Nursing Interventions and Risk Management Strategies

Shoulder Dystocia

Mary Wright, MSN, RNC, CNS Instructor/Maternity Nursing College of Nursing Health Sciences Center University of New Mexico

Definition(s)
Difficulty in the birth of the shoulders (Varney) Vertex delivery in which gentle lateral head traction and normal maternal pushing efforts fail to deliver the shoulders, in the absence of other causes of dystocia or slow progress (Piper & McDonald, 1994) Further progress toward delivery is prevented by impaction of the fetal shoulder within or above the maternal pelvis (Seeds, 1991 quoted by Hall, 1997)

Source: http://www.flash.net/~rustyj/SD.gif

Incidence
.23% to 2.09% of all vaginal births 0.15 1.7 per 100 vaginal births 0.2 6 per 1000 vaginal births Why the range?
Variation in definitions and incomplete documentation (Simpson, 1999)

Recognition of Shoulder Dystocia

Recoil of the head back against the perineum caused by impaction of the anterior shoulder behind the symphysis pubis

Turtle sign

http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm - retrieved on 7/19/05

Vaginal exam rules out other causes of difficulty:

Abdominal or thoracic enlargement of the infant Locked or conjoined twins Uterine constriction ring

Management

Anticipate and have experienced team available

If occurs unexpectedly, call team immediately!

10

Empty bladder prior to start of the birth

11

Assist with maternal positioning that maximizes pelvic size

Lying flat in bed compresses the sacrum

12

Risk Factors for Shoulder Dystocia

Macrosomia
Maternal diabetes Postdates pregnancy

Slow labor progress with adequate contractions Slow descent of presenting part in labor History of previous shoulder dystocia
Tight fit
14

Maternal Complications

Episiotomy
Extended

Lacerations Hematomas Uterine atony Hemorhage Bladder Injury Rectal Injury

16

Fetal Complications

Fractures of clavicle or humerus Brachial plexus injury or other spinal nerve damage
Erbs palsy

Asphyxia
Mental retardation

Death
18

Intervention Maneuvers

Unilateral shoulder dystocia is usually easily dealt with by standard techniques.

(B. Harris, Shoulder dystocia. Clinical Obstetrics and Gynecology, 1984l 27:106)

Source: www.shoulderdystocia.com

20

Gentle pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow, usually resulting in easy delivery of the anterior shoulder. Excessive angulation (>45 degrees) is to be avoided.
(Gabbe, Niebyl, and Simpson, Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)

Source: www.shoulderdystocia.com

21

Increase relative pelvic space:

Fetal shoulder rotation to the oblique

22

Delivery may be facilitated by counterclockwise rotation of the anterior shoulder to the more favorable oblique pelvic diameter, as illustrated here, or, alternative, clockwise rotation of the posterior shoulder. During these maneuvers, explusive efforts should be stopped and the head is never grasped.
(Grabbe, Niebyl, and Simpson, obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986.)

Source: www.shoulderdystocia.com

23

Altering pelvic angles

McRoberts maneuver Hands-knees position (Gaskin maneuver)

24

McRoberts maneuver Sharply flex the mother's thighs on to her abdomen. This will result in cephalic rotation of the pelvis, releasing the shoulder.
FROM: ACOG Practice Patterns No7, October 1997 Source: 192.215.104.222/obgyn/cobra/cobra/ TEXT/PROTOCOL/shoul.htm

25

Sharp ventral rotation of both maternal hips brings the pelvic inlet and outlet into a more vertical alignment, facilitating delivery of the fetal shoulders.
(Gabbe, Niebyl, and Simpson, Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)

26
Source: www.shoulderdystocia.com/ images_6.html

http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm - retrieved on 7/19/05

27

All-Fours Maneuver Gaskin Maneuver

Source: www.thefarm.org/lifestyle/ dystocia.html

28

Decreasing passenger shoulder diameter

Suprapubic pressure Delivery of the posterior arm Woods or Rubins screw maneuver

29

Moderate suprapubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant.
(Gabbe, Niebyl, and Simpson, Obstetrics: Normal and Problem Pregnancies, Churchhill Livingstone, New York, 1986.)

