Shoulder Dystocia - Lippincott Williams & Wilkins

Shoulder Dystocia 19
dystocia. 1,20 Shoulder dystocia results from shoulder
bones impacted against the pubic bone or the sacral
promontory, not against soft tissue; therefore, an episiotomy
does not improve outcomes and is not a necessary
component of shoulder dystocia management. 10,23
One nurse should become the scribe and timekeeper
during a shoulder dystocia. Documentation of
the time the shoulder dystocia started, head-to-body
delivery time, and the time other providers, such
as a nursery resuscitation team, arrived should be
noted by the nurse. 10 The Association of Women’s
Health, Obstetric, and Neonatal Nurses (AWHONN)
recommends a narrative summary that shows a “logical
step-by-step approach to relieving the affected
shoulder.” 20(p8) AWHONN cautions that recorded times
must be accurate. 20
A resuscitation area should be ready for the newborn.
Any resuscitation needed and Apgar scores should be
recorded by nursing. An arm that is limp, unmoving,
and extended with absent reflexes indicates brachial
plexus injury. 20 Any bruising of the newborn and limitations
in arm movement should be recorded in the
nurses’ immediate newborn assessment. The nurse
must communicate these findings to the midwife or
physician and the nursing staff receiving the newborn
for postpartum care.
Once the newborn and mother are settled and
starting postpartum recovery, nurses should complete
documentation and review it for consistency with the
documentation of other providers. If, for example,
the provider’s note says there was no episiotomy
but a second-degree laceration and the nurses’ labor
summary says there was an episiotomy, the documentation
must be reconciled for accuracy. Electronic fetal
monitoring time and comment recordings are another
potential source of discrepancy with the medical
record. 20
POSTPARTUM CARE
In the past, physicians, midwives, and nurses avoided
discussing the shoulder dystocia event or prognosis
for fear of receiving blame for mismanagement and increasing
the risk of a negligence claim. Immediate dialogue
following the shoulder dystocia can maximize
effective communication, which can minimize anger
and frustration for the mother and family. 24,25 Debriefing
offers the opportunity to explain the event to the
mother who may not remember or understand what
occurred. Vandekkieft 26 uses an ABCDE (Advance,
Build, Communicate, Deal, Encourage) approach that
includes Advance preparation (know relevant clinical
information). Build a therapeutic environment by determining
what the patient wants and needs to know
and discuss with supportive family members present.
Communicate effectively by being frank but compassionate
and avoiding medical jargon. The nurse further
deals with patient and family reactions allowing time
for tears, anger, and silence and by encouraging and
validating emotions.
The pediatric staff should discuss medical follow-up
with the family so they can anticipate home physical
therapy and additional physician visits. Mothers who
have had a shoulder dystocia need to be informed that
the risk of shoulder dystocia in subsequent pregnancies
is increased. 19 Nursing staff may link mothers with social
or chaplaincy services for extra support. 27
Following a shoulder dystocia with brachial plexus
injury, the nursing staff should contact the organizational
risk manager. The risk manager will assist the
staff with documentation and communication between
providers, the mother, and family. The risk manager can
lead a review of the dystocia management. The purpose
of the case review is not to assign blame but to determine
what measures were successful and what steps
might be refined or changed. The case review should
be attended by anyone present at the birth. This increases
information about the event and potential improvements
to shoulder dystocia management.
The risk for postpartum hemorrhage increases following
a shoulder dystocia. 1 The fundus should be
palpated to assess uterine contraction at least every
15 minutes during the first postpartum hour. Early
newborn breast-feeding increases endogenous maternal
oxytocin to decrease postpartum bleeding. In the
absence of breast-feeding, vigilant assessment and documentation
of maternal blood loss with exogenous
pitocin use can limit maternal blood loss. Perineal
trauma such as bruising and lacerations is common following
a shoulder dystocia. Ice packs applied to the
perineum immediately postpartum reduce edema and
perineal pain. After 24 hours, pain relief may be more
effective using warm sitz baths.
The newborn with a fractured clavicle or humerus
may wear a cloth sling to splint the injured arm. Recovery
is spontaneous. Approximately 80% of brachial
plexus injuries heal over 3 to 6 months postpartum. 7,8
Newborns who lack spontaneous arm movement or
show no improvement in 4 to 6 weeks postpartum
should be referred to pediatric neurologists for
evaluation. 8 Demonstrating any special arm care and
assessing parental comfort with that care are essential
components of newborn discharge planning. Parents
need to understand any newborn referrals and be able
to schedule the appointments.