Problems with Passageway

and Pelvic Proportion -

SHOULDER DYSTOCIA
Sheejay L. Saradi
BSN 2B
Problems with Passageway
and Pelvic Proportion -
CEPHALOPELVIC
DISPROPORTION
Khadija N. Ammad
BSN 2B
 CEPHALOPELVIC DISPROPORTION
(prepared by: Khadija N. Ammad)

 Cephalopelvic disproportion implies disproportion between the head of the baby and
the mother’s pelvis.
 Complications can occur if the fetal head is too large to pass through the pelvis and
birth canal.
 CPD is one of the most common causes of different complications in labor, which
causes prolonged labor, fetal distress, and delayed second stage.
 CPD is very frequently diagnosed and is a very common indication of cesarean
sections (especially when there is failure to progress in labor).

Causes of Cephalopelvic Disproportion (CPD):

 Increased Fetal Weight

 Very large baby due to hereditary factors; a baby whose weight is estimated to
be above 5kg or 10lbs
 Postmature baby
 Women with diabetes tend to have large babies.
 Each succeeding baby of a multipara tends to be larger and heavier.
 Abnormal Fetal Position
 Occipito-posterior position
 Brow presentation
 Face presentation
 Problems with the pelvis
 Small or narrow pelvis
 Abnormal shape of the pelvis due to diseases such as rickets, osteomalcia, and
tuberculosis
 Abnormal shape of the pelvis due to previous accidents
 Tumors of the bones
 Childhood poliomyelitis
 Congenital dislocation of the hips
 Congenital deformity of the sacrum or coocyx
 Problems with the genital tract
 Tumors like fibroids obstructing the birth passage
 Congenital rigidity of the cervix
 Scarring of the cervix due to previous operations
 Congenital vaginal septum

Signs and symptoms:

 Prolonged labor
  Fetal distress
 Large fundal height
 A higher than average volume of amniotic fluid (polyhydramnios)

Complications:

For mother:
 Labor progression problems
 Uterine rupture
 Bleeding post-delivery
For Child:
 Interruption to the oxygen supply
 Injury to the head, neck and shoulder area due to misuse of instruments
This potentially results to: Hemorrhaging, cerebral palsy, developmental delays, seizure
disorders, paralysis

Diagnosis of CPD:
 A “trial of labor” should always be given to all women with average sized pelvis and
an average sized fetus even if the pelvis appears too small for the baby.
 Methods of estimating the size of the pelvis:
1. Clinical pelvimetry
2. Radiological pelvimetry
3. Ultrasound

Management: Cesarean section

Nursing Interventions:

 Monitor heart sounds and uterine contractions continuously, if possible, during trial
labor – monitoring contractions will help identify some risk factors; the fetus is to be
monitored to determine presence of FHR or any signs of hypoxia.
 Monitor VS q4h or as ordered by the doctor – it will provide baseline for comparison
of any changes with the patient within intervals.
 Advise patient to sit and squat periodically – increases the outlet diameter and may
aid in fetal descent.
 Monitor mother and fetus for any signs of distress – psychological factors may affect
the labor process.
 Encourage patient to drink fluids – to maintain hydration.
 Instruct methods to conserve energy
 Convey confidence in mother’s ability to cope with current situation

References:

kardzmed.com

gynaeonline.com

americanpregnant.org
 SHOULDER DYSTOCIA
(prepared by Sheejay L. Saradi)

 The arrest of spontaneous delivery of shoulders secondary to impaction of the anterior

shoulder against the symphysis pubis.
 A birth problem that is increasing in incidence because weight and therefore the size
of newborn is increasing.
 The problem occurs at the second stage of labor, when the fetal head is born but the
shoulders are too broad to enter or to be born.
 First discovered in 1730

Complications:
Maternal
 Postpartum hemorrhage – major maternal risk
 3rd/4th perineal lacerations
 Uterine rupture
 Vulvar and vaginal hematomas
 Puerperal infections, especially with intrauterine manipulation.

