cases, death, because their shoulders get stuck during birth. The NICE (2008b) induction of labour guideline in the absence of any other indications recommends that induction of labour (IOL) should not be. The Trust to ensure all risks to both mothers and babies are discussed for those identified to be at increased risk of shoulder dystocia. %PDF-1.4 % HSIB identified that a review of cases where shoulder dystocia was identified as a factor that contributed to a severe brain injury or death, would generate potential learning for maternity care. Of all the mothers screened, 4 had confirmed GDM. The NICE (2020) guideline on intrapartum care for women with existing medical conditions or obstetric complication and their babies explains that these mothers are at increased risk of complications during labour such as shoulder dystocia, brachial plexus injury, assisted birth (where instruments such as forceps or a vacuum suction cup are used to help deliver the baby) or CS. There is no standardised definition of an LGA baby. The General Medical Council (2020) has published new guidance on decision making and consent. During the birth it was noted that the head was slow to deliver and help was called for as a shoulder dystocia was anticipated. The Trust to ensure that the information provided to mothers informs them of birth options and associated advantages and risks to support decision making and informed consent during childbirth. For example, for an estimated fetal weight (EFW) of 4,200g based on USS, 15% less would mean a birthweight of 3,570g, or 15% more would mean a birthweight of 4,830g. All maternity investigations reports are reviewed, and themes identified by a Healthcare Safety Investigation Branch (HSIB) multi- professional panel which includes neonatologists, midwives and obstetricians. Multiprofessional training for shoulder dystocia using recognised algorithms was commonplace and well embedded in all trusts and staff were able to undertake recognised manoeuvres. This section is in two parts, covering relevant issues relating to pregnancy (antenatal) and labour/birth (intrapartum). Within the 31 investigation reports analysed, HSIB found that the birthweights of the babies ranged from 3,565g to 5,177g. These babies were born in poor condition requiring resuscitation, which suggests there had been compression of the umbilical cord vessels allowing no transfer of oxygen to occur between the baby and the placenta or premature separation of the placenta during the shoulder dystocia. Available at https://www.nice.org.uk/guidance/cg19. Analysis of the 31 reports related to shoulder dystocia identified the following main findings: Examples of safety recommendations from HSIB maternity investigation reports. % There was varied information shared with mothers regarding the risks and benefits of having a vaginal birth or CS when an LGA baby was suspected. This leads to a wide variation in practice with some mothers having a discussion about the mode of birth and a small number of mothers being offered earlier IOL when a LGA baby is suspected on USS. These mothers did not have the opportunity to discuss what a raised SFH might mean for labour and birth. There was no documented antenatal counselling regarding risks of shoulder dystocia or what should occur should she go into labour prior to the date of the CS. Where we consider this requires national change, we have noted this as an HSIB national safety recommendation. Mrs Montgomery has Type 1 diabetes, which increases the risk of having a larger than average baby, a risk compounded by Mrs Montgomerys small stature. 0000005244 00000 n In the investigation reports reviewed, HSIB identified that 14 of the 31 babies were suspected to have a predicted birthweight of more than 4,000g after a growth USS. Available at https://www.rcog.org.uk/globalassets/documents/members/membership-news/og-magazine/december-2016/montgomery.pdf. The NICE (2020) intrapartum care for women with obstetric complications guideline recommends mothers in labour should be informed of the higher chance of shoulder dystocia and brachial plexus injury with vaginal birth. (2018) Estimating fetal weight via ultrasound [Online]. The majority of cases of shoulder dystocia occur when the uppermost shoulder of a baby impacts behind a mothers pelvic bone after the birth of the head, preventing the birth of the body. 0000007680 00000 n Grunebaum, A. National Institute for Health and Care Excellence. 0000003559 00000 n A shoulder dystocia with a HBI of three minutes occurred. (2020) Intrapartum care: existing medical conditions and obstetric complications. 2 0 obj hb```b````e` @1V~$`r\ku5Re68 ` B#Y(MRgg0`0aM:3`Vnc[Ab@Xq _\X("w There are multiple national guidelines that refer to some aspects of management for an LGA baby many of which are contradictory: The array of varying national guidance reflects the lack of robust evidence regarding the diagnosis and management of LGA babies, and how best to share this information with mothers to support them to make an informed choice about their birth preference.
