ICOE Guru’s Chops
Our Trainers’ Experience
ICOE Guru’s Chops
Our Trainers’ Experience
SHOULDER DYSTOCIA IN MANDARIN?
After signing up for ICOE China, I had butterflies in my stomach. It’s my first ICOE and the program would be conducted in Chinese. Mandarin is my mother tongue; however, I had never been exposed to Chinese medical terminology. I did not even know how to translate ‘shoulder dystocia’ into Mandarin. All trainers shared the same worry. For every topic, we translated the medical jargon, formulated our sentences and paired up to practise speaking medical colloquies in Mandarin. Our trainer manuals were full of scribbles in Chinese characters. I felt like I was practising for Part 3 MRCOG exam.
My initial concern about my unproficiency in Mandarin turned out to be unnecessary. The participants were very understanding and helpful. When I was tongue-tied, they would fill in the gap spontaneously. I was very delighted to discover that they were familiar with the common English medical jargon such as ‘McRoberts’, ‘Wood screw’ and the shoulder dystocia management flowchart is similar in China. I also learnt the local common terminology such as ‘wash face method’ to describe ‘sweep the hand across the chest’ for
delivery of posterior arm. The learning process was certainly bidirectional.
One of the highlights was the force feedback using the Prompt Flex model. It was interesting to discover that the senior obstetricians tend to exert stronger force than the registrars. The participants were amazed by how little force was actually needed during traction to reach 100 Newton. They repeatedly practise to get a feel for what the appropriate level of force felt like. Most of them decided to purchase the simulator for their centre for future training.
Teaching shoulder dystocia in China was challenging but truly rewarding and memorable.
UNFORGETTABLE RED AND BLUE ALERT
Red AND blue alert in my hospital means either two things: cord prolapse or shoulder dystocia.
Few years ago, a case of shoulder ‘D’ taught me a few golden points in life.
The mother was 19 years old, newly married and pregnant with her first child. She was screened for diabetes based on family history and diagnosed as ‘overt DM’. She was 35 weeks into her pregnancy, with her sugars relatively controlled by Metformin. She was 149cm tall, with a BMI of 29. She presented with preterm prelabor rupture of membranes. I saw her in the antenatal ward on that fateful Saturday oncall morning, palpated her abdomen and estimated the baby to be about 3.2 – 3.4kg, which corresponded to the admission ultrasound scan findings. I thought to myself that she should be delivering soon as the baby’s head was engaged and she had 1:10 contraction with os of 2cm.
At 1800H, the buzzer on the PA system went off, announcing the dreaded ‘RED AND BLUE ALERT IN LABOR ROOM’. Running into the room, I found my medical officers halfway through the HELPPER algorithm, attempting to deliver the baby. I quickly took over to perform the rotational and removal of posterior arm manoeuvre. It did not work! I started again from the top, even turning the patient on all-fours, but to no avail. For the first time in my 16 years as a doctor, I took a deep breath, tried to stay calm and asked the mother to turn on her back, and tried the mnemonic again. Preparing for the worst case scenario, I silently asked myself if I had the courage to break the baby’s clavicle.
Miraculously the baby was delivered by the posterior shoulder this time. I suspected that being on all-fours have helped relieved some pressure somewhere. The baby was born flat after 7 minutes of initiating for help. The Paediatric team who was on standby, resuscitated and intubated the baby, before admitting him to level 3 NICU. The 3.5kg baby survived 13 days before finally succumbing.
Upon reflection, I learnt to:
MIDWIFE'S ROLE IN SHOULDER DYSTOCIA
Nowadays, midwives handle a greater number of high-risk pregnancies and deal with various childbirth emergencies. Shoulder dystocia is an obstetric emergency which midwives do occasionally encounter. To make matters worst, it is usually unpredictable.
I have been working as a Labour Room midwife for 19 years and is now the Nursing Supervisor in my hospital. From my experience, shoulder dystocia were often chaotic. Most nurses tend to lose their composure and forget the appropriate actions to take.
In my opinion, anticipation, recognition and reaction are essential when dealing with shoulder dystocia. During intrapartum period, a midwife should identify the patient’s risk factors for shoulder dystocia such as diabetes, obesity or previous history of shoulder dystocia. We should also perform abdominal palpation to estimate the fetal weight, and pay close attention to the patient’s labour progress. If the labour progress is suboptimal, the midwife should report promptly to the doctor on-duty.
After delivery of the fetal head, the midwife should watch out for turtle-neck sign which would indicate shoulder dystocia. In the event of such an emergency, we need to always remain calm and called for help. We should also instruct the patient to stop pushing while we carry out various manoeuvres systematically to deliver the fetal shoulders.
Once the emergency is over, the midwife should document the events in a timely manner in patient’s case notes.
With regular training or drills, midwives can have more confidence in managing shoulder dystocia.
PERILOUS ROTATIONAL MANOEUVRE FOR SHOULDER DYSTOCIA
Excited and anxious, I started my journey to a LEDC country in South Asia, liberated in 1971 and the 8th most populous country in the world. The responsibility of an International ICOE Course director includes being a team leader to plan and arrange travel with accommodation for my team, in order to smoothly conduct the course in a foreign land on a limited budget. From the beginning, the odds were against our team due to sudden cancellation of our direct flight. Fortunately, we managed to reach our destination via alternative flights (at extra costs and much delay), after fighting with taxi drivers to catch the unbooked flight on time. We arrived groggy, and much the worse for wear.
Yet, we immediately sprang to action to arrange our stations and began the pre- skills test OSCE circuit. I was in-charge of the shoulder dystocia skills test and met my challenge when a middle-aged local O&G specialist approached as an anxious participant. She managed to correctly perform the McRoberts and Rubin I manoeuvres, but stumbled when asked to perform the rotational manoeuvre to deliver the baby’s shoulders. I was shocked to observe that she rotated the (mannequin) fetal head directly clockwise, a full 360 degrees! She was also unfamiliar with the technique to deliver baby’s posterior arm in shoulder dystocia.
This experience showed that theoretical knowledge doesn’t always confer practical competency. Simulation training helps in developing our skills to efficiently manage ostetric emergency, enabling us to provide safe child birth practices for our patients.