Fetal
 Asphyxia – most immediate danger
 Brachial plexus injury
 Fractured clavicle/humerus
 Intracranial hemorrhage
 Torticollis

Pathophysiology and Etiology

1. Prepregnancy risk factors:

o Maternal birth weight
o Prior shoulder dystocia
o Prior macrosomic infant
o Preexisting maternal diabetes
o Obesity
o Multiparity
o Advanced maternal age(older than age 35)
2. Prepartum factors:
o Glucose intolerance of pregnancy
o Excessive weight gain
 o Diagnosed or suspected fetal macrosomia.
o Abnormal pelvic size or shape
o Postdatism
o Multiparity
o Male fetus
3. Intrapartum factors:
o Abnormal labor progress (prolonged 2nd stage of labor)
o Operative vaginal delivery (use of vacuum, forceps or both)
o Pronounced fetal head molding

Diagnosis
 2nd stage of labor is prolonged
 Arrest of descent
 When the head appears on the perineum (crowning)
 When the head retracts instead of protruding with each contraction (Turtle sign)

There is poor predictability of shoulder dystocia which is caused by a dynamic/evolving

mechanical event. Even though with its poor predictability, the shoulder dystocia incidence
can be reduced by diagnosing and treating gestational diabetes.

Management
 Identification by evidence of the Turtle sign.
 Prevention is the key because of its poor precitability.
a. Early identification and treatment of gestational diabetes mellitus.
b. Good diabetic control for patients with insulin-dependent DM.
c. Recorded estimated fetal weight measurements.
d. Prevent postdate deliveries.
e. Prevent abnormal progression of labor.
f. Prevent excessive maternal weight gain.
 Most effective treatment is:
a. Recognizing that delivery of shoulders wil be difficult.
b. Avoiding excessive fundal pressure or downward traction on fetal head.
 Anticipation with plan of action
a. Utilize available personnel.
b. Step stool at the bedside to allow for appropriate suprapubic pressure.
c. Have resuscitaion equipment and personnel readily available.
 Nursing procedures:
a. McRobert’s maneuver
b. Suprapubic pressure
 Health care provider procedures:
a. Rotation of the anterior shoulder to oblique position.
b. Delivery of the posterior arm.
c. Rubin’s maneuver
d. Wood’s screw maneuver
e. Zavanelli’s maneuver

Nursing Assessment
1. Continuously evaluate labor curve elevating cervical dilation, effacement and fetal
descent.
 2. Observe for Turtle Sign, notify primary care provider if shoulder dystocia is
suspected.
3. Continue fetal monitoring after the fetal head is delivered. Keep provider aware of
time frame.

Nursing Diagnoses Nursing Interventions

 Fear and Anxiety r/t  Give brief explanation to the woman and her support
inability to deliver person about procedures being performed to facilitate
and fetus. understanding of situation.
 Limit numbers of personnel in the room during delivery if
shoulder dystocia occur.
 Keep voice calm and situation in labor and delivery room
controlled.
 Acute Pain  Ensure appropriate anesthesia/analgesia available for
associated with woman.
operative and  Provide woman with appropriate anesthesia/analgesia after
instrumental delivery to maintain “acceptable” level of pain.
procedures or
uterine
manipulation
 Risk for Injury to  Do not perform fundal pressure.
fetus or mother  Perform critical assessment of neonate after delivery –
secondary to moro reflex, cord gases, range of motion.
instrumented
 Monitor labor curve, and notify primary care provider if
delivery.
the normal labor curve is not met.

NURSING ALERT FUNDAL PRESSURE is never applied for the treatment of shoulder
dystocia. It can lead to further IMPACTION OF THE ANTERIOR SHOULDER,
IRREVERSIBLE BRACHIAL PLEXUS INJURY, FETAL NEUROLOGUUC INJURY
SECONDARY TO HYPOXIA, AND EVEN FETAL DEATH.

References:

Maternal and Child Health Nursing: Care of the Childbearing & Childbeaaring Family/ Adele
Pilliteri, - 7th edition

Lippincott Manual of Nursing Practice, 8th edition

Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales/ Marilyn E. Doenges,
Mary Frances Moorhouse, Alice C. Murr, - 12th edition

en.m.wikipedia.org

emedicine.medscape.org/article/1602970-overview#a1