National Institute for Health and Care Excellence. Shoulder dystocia is associated with prolonged first and second stages of labour and assisted vaginal birth. endobj H\0?$I:RQ> 'Ej H9`MCvyLI'%\iL?29I]l~o&=oa1kSf\Ii/.KyLscS!M?uriL5~:?8.uW+$^gGIeeesr.-Xd77[dA p:\a W+ Cochrane Database of Systematic Reviews, Issue 5 [Online]. 0000011740 00000 n The HSIB database of completed reports, excluding reports related to maternal deaths, was searched on 28 January 2020 using the key phrase shoulder dystocia. Clinical guideline [CG62] [Online]. Shoulder dystocia may also cause increased injury to the mother including bleeding and perineal trauma. Mothers with a suspected LGA baby are more likely to have an assisted vaginal birth or CS. The other 28 babies were treated in neonatal intensive care units with therapeutic cooling (a procedure where a baby is cooled to between 33C and 34C with the aim of preventing further brain injury following a hypoxic (lack of oxygen) injury and were diagnosed with HIE. The RCOG (2012) shoulder dystocia guideline suggests that IOL does not reduce the incidence of shoulder dystocia in the absence of diabetes. For instructions on how to enable JavaScript, please visit enable-javascript.com. A Cochrane review (Boulvain et al, 2016) found that IOL in mothers with LGA babies reduced the number of babies who had a shoulder dystocia, when compared with expectant management (allowing the pregnancy and labour to progress without specific intervention). If they do undertake a USS, some trusts carry out further investigations and then discuss with the mother her options for birth while other trusts do not do anything further. Following a growth USS the EFW was >95th centile and predicted to be greater than 4,000g at birth. In the investigation reports reviewed, the majority of mothers gave birth in an obstetric-led unit with 20 of the 31 mothers undergoing IOL. The reports identified were reviewed by a multi-professional panel using a quantitative analysis tool and the findings were categorised into themes. When considering this a 15% margin of error in a baby that is LGA is significant. (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies. The umbilical cord blood gases showed severe hypoxia. The trial aims to collect data from 4,000 mothers identified as having LGA pregnancies confirmed by USS to be recruited and randomised to either IOL at 38 weeks or for the mother to await the natural onset of labour. )* #w8V: There is no specific national guidance that provides recommendations for the management of pregnancies where the baby is LGA.
This guideline relates to mothers already in labour rather than those during the antenatal period. stream The reported incidence of shoulder dystocia varies between 0.58% and 0.70% of births (Royal College of Obstetricians and Gynaecologists, 2012). (2008b) Inducing labour. Several antenatal (pregnancy) and intrapartum (labour and birth) characteristics have been reported to be associated with shoulder dystocia. In 3 of the 31 cases the baby died: 2 were intrapartum stillbirths related to the shoulder dystocia and 1 was a neonatal (newborn) death which was not attributed to the shoulder dystocia as there were other health concerns present. (2015) Diabetes in pregnancy: management from preconception to the postnatal period. stream endobj A mother was admitted to a co-located birth centre in spontaneous labour at 39+5 weeks. The Cochrane review recommends that further trials of IOL for LGA babies are needed in order to determine what the possible management options might be to reduce harm such as fractures and hypoxic injury (signs of babies not receiving enough oxygen during birth). The Trust to ensure all mothers with an identified increased risk of shoulder dystocia receive counselling regarding the risks and benefits associated with a vaginal birth and alternative options for care. Diabetes can also cause a baby to grow bigger and extra growth surveillance is recommended during the pregnancy (National Institute for Health and Care Excellence, 2015). All but one of the cases involved a shoulder dystocia of more than 6 minutes (durations ranged from 2 to 14 minutes). During pregnancy it was noted that the SFH was measuring very large, this was plotted on a population based SFH chart. 