Shoulder dystocia action strategy guide: Contributing factors and key strategies for mitigation (August 2024)

Summary

Shoulder dystocia is an uncommon but high-risk obstetric emergency that happens when a baby's shoulders fail to deliver spontaneously following delivery of their head. When it happens, the healthcare team has to carry out specialised obstetric manoeuvres designed to correct the positioning of the baby. This guide was co-produced by the Pennsylvania Patient Safety Authority (PSA), the Institute for Safe Medication Practices (ISMP) Patient Safety Organization and ECRI. It records the findings of a 'safe table' meeting—a protected environment where Pennsylvania healthcare professionals had an opportunity to discuss the risk factors, challenges and mitigation strategies associated with shoulder dystocia. The guide includes comments and recommendations relating to debriefing and documentation after a shoulder dystocia event, reporting and legal concerns, risk assessment and simulation and training.