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Shoulder Dystocia - Lippincott Williams & Wilkins

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<strong>Shoulder</strong> <strong>Dystocia</strong> 17<br />

more often during pregnancy, every 2 weeks instead of<br />

monthly, to provide more frequent nutrition coaching.<br />

They many benefit from a referral to a nutritionist. Nutrition<br />

counseling for some women may be obtained<br />

through the Women, Infants and Children’s Supplemental<br />

Nutrition Program (WIC). Obese women may<br />

qualify for WIC, for example, by being anemic. Women<br />

who are overweight or obese demonstrate periods of<br />

excess caloric intake, not necessarily adequate nutrient<br />

ingestion.<br />

Diabetes in pregnancy<br />

Obesity and excessive weight gain are risk factors<br />

for gestational diabetes. 13 Pregestational and gestational<br />

diabetes complicated by obesity, poor glycemic<br />

control, or excessive weight gain increase risk for<br />

shoulder dystocia. 1,17,13 All pregnant women should<br />

be screened for diabetes during pregnancy by using<br />

national standards. 13 The 2005 American College of<br />

Obstetricians and Gynecologists standards for obesity<br />

management during pregnancy advise consideration of<br />

gestational diabetes screening at the first-trimester firstprenatal<br />

visit with repeated screening later in pregnancy<br />

if the first screen is within a reference range. 13<br />

The prenatal nurse can ensure that these guidelines<br />

are integrated into practice and that abnormal screens<br />

are followed by 3-hour glucose testing and treatment<br />

as needed. Testing, treatment plans, and blood glucose<br />

records should be copied into the prenatal record so<br />

that all providers can assess progress with glucose control.<br />

If diabetes management is provided by a perinatologist<br />

or diabetologist outside of the prenatal practice,<br />

the nurse can enhance communication between<br />

practices by seeing that both practices have copies of<br />

laboratory values, visit records, and consultation summaries.<br />

These complete records should also be available<br />

in the prenatal records that are used for the labor<br />

and delivery record.<br />

Macrosomia<br />

Regular fundal height assessment during prenatal visits<br />

documents fetal growth and can be a screen for<br />

macrosomia. 17 Estimated fetal weight based on clinical<br />

palpation including Leopold’s maneuvers is as accurate<br />

as ultrasound estimation of fetal weight 17 ; therefore,<br />

nurses should practice their palpation skills and<br />

have confidence in their ability to estimate fetal size.<br />

The estimated weight of fetuses with fundal heights<br />

greater than 40 cm should be measured carefully. Fetal<br />

chest circumferences equaling or exceeding fetal head<br />

circumferences measured by ultrasound may indicate<br />

shoulder dystocia risk. 3 When estimated fetal weight<br />

exceeds 5000 g in women without diabetes and 4500 g<br />

in women with diabetes, the prenatal care provider<br />

needs to determine whether an induction of labor or<br />

elective cesarean birth is indicated and whether a plan<br />

has been made with the mother for the timing and manner<br />

of birth. 1,18<br />

PRIOR SHOULDER DYSTOCIA<br />

A previous shoulder dystocia with or without brachial<br />

plexus injury should be recorded on the prenatal problem<br />

list. 10 A prior shoulder dystocia increases the risk<br />

for a subsequent shoulder dystocia (9.8%–16.7%), although<br />

most subsequent births do not involve shoulder<br />

dystocia. 19 Women who have had a prior shoulder dystocia<br />

need careful informed consent on prenatal weight<br />

gain, the risk of recurrence, and birth options. 1,10 The<br />

prenatal care provider should form a plan for time and<br />

place of birth with the mother that is documented in<br />

the prenatal record. The nurse can help prepare the<br />

mother for scheduled births by teaching about induction<br />

of labor or presurgical routines.<br />

CHILDBIRTH PREPARATION<br />

Nurses who teach childbirth preparation can prepare<br />

mothers and their families for the common maneuvers<br />

used in shoulder dystocia management without scaring<br />

the family with worst-case complications. 10 The childbirth<br />

preparation nurse can say,<br />

Some large newborns are tight fits through the vagina. The<br />

labor and delivery nurses may help you pull your legs back<br />

to your chest to help move the pubic bone over the baby’s<br />

shoulder. A nurse might also push down just above your pubic<br />

bone to nudge the baby’s shoulder under the bone. Sometimes<br />

the midwife or doctor might put a hand behind the<br />

baby’s back to push it sideways into a large part of the pelvis<br />

so the shoulders move down.<br />

Mothers can practice McRobert’s maneuver in class by<br />

pulling their legs to their chests while sitting on the<br />

floor resting against their seated coaches. The childbirth<br />

preparation teacher can demonstrate suprapubic<br />

pressure on a recumbent mother without using any<br />

pressure.<br />

INTRAPARTUM NURSING PREVENTION<br />

OF SHOULDER DYSTOCIA<br />

Risk assessment<br />

Although shoulder dystocia is unpredictable, the labor<br />

admission history and physical examination give the<br />

labor nurse the opportunity to recognize risk factors

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