127 0 obj <> endobj xref 0000008855 00000 n This plan is to be made available to the maternity team and to the family. HSIB has considered the Cochrane review (Boulvain et al, 2016) regarding IOL at or near term for suspected fetal macrosomia (another term for a larger baby) and considers this a useful tool for trusts to adopt to inform discussions with mothers to enable shared decision making.See Appendix A. HSIB has reviewed two further tools that may be of benefit for trusts to support discussions with mothers. 0000001263 00000 n (2020) IDECIDE a new consent tool is on its way [Online]. National guidance recommends intrapartum care should be transferred to obstetric-led care if an LGA baby is suspected during pregnancy or on assessment in labour. A recent large literature review (Moraitis et al, 2020) found that third trimester USS screening reliably predicted delivery of an LGA baby. Boulvain, M., Irion, O., Dowswell, T. and Thornton, J. G. (2016) Induction of labour at or near term for suspected fetal macrosomia. 0000003445 00000 n The head to body interval was 13 minutes. The rationale supporting the use of customised charts compared to population- based centile charts (which show national average size) is that individual factors relating to a mother, for example her weight, height, ethnicity, and parity (number of previous births) are taken into consideration. This is expected to be piloted in 2021 and will be supported by a training package. Mrs Montgomery had expressed concerns about her ability to deliver her baby safely and indicated that, had she been advised of the risks, she would have chosen a caesarean section. Where we consider this requires national change, we have suggested a HSIB safety recommendation. When a shoulder dystocia was recognised there was not always an emergency call made. The clinicians adopted a confirmatory strategy to deal with the issues of time focus and perception.
previous LGA baby weighing 4,500g or above. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Mothers who have a higher chance of being pregnant with an SGA baby are often on a serial growth ultrasound scan (USS) pathway or a combination of SFH and indicated growth USS (NHS England, 2019). Available at https://www.england.nhs.uk/wpcontent/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf. 4 0 obj endobj When the USS found the babys EFW to be above the 90th centile the Mother was screened for GDM to enable a full discussion with the Mother about birth choices. Barel, O., Vaknin, Z., Tovbin, J., Herman, A. and Maymon, R. (2013) Assessment of the accuracy of multiple sonographic fetal weight estimation formals. (2019) Saving Babies Lives version two. It is a time-critical obstetric emergency that can result in severe brain injury or death and other injuries such as brachial plexus injuries (nerve injuries affecting the arm) or fractures to the arm or collar bone of a baby. If LGA is suspected in labour NICE advises that mothers in labour should be offered the option to continue, to augment (speed up) the labour, or to have a CS. HWnF}`ER8u-"(X+qkrIwf"Xa/x33ggrKvz%o=/WWy#3Q\q~7%7o~$5cY@|`$|2iC#| =B?4G|JyE&d$;+^IU @[4P8=::- s^D"%c! + 0000012549 00000 n The baby was born with Apgar scores of 1 at 1 minute, 6 at 5 minutes and 9 at 10 minutes. The NICE intrapartum care guideline (2014) is clear that mothers who are suspected to have an LGA baby should be under obstetric-led care and transferred to an obstetric-led unit for birth.
m .K endstream endobj 150 0 obj <>/Filter/FlateDecode/Index[37 90]/Length 22/Size 127/Type/XRef/W[1 1 1]>>stream The signs of imminent shoulder dystocia were not always recognised during birth and this led to delays in escalation for obstetric and neonatal support. By using this website, you agree to our use of cookies. The trial aims to be completed in 2022. Available Cambridge university press. HSIB Healthcare Safety Investigation Branch, NICE National Institute for Health and Care Excellence, RCOG Royal College of Obstetricians and Gynaecologists, At HSIB we welcome feedback on our investigation reports. The OGTT may not be accurate late in the third trimester and other methods are required such as home blood sugar monitoring, which is more time consuming and invasive for a mother. When a shoulder dystocia was recognised there was not always an emergency response using the national emergency 2222 call system. This did not enable staff to recognise the importance of the accelerating SFH growth trajectory and a growth USS or testing for GDM were not undertaken. The baby was born after a shoulder dystocia and was noted to be LGA.. When mothers are identified as having a suspected LGA baby some trusts test for GDM to. Available at https://www.nice.org.uk/guidance/cg62. Available