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Shoulder Dystocia Nursing Roles and Responsibilities

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Shoulder Dystocia Nursing Roles and Responsibilities Shoulder Dystocia Nursing Roles and Responsibilities 1 What Is Shoulder Dystocia? • Most commonly diagnosed as failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery. • ACOG, 2017 (reaffirmed 2019) 2 1 Incidence of Shoulder Dystocia • There are differences in reported rates due to clinical variation in defining shoulder dystocia – Reported incidence among vaginal deliveries in vertex presentation is 0.2% to 3% • ACOG, 2017, (Reaffirmed 2019) 3 • Shoulder dystocia cannot be reliably predicted or prevented – Baird & Kennedy, 2017, p. 448 • Be prepared at every delivery 4 2 Associated Risk Factors • Suspected fetal macrosomia • History of prior shoulder dystocia • Mid-pelvic operative birth with an EFW of 4000 grams • Baird & Kennedy, 2017, p. 448 5 Risk Factors • Maternal diabetes • Maternal obesity • Several other associated factors – Lack high predictive value 6 3 Watch For The Turtle Sign • May or may not occur simultaneously – The fetal head delivers and then suddenly retracts back against the mother's perineum after it emerges from the vagina. – The baby may have a double chin – Similar to a turtle pulling its head back into its shell – This retraction of the fetal head is caused by the baby's shoulder being trapped on the pubic bone 7 The Turtle Sign 8 4 •Call For Help 9 Nurse’s Role: Be Prepared • Step stools readily available for all deliveries – Rationale: • to use when performing suprapubic pressure if needed 10 5 Head to Body Delivery Interval • Note time of delivery of fetal head • Note time of diagnosis of shoulder dystocia – Provider makes the diagnosis and communicates to team • Note time of delivery of fetal body • Note: One way to time head to body delivery interval is to press the mark button on the fetal monitor 11 Lower Head of Bed • Lower the head of the bed – To make room for the nurse to perform suprapubic pressure – Baird & Kennedy, 2017, p. 239 12 6 Pushing (Bearing Down Efforts) • Follow the provider’s instructions regarding when to have the patient push and when to request she not push 13 •McRobert’s Maneuver 14 7 McRoberts • Hyperflexion of woman’s thighs against her abdomen – AWHONN Perinatal Nursing 2021 p. 359 • Typically considered the first-line maneuver 15 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf 16 8 http://www.odemsaprotocols.com/Protocols/Section06/6.4%20Delivery%20-%20Shoulder-Dystocia.pdf 17 McRoberts • Avoid prolonged or overly aggressive application of the McRobert’s maneuver • Gabbe, 2017, p. 389 • Symphyseal separation and lateral femoral cutaneous neuropathy has been shown to be associated with aggressive hyperflexion of the maternal legs • ACOG, Shoulder Dystocia, Number 178, May 2017 18 9 https://link.springer. com/chapter/10.100 7/978-3-319-27482- 9_67 19 Lerner www.shoulderdystociainfo.com 20 10 Suprapubic Pressure 21 Firm Suprapubic Pressure • Can be used to dislodge the impacted anterior shoulder • MD or CNM may request nurse to apply suprapubic pressure using either a posterior or lateral technique – Posterior pressure used to dislodge the anterior shoulder and push it under symphysis – Lateral pressure to the back surface of the fetal anterior shoulder • used to push fetal anterior shoulder toward the fetal chest – Kennedy and Baird, 2017, p. 239; Simpson & Abel, AWHONN Perinatal Nursing, 2021, p. 359 22 11 Suprapubic Pressure • Posterior suprapubic pressure – Place hands just above pubic bone – Apply pressure straight down • Laterally, to either the right or left side – Apply pressure on the side of the mother where the fetal back is located and toward the direction of the fetal face 23 Lateral suprapubic pressure using palms of hands Fetal back Fetal face https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf 24 12 #1 shows McRobert’s maneuver #2 shows posterior downward suprapubic pressure using a fist https://commons.wikimedia.org/wiki/File:Mc Roberts_maneuver.svg 25 https://www.anatomynote.com/disease-anatomy/woman-disease- gynaecology-and-obstetrics/shoulder-dystocia-when-labor/ 26 13 Fundal Pressure • Generally regarded as contraindicated for shoulder dystocia 27 •Gaskin Maneuver 28 14 Delivery in all-fours Position change and gravity may dislodge the shoulder Gaskin Maneuver From Bruner, J. P., Drummond, S. B., Meenan, A. L., & Gaskin, I. M. (1998). All-fours maneuver for reducing shoulder dystocia during labor. Journal of Reproductive Medicine, 43, Figure 1, p. 440. 