Source: www.shoulderdystocia.com

30

After proper suprapubic pressure, the fetal head will reassume a natural relationship to the shoulders which are in the opposite oblique diameter of the maternal pelvis.
(Gabbe, Niebyl, and Simpson, Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986)

Source: www.shoulderdystocia.com/ images_2.html

31

This type of suprapubic pressure by an assistant may reduce the impaction in some cases.
(B. Harris, Shoulder dystocia. Clinical Obstetrics and Gynecology, 1984; 27:106)

Source: www.shoulderdystocia.com/ images_2.html

32

Best method for suprapubic pressure. This demonstrates the use of the palm of the hand giving lateral pressure.
(C. Pauerstein [ed.], Clinical Obstetrics, Churchill Livingstone, New York, 1987)
Source: www.shoulderdystocia.com/ images_2.html 33

Suprapubic Pressure

http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm - retrieved on 7/19/05

34

Woods corkscrew maneuver Place hand behind the posterior shoulder and rotate 180 towards the anterior shoulder.
FROM: ACOG Practice Patterns No7, October 1997

Source: 192.215.104.222/obgyn/cobra/cobra/ TEXT/PROTOCOL/shoul.htm

35

Wood's screw maneuver. The shoulders must be rotated utilizing pressure on the scapula and clavicle. The head is never rotated.
(B. Harris, Shoulder dystocia. Clinical Obstetrics and Gynecology, 1984; 27:106)

Source: www.shoulderdystocia.com/ images_2.html

36

If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum.
(Figures A and C: reprinted with permission from Gabbe, Niebyl, and Simpson, Obstetrics: Normal and Problem Pregnancies, Churchill Livingstone, New York, 1986. Figure B: reprinted with permission from B. Harris, Shoulder dystocia, Clinical Obstetrics and Gynecology, 1984; 27:106.)

Source: www.shoulderdystocia.com

37

Posterior arm sweep The fetal arm is swept forward along the chest keeping the arm flexed at the elbow, the hand is grasped, and the arm extended along the side of the face.
FROM: ACOG Practice Patterns No7, October 1997 Source: 192.215.104.222/obgyn/cobra/cobra/ TEXT/PROTOCOL/shoul.htm

38

Assisting with Management of Shoulder Dystocia

McRoberts Maneuver Suprapubic Pressure

Ask which direction to apply pressure

Record sequence and timing of events during birth

Accurately label fundal vs. suprapubic pressure in documentation

40

Do not apply fundal pressure

Will impact the shoulders more firmly in the inlet

Exception:
Fundal pressure may be appropriate after the shoulder has been disimpacted to help ease the fetus under the symphysis
(Simpson, 1999)

41

The Hibbard maneuver. Release of the anterior shoulder is initiated by firm pressure against the infant's jaw and neck in a posterior and upward direction. An assistant is poised, ready to apply fundal pressure after proper suprapubic pressure.
(Reprinted with permission from The American College of Obstetricians and Gynecologists. Obstetrics and Gynecology, 1969; 34 [3]:426) Source: www.shoulderdystocia.com

42

As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly toward the rectum. Proper suprapubic pressure is continued.
(Reprinted with permission from The American College of Obstetricians and Gynecologists. Obstetrics and Gynecology, 1969; 34 [3]:427)

Source: www.shoulderdystocia.com

43

Continued fundal and suprapubic pressure results in an upward-inward rotation of the newly freed anterior shoulder and a further descent in a position beneath the pubic symphysis.
(Reprinted with permission from the American College of Obstetricians and Gynecologists, Obstetrics and Gynecology, 1969; 34 [34]: 427.)

Source: www.shoulderdystocia.com

44

As a result of the previous maneuvers, the transverse diameter of the shoulders is reduced. Lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum.
(Reprinted with permission from The American College of Obstetricians and Gynecologists, Obstetrics and Gynecology,1969; 34 [34]: 428.)

Source: www.shoulderdystocia.com

45

With both shoulders freed, delivery is accomplished without the necessity of additional fundal pressure.
(Reprinted with permission from The American College of Obstetricians and Gynecologists, Obstetrics and Gynecology,1969; 34 [34]: 428.)