at https://www.birthrights.org.uk/2020/01/30/idecide-a-newconsent-tool-is-on-its-way. A mother had concerns during the pregnancy that her baby was too big for a vaginal birth. ^|ZFnfJF~WxX k\MV}y-O{]VPhC pmed.1003190. During pregnancy, a mothers symphysis fundal height (SFH) is measured on a two to three weekly basis commencing from 24 to 26 weeks to screen for small for gestational (SGA) babies. As defined by the Royal College of Obstetricians and Gynaecologists (RCOG), shoulder dystocia is where additional manoeuvres are required to complete the birth of a baby, after routine traction has failed to release the shoulders during a vaginal birth (Royal College of Obstetricians and Gynaecologists, 2012). The Montgomery ruling makes it clear that all healthcare professionals must inform a mother of the risks and benefits of different birth options in all pregnancies, not exclusive to LGA or shoulder dystocia, so that she can make an informed choice about her care. BJOG, 2011; 118;474-9. I Identify urgencyD Details of the current situationE Exchange objective and subjective information (history, organisational context, mothers perspective, healthcare professionals expertise)C Choices available (evidence- based information will be on the tool generic at first but in time individualised)I I (the mother) confirm my understanding and seek any further clarification neededD Decision is made (by mothers) and recorded on the toolE Evaluation takes place a few days/weeks later using a recorded experience measure. Current practice for the management of suspected LGA babies in England is varied. BJOG, 123 (1), 111-118. There is no guidance in the antenatal period locally or nationally for the management of babies who are suspected to be LGA in the absence of diabetes. NICE guideline NG121 [Online]. 0000019391 00000 n
Risk factor screening for GDM appears to be in line with national guidance which does not always take into consideration previous births of an LGA baby. 3 0 obj Mothers may also undergo ultrasound scans (USS) to monitor their babys growth if risk factors are identified or if there is a concern about SFH measurements. Safety recommendation R/2021/114:It is recommended that the Royal College of Obstetricians and Gynaecologists (RCOG) takes into consideration the findings of this HSIB review when updating the RCOG Green Top shoulder dystocia guideline (No.42). The pathways include guidance on the frequency of growth USS, testing for GDM in late pregnancy (using home blood sugar monitoring) and sharing information with mothers regarding their options for timing and mode of delivery. Moraitis, A. Each of the characteristics is recognised as being poorly predictive of a shoulder dystocia occurring. 0000005846 00000 n 0000012142 00000 n The Trust to ensure that staff are supported to follow the escalation process to alert the neonatal team to attend so that skilled staff are present at a babys resuscitation. HSIB found that in the incidents it reviewed, 22 of the 31 babies (71%) weighed more than 4,000g at birth (see table 1).
Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf.
qZ6l\/rnnY,O)m8uRUVzkBl=+cCQ'WdbOmqb9y{=xI^5xCYkZ,-UV /UM& The baby is also at increased risk of shoulder dystocia and birth trauma, in particular fractures of the arms, collar bone or a brachial plexus injury. xZn8}7Tx)(,^Cmae+k)I;CmI"3938eL of|f?&[$b>v/#/~oxc4v1#*a(B*87MyP2]{An.a/xN gEA^eYrp`];QSM@1eM G%YJ;R6.k,w/([Wv!7$&DHKA5nmx grx'ifa`rf6T MD8gd'-@xM Y?^R?M%6-1Ast_lGKNJuts{Zu@=F8eCuX]vP9?bJqBfF]A Sq,s C 2gbsx!`p!u%Q[x^. HSIB investigations found that there was a wide variation in what action trusts take when there is a suspected LGA baby identified by increased SFH measurement; some trusts do not refer the mother for a growth USS whereas others do. GDM may affect up to 18% of mothers during pregnancy. This is due to the Cochrane review (Boulvain et al, 2016) which concluded that earlier induction of labour may reduce the incidence of shoulder dystocia in babies estimated to weigh more than 4,000g. The Trust to ensure mothers are advised of the risks and offered all available options when a baby is suspected of being LGA.
ISBN 978-108-43029-6.Royal College of Obstetricians and Gynaecologists. In other definitions it refers to a birthweight more than the 95th centile or a birthweight above 4,000g (Boulvain et al, 2016) or more than 4,500g (Royal College of Obstetricians and Gynaecologists, 2012; National Institute for Health and Care Excellence, 2019). NHS England.
