Shoulder Dystocia (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Let's talk about the next complication.

    00:03 A shoulder dystocia.

    00:06 So a shoulder dystocia occurs when the head of the fetus is actually delivered, but the shoulder gets caught on the pelvis, and so it's unable to deliver.

    00:17 And this happens about 2% to 3% of the time.

    00:21 So thinking about risk factors, if we have a really large baby, so that's called macrosomia, large body, then it may be likely that the shoulder would get stuck.

    00:33 Otherwise, we may have a situation called fetopelvic disproportion, where the fetus is in disproportion to the pelvis.

    00:42 And we differentiate these two because sometimes it's not that the baby is unusually large, it may be that this pelvis is particularly small.

    00:50 So any inequality in the size of the fetus and the openness of the pelvis can lead to a shoulder dystocia.

    00:58 Other risk factors that the nurse might notice that might clue them into the possibility of a shoulder dystocia is a prolonged second stage.

    01:06 So remember, second stage occurs from when the cervix is completely dilated to the delivery of the fetus.

    01:13 So if that timeframe is particularly long, the patient's been pushing for a really long time and not really making very much progress, or it's very slow, then that may be an indicator to suspect a shoulder dystocia.

    01:26 If they've had a shoulder dystocia in a previous delivery, definitely want to think about the fact that they could have another one in this one.

    01:34 If the patient has a history of diabetes.

    01:36 Now, it's not the diabetes itself, it's the effect of the high blood sugars.

    01:40 Because if we have a high blood sugar in the mom, the baby is just eating all of that glucose and getting nice and plump.

    01:47 Remember that risk factor of macrosomia? If we have diabetes, we're at risk of having a really large baby.

    01:55 So thinking about what we might see in terms of assessment, one of the more obvious signs of shoulder dystocia, is what we call a Turtle sign.

    02:04 So I know, you know, what a turtle is.

    02:07 So let's think about what a turtle does.

    02:10 So a turtle lives in its house, and then it pokes its little head out, and then if it wants to go back in, it pokes it back in.

    02:16 Well, that's what happens.

    02:18 So as the baby's head is emerging from the perineum, if the shoulder is caught on the anterior part of the pelvis, then the head will poke out, and then it'll poke back.

    02:29 Turtle.

    02:31 I hope that's working for you.

    02:33 The other thing that will happen is that the shoulder will not deliver.

    02:37 The shoulder is actually caught on the symphysis pubis, and it will not move.

    02:42 Its a bone to bone, shoulder to pelvis.

    02:45 Those are two immovable objects.

    02:48 And if we don't collapse that shoulder, then it will get stuck and the baby will not come out.

    02:54 Now, this is a problem because once the head starts to come out, the baby's going to begin to try to take a breath.

    03:00 And if they're still inside the vagina, then they will not be able to expand the chest and the cord may also be compressed.

    03:07 So thinking about a prolapse cord, and how that compression really decreased oxygen flow, that's the very same thing that's happening with the shoulder dystocia.

    03:16 The other issue is that we're placing a lot of pressure on the shoulder, and we can actually cause a brachial plexus injury.

    03:24 and that can cause numbness and paralysis in the baby's arm, once they're delivered.

    03:29 So what do we do? The first thing we want to do is communicate with the provider.

    03:33 Hopefully, they are at the bedside doing the delivery, that would be ideal.

    03:37 But we want to make sure that we have eye contact because they're going to be some instructions that the provider is going to give the nurse and the delivery team, and we all want to make sure we're on the same page.

    03:47 We want to set the clock.

    03:49 And this might not be literal, it may be just noticing what time it is because we have about four minutes.

    03:55 So thinking about the amount of time that we can go without oxygen, before we begin to see hypoxic injury.

    04:01 We want to be able to count that and this is important for documentation.

    04:05 The nurse may also keep the provider aware of how much time has passed.

    04:10 The next thing we can do is execute McRoberts maneuver.

    04:14 So McRoberts was a person who, I guess founded this maneuver.

    04:19 Basically what it looks like is that the legs are flexed back up against the pelvis.

    04:24 And this is kind of like a squat.

    04:25 So if you think about squatting down, and if you squat, your pelvis opens.

    04:30 So we can't always have the client squat while they're in the middle of delivering the baby.

    04:35 So we make a squat.

    04:36 We pull the legs back, it opens up the pelvis, which hopefully will create more space for the shoulder to be delivered.

    04:44 We can also help this along by applying suprapubic pressure.

    04:48 So as you can see in this diagram, the nurse is actually making a fist and helping to push that shoulder out.

    04:56 This is very important that you do it in communication with the provider because if you don't, then you could actually impact the shoulder even more.

    05:05 This is why communication is so important.

    05:08 Now, if you have a client that can get up and move, then what we may try is what's called the Gaskin maneuver.

    05:15 And this was named after a lay midwife from Kentucky named Ina May Gaskin.

    05:19 We actually have the patient turnover on all fours.

    05:22 And the mechanism of rolling the patient sometimes helps to dislodge the shoulder.

    05:28 Either way, whatever we're doing the minute we recognize that we have a shoulder dystocia, we want to call the NICU or some other person to come and take care of the baby.

    05:37 There is a possibility that we could have some newborn distress, and we want someone there who's able to manage that.

    05:45 Now, above all, we want to stay calm, because this again can be a very scary situation for the family, for the providers, and everyone else in the room.

    05:53 So it wouldn't do any good for the nurse to get panicked when they need to be communicating and thoughtful about what's going on.

    06:00 And always remember to talk to the client.

    06:03 Now sometimes, it's going to be the provider talking to the client and we don't want to get in the way of that.

    06:07 So make sure that that communication path is clear.

    About the Lecture

    The lecture Shoulder Dystocia (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Complications in Labor (Nursing).

    Included Quiz Questions

    1. Large fetus or macrosomia
    2. The prolonged second stage of labor
    3. Maternal diabetes
    4. Large pelvis and small fetus
    5. Rupture of membranes (AROM)
    1. Fetal head goes in and out of the birth canal
    2. Fetal head is stuck in the birth canal
    3. Delivery of the fetal arm before the head
    4. Shoulder is stuck in the birth canal
    1. Note the time and amount of time passed
    2. Prepare for imminent birth
    3. Alert team to prepare for cesarean birth
    4. Increase oxytocin infusion
    1. Flex the mother's thighs toward her shoulders in the supine position
    2. Roll the mother on her hands and knees to dislodge the fetal shoulder
    3. Apply suprapubic pressure to push the shoulder out and dislodge it
    4. Extend the mother's legs away from the body's midline in the supine position
    5. Position the mother on her left lateral side with the right leg extended outward

    Author of lecture Shoulder Dystocia (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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