Shoulder Dystocia - Lippincott Williams & Wilkins

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Shoulder Dystocia 17 more often during pregnancy, every 2 weeks instead of monthly, to provide more frequent nutrition coaching. They many benefit from a referral to a nutritionist. Nutrition counseling for some women may be obtained through the Women, Infants and Children’s Supplemental Nutrition Program (WIC). Obese women may qualify for WIC, for example, by being anemic. Women who are overweight or obese demonstrate periods of excess caloric intake, not necessarily adequate nutrient ingestion. Diabetes in pregnancy Obesity and excessive weight gain are risk factors for gestational diabetes. 13 Pregestational and gestational diabetes complicated by obesity, poor glycemic control, or excessive weight gain increase risk for shoulder dystocia. 1,17,13 All pregnant women should be screened for diabetes during pregnancy by using national standards. 13 The 2005 American College of Obstetricians and Gynecologists standards for obesity management during pregnancy advise consideration of gestational diabetes screening at the first-trimester firstprenatal visit with repeated screening later in pregnancy if the first screen is within a reference range. 13 The prenatal nurse can ensure that these guidelines are integrated into practice and that abnormal screens are followed by 3-hour glucose testing and treatment as needed. Testing, treatment plans, and blood glucose records should be copied into the prenatal record so that all providers can assess progress with glucose control. If diabetes management is provided by a perinatologist or diabetologist outside of the prenatal practice, the nurse can enhance communication between practices by seeing that both practices have copies of laboratory values, visit records, and consultation summaries. These complete records should also be available in the prenatal records that are used for the labor and delivery record. Macrosomia Regular fundal height assessment during prenatal visits documents fetal growth and can be a screen for macrosomia. 17 Estimated fetal weight based on clinical palpation including Leopold’s maneuvers is as accurate as ultrasound estimation of fetal weight 17 ; therefore, nurses should practice their palpation skills and have confidence in their ability to estimate fetal size. The estimated weight of fetuses with fundal heights greater than 40 cm should be measured carefully. Fetal chest circumferences equaling or exceeding fetal head circumferences measured by ultrasound may indicate shoulder dystocia risk. 3 When estimated fetal weight exceeds 5000 g in women without diabetes and 4500 g in women with diabetes, the prenatal care provider needs to determine whether an induction of labor or elective cesarean birth is indicated and whether a plan has been made with the mother for the timing and manner of birth. 1,18 PRIOR SHOULDER DYSTOCIA A previous shoulder dystocia with or without brachial plexus injury should be recorded on the prenatal problem list. 10 A prior shoulder dystocia increases the risk for a subsequent shoulder dystocia (9.8%–16.7%), although most subsequent births do not involve shoulder dystocia. 19 Women who have had a prior shoulder dystocia need careful informed consent on prenatal weight gain, the risk of recurrence, and birth options. 1,10 The prenatal care provider should form a plan for time and place of birth with the mother that is documented in the prenatal record. The nurse can help prepare the mother for scheduled births by teaching about induction of labor or presurgical routines. CHILDBIRTH PREPARATION Nurses who teach childbirth preparation can prepare mothers and their families for the common maneuvers used in shoulder dystocia management without scaring the family with worst-case complications. 10 The childbirth preparation nurse can say, Some large newborns are tight fits through the vagina. The labor and delivery nurses may help you pull your legs back to your chest to help move the pubic bone over the baby’s shoulder. A nurse might also push down just above your pubic bone to nudge the baby’s shoulder under the bone. Sometimes the midwife or doctor might put a hand behind the baby’s back to push it sideways into a large part of the pelvis so the shoulders move down. Mothers can practice McRobert’s maneuver in class by pulling their legs to their chests while sitting on the floor resting against their seated coaches. The childbirth preparation teacher can demonstrate suprapubic pressure on a recumbent mother without using any pressure. INTRAPARTUM NURSING PREVENTION OF SHOULDER DYSTOCIA Risk assessment Although shoulder dystocia is unpredictable, the labor admission history and physical examination give the labor nurse the opportunity to recognize risk factors