These charts were designed to identify small for gestational age (SGA) babies or babies with suspected growth restriction. If a baby is in good condition (not hypoxic) entering the shoulder dystocia, they may be more likely to be able to withstand a longer HBI. LGA is often considered to mean a baby weighing more than the 90th birthweight centile. The RCOG (2012) shoulder dystocia guideline determines that IOL does not prevent shoulder dystocia in non-diabetic mothers with a suspected LGA baby. The mother had an USS with an EFW of greater than 90th centile. In some of these mothers there was an opportunity to offer a growth USS as the SFH was above the expected range. (2016) Prevention of brachial plexus injury-12 years of shoulder dystocia: an interrupted time-series study. Signs of a potential shoulder dystocia include slow or difficult delivery of the babys head. This is because the babies were born earlier and thus had a lower birthweight. Available at https://www.nice.org.uk/guidance/ng121/evidence/q-largeforgestationalage-baby-pdf-241806242780. 0000000016 00000 n In most babies with HIE following a shoulder dystocia this can be explained by the shoulder dystocia alone; in some babies HIE is the result of multiple factors. assisted vaginal birth (using forceps or vacuum). Royal College of Obstetricians and Gynaecologists. (2014) Intrapartum care for healthy women and babies. We use cookies to help our website run effectively. This report is based on the analysis of 31 HSIB maternity investigation reports. There were several mothers with a greater than expected SFH (greater than 90th centile) who did not have a growth USS with EFW calculation before birth. National guidance by the National Institute for Health and Care Excellence (NICE) (2019) recognises that LGA babies are at increased risk of a birth injury, brain injury or in rare cases, death, because their shoulders get stuck during birth. The NICE (2008b) induction of labour guideline in the absence of any other indications recommends that induction of labour (IOL) should not be. The Trust to ensure all risks to both mothers and babies are discussed for those identified to be at increased risk of shoulder dystocia. %PDF-1.4 % HSIB identified that a review of cases where shoulder dystocia was identified as a factor that contributed to a severe brain injury or death, would generate potential learning for maternity care. Of all the mothers screened, 4 had confirmed GDM. The NICE (2020) guideline on intrapartum care for women with existing medical conditions or obstetric complication and their babies explains that these mothers are at increased risk of complications during labour such as shoulder dystocia, brachial plexus injury, assisted birth (where instruments such as forceps or a vacuum suction cup are used to help deliver the baby) or CS. There is no standardised definition of an LGA baby. The General Medical Council (2020) has published new guidance on decision making and consent. During the birth it was noted that the head was slow to deliver and help was called for as a shoulder dystocia was anticipated. The Trust to ensure that the information provided to mothers informs them of birth options and associated advantages and risks to support decision making and informed consent during childbirth. For example, for an estimated fetal weight (EFW) of 4,200g based on USS, 15% less would mean a birthweight of 3,570g, or 15% more would mean a birthweight of 4,830g. All maternity investigations reports are reviewed, and themes identified by a Healthcare Safety Investigation Branch (HSIB) multi- professional panel which includes neonatologists, midwives and obstetricians. Multiprofessional training for shoulder dystocia using recognised algorithms was commonplace and well embedded in all trusts and staff were able to undertake recognised manoeuvres. This section is in two parts, covering relevant issues relating to pregnancy (antenatal) and labour/birth (intrapartum). Within the 31 investigation reports analysed, HSIB found that the birthweights of the babies ranged from 3,565g to 5,177g. These babies were born in poor condition requiring resuscitation, which suggests there had been compression of the umbilical cord vessels allowing no transfer of oxygen to occur between the baby and the placenta or premature separation of the placenta during the shoulder dystocia. Available at https://www.nice.org.uk/guidance/cg19. Analysis of the 31 reports related to shoulder dystocia identified the following main findings: Examples of safety recommendations from HSIB maternity investigation reports. % There was varied information shared with mothers regarding the risks and benefits of having a vaginal birth or CS when an LGA baby was suspected. This leads to a wide variation in practice with some mothers having a discussion about the mode of birth and a small number of mothers being offered earlier IOL when a LGA baby is suspected on USS. These mothers did not have the opportunity to discuss what a raised SFH might mean for labour and birth. There was no documented antenatal counselling regarding risks of shoulder dystocia or what should occur should she go into labour prior to the date of the CS. Where we consider this requires national change, we have noted this as an HSIB national safety recommendation. Mrs Montgomery has Type 1 diabetes, which increases the risk of having a larger than average baby, a risk compounded by Mrs Montgomerys small stature. 