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.