Source: www.shoulderdystocia.com

46

Nursing Implications

Intrapartum:
Identify antepartum risk factors Identify and report deviations from normal labor progress Prepare for potential shoulder dystocia
Personnel Supplies Empty maternal bladder Maternal positioning for birth

48

Birth:
Observe for turtle sign or obvious resistance of the anterior shoulder Document emergence of head Call for help if not already there Document any additional maneuvers attempted Assist with maternal positioning McRoberts Suprapubic pressure (in direction indicated by provided) Fundal pressure (only upon provider request) All-fours Support mother about bearing down when instructed by provider

49

If vaginal birth is not successful:

Prepare for immediate surgical birth

Continuously monitor fetus during the Zavanelli maneuver until birth

50

A bilateral shoulder dystocia. The posterior shoulder is not in the hollow of the pelvis. This presentation often requires a cephalic replacement.
(C.Pauerstein [ed.], Clinical Obstetrics, Churchill Livingstone, New York, 1987.) Source: www.shoulderdystocia.com

51

Diagram of the first part of the Zavanelli maneuver. If restitution has occurred following expulsion of the head, as in this case, the head is first manually returned to its prerestitution position, full extension in a direct occipitoanterior position.
(E.C. Sandberg. The Zavanelli maneuver: A potentially revolutionary method for the resolution of shoulder dystocia. American Journal of Obstetrics and Gynecology, 185; 152:481)
Source:www.shoulderdystocia.com/ images_6.html

52

Diagram of second part of the Zavanelli maneuver. The head is manually flexed recapitulating, in reverse, the birth of the head by extension. Upward pressure to recapitulate expulsion, in reverse, was not required in this instance.
(E.C. Sandberg. The Zavanelli maneuver: A potentially revolutionary method for the resolution of shoulder dystocia. American Journal of Obstetrics and Gynecology, 185; 152:481)
Source:www.shoulderdystocia.com/ images_6.html

53

Post birth (Maternal)

Assess for
Hematoma Uterine atony Excessive bleeding Bladder injury Rectal injury

Provide explanations to family as needed Document birth events

54

Neonatal
Neonatal resuscitation as needed Assess for broken clavicle Assess for brachial plexus injury

55

Broken Clavicle Management

Minimize pain or discomfort
Immobilize the affected arm

56

Brachial Plexus Injuries

Weakness or total paralysis of muscles innervated by the brachial plexus C5 to C8 and T1 Incidence: 0.5 to 2.0 per 1000 live births
(Mouser, 1997)

57

Normal Delivery Traction

http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm - retrieved on 7/19/05

58

Erbs Palsy
Involves C5 and C6 +/- C7 which results in proximal muscle weakness 90% of brachial plexus injuries
(Mouser, 1997)

59

brachialplexus.wustl.edu/ presentation.html

60

brachialplexus.wustl.edu/ presentation.html

61

www.erbs-palsy-help.com/ erbs-palsy-about.html 62

Assessment Cues
Erbs palsy
Grasp reflex present Moro abnormal

Total plexus palsy

Paralysis extends into hand and grasp reflex is absent
(Mouser, 1997)

63

Traumatic lesions associated with brachial plexus injuries

Fractured clavicle (10%) Fractured humerus (10%) Subluxation of cervical spine (5%) Cervical cord injury (5-10%) Facial palsy (10-20%)
(Mouser, 1997)

64

Brachial Plexus Injury Management

Prevent contractures (PT and/or OT consults)
Immobilize limb gently across abdomen for first week Start passive range of motion exercises at all joints of the limb Use supportive wrist splints Surgery may be necessary if significant functional recovery does not happen by 3 to 4 months of age
(Mouser, 1997)

65

Source: Simpson, K. (1999) Shoulder Dystocia Nursing Interventions and Risk-Management Strategies. MCN, 24(6), 305-311.