0000005244 00000 n In the investigation reports reviewed, HSIB identified that 14 of the 31 babies were suspected to have a predicted birthweight of more than 4,000g after a growth USS. Available at https://www.rcog.org.uk/globalassets/documents/members/membership-news/og-magazine/december-2016/montgomery.pdf. The NICE (2020) intrapartum care for women with obstetric complications guideline recommends mothers in labour should be informed of the higher chance of shoulder dystocia and brachial plexus injury with vaginal birth. (2018) Estimating fetal weight via ultrasound [Online]. The majority of cases of shoulder dystocia occur when the uppermost shoulder of a baby impacts behind a mothers pelvic bone after the birth of the head, preventing the birth of the body. 0000007680 00000 n Grunebaum, A. National Institute for Health and Care Excellence. 0000003559 00000 n A shoulder dystocia with a HBI of three minutes occurred. (2020) Intrapartum care: existing medical conditions and obstetric complications. 2 0 obj hb```b````e` @1V~$`r\ku5Re68 ` B#Y(MRgg0`0aM:3`Vnc[Ab@Xq _\X("w There are multiple national guidelines that refer to some aspects of management for an LGA baby many of which are contradictory: The array of varying national guidance reflects the lack of robust evidence regarding the diagnosis and management of LGA babies, and how best to share this information with mothers to support them to make an informed choice about their birth preference.
National Institute for Health and Care Excellence. Shoulder dystocia is associated with prolonged first and second stages of labour and assisted vaginal birth. endobj H\0?$I:RQ> 'Ej H9`MCvyLI'%\iL?29I]l~o&=oa1kSf\Ii/.KyLscS!M?uriL5~:?8.uW+$^gGIeeesr.-Xd77[dA p:\a W+ Cochrane Database of Systematic Reviews, Issue 5 [Online]. 0000011740 00000 n The HSIB database of completed reports, excluding reports related to maternal deaths, was searched on 28 January 2020 using the key phrase shoulder dystocia. Clinical guideline [CG62] [Online]. Shoulder dystocia may also cause increased injury to the mother including bleeding and perineal trauma. Mothers with a suspected LGA baby are more likely to have an assisted vaginal birth or CS. The other 28 babies were treated in neonatal intensive care units with therapeutic cooling (a procedure where a baby is cooled to between 33C and 34C with the aim of preventing further brain injury following a hypoxic (lack of oxygen) injury and were diagnosed with HIE. The RCOG (2012) shoulder dystocia guideline suggests that IOL does not reduce the incidence of shoulder dystocia in the absence of diabetes. For instructions on how to enable JavaScript, please visit enable-javascript.com. A Cochrane review (Boulvain et al, 2016) found that IOL in mothers with LGA babies reduced the number of babies who had a shoulder dystocia, when compared with expectant management (allowing the pregnancy and labour to progress without specific intervention). If they do undertake a USS, some trusts carry out further investigations and then discuss with the mother her options for birth while other trusts do not do anything further. Following a growth USS the EFW was >95th centile and predicted to be greater than 4,000g at birth. In the investigation reports reviewed, the majority of mothers gave birth in an obstetric-led unit with 20 of the 31 mothers undergoing IOL. The reports identified were reviewed by a multi-professional panel using a quantitative analysis tool and the findings were categorised into themes. When considering this a 15% margin of error in a baby that is LGA is significant. (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies. The umbilical cord blood gases showed severe hypoxia. The trial aims to collect data from 4,000 mothers identified as having LGA pregnancies confirmed by USS to be recruited and randomised to either IOL at 38 weeks or for the mother to await the natural onset of labour. )* #w8V: There is no specific national guidance that provides recommendations for the management of pregnancies where the baby is LGA.