29 Provider Maneuvers • Episiotomy – Based upon clinical circumstances • Posterior arm release • Rubin’s maneuver • Wood’s maneuver 30 15 The Bladder • Promote emptying of the bladder throughout the labor process 31 What About Fetal Assessment? • Once the head has been delivered the focus of the team should be on maneuvers to resolve the shoulder dystocia • “Continued attempts to find or record the FHR once the vertex is delivered are unnecessary and could delay important nursing actions such as patient positioning or suprapubic pressure” • Freeman, Garite, Nageotte, & Miller (2012, p.252) 32 16 Communication • Communication is vital – With patient – Between provider and nurse 33 Documentation • Recommend that provider and nurse document events together after the delivery… • Consistency in documentation is important • Some institutions use a checklist – The checklist sample shown in the next slide shows specific actions and interventions for provider and nurse documentation 34 17 Sample Checklist Form 35 •Assess for possible neonatal and maternal complications 36 18 Possible Neonatal Complications • Brachial Plexus Injury (C4-6 nerve roots) – Approximately 50% of injuries NOT a result of SD • DuChenne-Klumpke – Involves entire brachial plexus • Klumpke’s (C8-T1) – affects forearm and small muscles of hand • Clavicular fracture • Humerus fracture • Contusions • Horner’s Syndrome – Damage of sympathetic nerves traversing T1 due to a brachial plexus injury • Depression of eyelid, drooping of mouth on affected side 37 Possible Neonatal Complications • Hypoxic ischemic encephalopathy • Death 38 19 Possible Maternal Complications • Hemorrhage – Uterine atony – Lacerations – Uterine rupture • Postpartum bladder atony – Usually temporary • Femoral nerve damage • Lerner, 2017 39 Summary • The healthcare team should be prepared for a shoulder dystocia at every delivery • Communication and teamwork is vital whenever a shoulder dystocia occurs • The nursing role includes assisting with maternal maneuvers – McRobert’s, suprapubic pressure, Gaskin 40 20 Summary • Team documentation following a shoulder dystocia delivery is important for an accurate and consistent record of events • It is important to assess for maternal and neonatal complications following a shoulder dystocia 41 Videos for Learning • https://www.hopkinsmedicine.org/gynecolo gy_obstetrics/education/training/shoulder- dystocia • McRoberts, Suprapubic, and drill (scroll forward to 4:10 on the video to the start of the scenario) 42 21 References • American College of Obstetricians and Gynecologists (2017) (Reaffirmed 2019). Shoulder dystocia. ACOG Practice Bulletin Number 178, May 2017. • American College of Obstetricians and Gynecologists (2020). Fetal Macrosomia. ACOG Practice Bulletin Number 216, January 2020. 43 • Athukorala, C., Middleton, P., & Crowther, C. A. (2006). Intrapartum interventions for preventing shoulder dystocia. Cochrane Database of Systematic Review, Issue 4. (last reviewed 2009 with no change to conclusions) 44 22 • Baird, S. M., & Kennedy, B. B. (2017). Obstetric Emergencies in Betsy B. Kennedy & Suzanne McMurtry Baird (eds.) Intrapartum Management Modules, 5th ed., Philadelphia: Wolters Kluwer. • Bruner, J. P., Drummond, S. B., Meenan, A. L., & Gaskin, I. M. (1998). All-Fours maneuver for reducing shoulder dystocia during labor. Journal of Reproductive Medicine, 43, 439-443. • Freeman, R. K., Garite, T. J., Nageotte, M. P., & Miller, L. A. (2012). Fetal Heart Rate Monitoring, 4th edition. Philadelphia: Wolters Kluwer/Lippincott. 45 • Lerner, H. (2004-2020). Shoulder Dystocia: Facts, evidence, and conclusions. www.shoulderdystociainfo.com • Simpson, K. R., & Creehan, P. A., et. al. (2021). AWHONN Perinatal Nursing, 5th ed. Philadelphia: Wolters Kluwer. 46 23.
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