Suggestions for Medical Record Documentation

Narrative note summarizing the series of interventions and clinical events

67

Attempt to closely approximate time interval between delivery of fetal head and body

68

Note that nursing assistance with maneuvers was under direction of physician or CNM

69

Correctly note if suprapubic or fundal pressure was used

70

Include times for calls for assistance and when other providers arrived

71

Describe resuscitation efforts and those who attended the newborn

72

Make sure umbilical cord blood gasses become part of the record if they were obtained

73

Include notes of discussions between the physician or CNM and the woman and her family about the shoulder dystocia

74

Public Internet Resources

http://www.shoulder-dystocia-attorneys.com/ Shoulder Dystocia Attorneys is the best resource on the internet for locating a shoulder dystocia attorney for handling your legal needs http://www.shoulderdystocia.com/ Shoulder Dystocia & Brachial Plexus Informational Web Site http://www.erbs-palsy-birth-injuries.com/ We are a network of attorneys who handle Erb's Palsy-Shoulder Dystocia Birth Injury Center in the United States Submit your case for confidential discussion with an attorney.
75

Erbs Palsy Shoulder Dystocia Birth Injury Center. Doctors deliver nearly five thousand children a year who suffer from Brachial Plexus Palsy (Erbs Palsy). In 90 percent of Brachial Plexus Palsy cases, traumatic stretching of the infant's plexus during birth causes the palsy. Estimates suggest that one to two out of every one thousand births result in a brachial plexus injury. Of those, one out of every ten represent an injury serious enough to require some form of treatment. If your child has suffered from this type of injury, medical malpractice may be involved. Contact us here to determine your legal options.

http://www.erbs-palsy-birth-injuries.com/
76

Nursing Risk Management Strategies

(Simpson, 1999)

Be aware of maternal risk factors for shoulder dystocia

78

Keep in mind that shoulder dystocia is unpredictable

79

Be prepared to assist if shoulder dystocia occurs

80

Stay calm and call for help as needed

81

Avoid use of fundal pressure (except as noted)

82

Have a neonatal resuscitation team available at the birth

83

Document the sequence of events with time frames as accurate as possible

84

Provide emotional support to the woman and her family

85

Be prepared for emergency with shoulder dystocia drills

86

Shoulder Dystocia Drills

Component Suggestions
Review article(s)
Shoulder Dystocia: Nursing Interventions and RiskManagement Strategies by Kathleen Rice Simpson in MCN, (November/December 1999) The Nurses Role in the Identification of Risks and Treatment of Shoulder Dystocia by Sharon P. Hall in JOGNN, Vol. 26, No. 1 (January/February 1997)

Shoulder Dystocia Drill Video (AVL103) William Young, MD (ACOG) Written Post-Test Demonstration of correct application of suprapubic pressure and McRoberts Maneuver

Vol. 24, No. 6

88

Source: http://www.gaumard.com/html/hnp20.html 89

References

Hall, S. P. (1997). The nurses role in the identification of risks and treatment of shoulder dystocia. JOGNN, 26(1), 25-32. Lerner, H. (2004). Shoulder Dystocia; Fact, Evidence, and Conclusions. Retrieved from http://www.shoulderdystociainfo.com/resolvedwithout fetal.htm on 7/19/05 at 11:30am. Meenan, A., Gaskin, I., Hunt, P., & Ball, C. A new (old) maneuver for the management of shoulder dystocia. Retrieved from http://www.thefarm.org/midwives/dystocia.html on 10/8/2003 at 10:27am. Mouser, P. (1997). Brachial plexus injuries in the newborn. Retrieved from http://www.shoulderdystocia.com/newborn.html on 10/12/2003 at 09:11pm.

91

Penny, D. S. & Perlis, D. W. (1992). Shoulder dystocia: When to use suprapubic or fundal pressure. MCN, 17(1), 34-36. Piper, D. & McDonald, P. (1994). Management of anticipated and actual shoulder dystocia-interpreting the literature. Journal of Nurse-Midwifery, 39(2-Supplement), 91S-105S. Simpson, K. (1999). Shoulder dystocia nursing interventions and riskmanagement strategies. MCN, 24(6), 305-311. Simpson, K. & Creehan, P. (2001). Perinatal Nursing, Second Edition. Lippincott, Philadelphia. Wright, M. & Higgins, P. (1999). How competent are you (or your staff) with shoulder dystocia. Lifelines, February/March.

92