18 Journal of Perinatal & Neonatal Nursing/January–March 2008 for shoulder dystocia. Pregravid height, weight, and BMI should be included in the health record. 10 Estimated fetal weight or fundal height should be assessed and recorded at labor admission along with clinical pelvimetry and a determination of clinical adequacy for labor. 10 Although these elements of the physical examination are most often done by the midwife or physician, the labor nurse can remind the birth attendant if items are missing from the admission record. The labor nurse might also advocate for the use of a standard labor admission form or electronic template that contains blank fields for estimated fetal weight, fundal height, and assessment of pelvic adequacy. Blank fields remind clinicians to document these elements of assessment. Fetal position should be palpated and documented as part of the nursing labor admission. Palpation may be difficult if the mother is obese. Location of the fetal heart tones may assist in determining fetal position. Knowing the location of the fetal back will assist the nurse in giving the most effective suprapubic pressure if needed during the birth. Family and environmental preparation Early labor gives the nurse another chance to prepare the family for shoulder dystocia management. The art of prevention nursing is in recognizing the risk factors for shoulder dystocia, being physically and mentally prepared for the emergency, but conveying only optimism and confidence to the parents. The nurse can have the mother and family practice McRobert’s maneuver. The nurse can also assist the mother in moving to her left side or onto all fours if the birth attendant uses these positions during shoulder dystocia maneuvers. 10 The nurse can also use early labor to review shoulder dystocia assistance preferences with the birth attendant. The nurse anticipates if the birth attendant will want suprapubic pressure, changes in the birth bed configuration, or the mother assisted into a left lateral position if a shoulder dystocia occurs. Since even small infants can have a shoulder dystocia, a well-prepared labor nurse will have each birth room ready for this emergency. Resuscitation equipment should be in place and working. A stool for nurses to stand on during suprapubic pressure should be near the bed. Although there are conflicting reports of the relationship of prolonged labors and shoulder dystocia, 1 protracted labors are risk factors for a number of maternal and fetal morbidities and should be managed attentively. Extra caution is warranted when preparing for a forceps or vacuum-assisted birth especially when multiple risk factors for shoulder dystocia and brachial plexus injury coexist. 19 Instrumental births are associated with shoulder dystocia. 1,19 NURSES’ ACTIONS DURING A SHOULDER DYSTOCIA Although the midwife or physician will perform the maneuvers to dislodge an impacted shoulder, the labor nurses provide essential support measures. To act efficiently when seconds matter, nurses must thoroughly understand the safety measures employed during a shoulder dystocia. Shoulder dystocia drills done with the regularity of fire or code blue drills provide nursing with the practice necessary to act automatically during a dystocia. 20 The midwife or physician will request that the nurse summon additional help. Other personnel might include additional nursing staff, a resuscitation team from the nursery or respiratory therapy, or another midwife or physician. If the mother is semisitting for the birth, nurses will be expected to assist the mother into McRobert’s position by flexing the maternal thighs toward the maternal chest. McRobert’s maneuver slides the pubic bone over the anterior shoulder. 20 It is not useful as shoulder dystocia prophylaxis and should be employed only once a dystocia is evident. 21 If McRobert’s maneuver does not dislodge the dystocia, the birth attendant will request suprapubic pressure. Optimal suprapubic pressure is accomplished by placing a clenched fist or the heel of the hand behind the anterior shoulder and pushing the shoulder toward the fetal chest and down. 20 This pushes the shoulder into the larger oblique diameter of the pelvis and presses it under the suprapubic bone. Adequate force must accompany suprapubic pressure. For the most effective strength, the nurse may place the second hand on top of the clenched fist and with both elbows straightened lean into the maternal abdomen. Short nurses may need to stand on a stool to have sufficient height and reach for the maneuver. If McRobert’s maneuver and suprapubic pressure do not release the shoulder, the birth attendant may use Rubin’s maneuver, Wood’s screw maneuver, or several other techniques. 1,10,20,22 There is no correct order or superior order for maneuver use; however, fundal pressure should be avoided. 1,20 Fundal pressure is steady pressure exerted by one hand pushing on the uterine fundus, assisting movement of the fetus down the birth canal. It may cause or further aggravate a shoulder dystocia. 1,20 The perinatal nurse has the right to refuse an order to do fundal pressure during a shoulder
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Shoulder Dystocia - Lippincott Williams & Wilkins

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