Shoulder Dystocia - Awhonn-nm.org

Shoulder Dystocia
Nursing Interventions and
Risk Management StrategiesВ©
Mary Wright, MSN, RNC, CNS
Instructor/Maternity Nursing
College of Nursing
Health Sciences Center
University of New Mexico
Definition(s)
В„
Difficulty in the birth of the shoulders (Varney)
В„
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)
В„
Further progress toward delivery is prevented by
impaction of the fetal shoulder within or above the
maternal pelvis (Seeds, 1991 quoted by Hall, 1997)
2
Source: http://www.flash.net/~rustyj/SD.gif
3
Incidence
В„
.23% to 2.09% of all vaginal births
В„
0.15 вЂ“ 1.7 per 100 vaginal births
В„
0.2 вЂ“ 6 per 1000 vaginal births
В„
Why the range?
В„
Variation in definitions and incomplete documentation
(Simpson, 1999)
4
Recognition of
Shoulder Dystocia
Recoil of the head back against the
perineum caused by impaction of
the anterior shoulder behind the
symphysis pubis
6
вЂњTurtle signвЂќ
http://www.shoulderdystociainfo.com/resolvedwithoutfetal.htm - retrieved on 7/19/05
7
Vaginal exam rules out other causes of
difficulty:
В„
Abdominal or thoracic enlargement of the infant
В„
Locked or conjoined twins
В„
Uterine constriction ring
8
Management
Anticipate and have experienced
team available
В„
If occurs unexpectedly, call team immediately!
10
Empty bladder prior to start of the birth
11
Assist with maternal positioning that
maximizes pelvic size
В„
Lying flat in bed compresses the sacrum
12
Risk Factors for
Shoulder Dystocia
В„
Macrosomia
В„
В„
Maternal diabetes
Postdates pregnancy
В„
Slow labor progress with adequate
contractions
В„
Slow descent of presenting part in labor
В„
History of previous shoulder dystocia
В„
вЂњTight fitвЂќ
14
Maternal
Complications
В„
Episiotomy
В„
Extended
В„
Lacerations
В„
Hematomas
В„
Uterine atony
В„
Hemorhage
В„
Bladder Injury
В„
Rectal Injury
16
Fetal Complications
В„
Fractures of clavicle or humerus
В„
Brachial plexus injury or other spinal
nerve damage
В„
В„
Asphyxia
В„
В„
ErbвЂ™s palsy
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:
В„
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
В„
McRoberts maneuver
В„
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
вЂњGaskin ManeuverвЂќ
Source: www.thefarm.org/lifestyle/ dystocia.html
28
В„
Decreasing passenger shoulder diameter
В„
Suprapubic pressure
В„
Delivery of the posterior arm
В„
WoodsвЂ™ or RubinвЂ™s 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 180В° 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
В„
McRoberts Maneuver
В„
Suprapubic Pressure
В„
В„
Ask which direction to apply pressure
Record sequence and timing of
events during birth
В„
Accurately label fundal vs. suprapubic pressure in
documentation
40
В„
Do not apply fundal pressure
В„
Will impact the shoulders more firmly in the inlet
Exception:
В„
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:
В„
Identify antepartum risk factors
В„
Identify and report deviations from normal labor
progress
В„
Prepare for potential shoulder dystocia
В„
В„
В„
В„
Personnel
Supplies
Empty maternal bladder
Maternal positioning for birth
48
Birth:
В„
Observe for вЂњturtle signвЂќ or obvious resistance of the anterior
shoulder
В„
Document emergence of head
В„
Call for help if not already there
В„
Document any additional maneuvers attempted
В„
Assist with maternal positioning
В„ McRoberts
В„ Suprapubic pressure (in direction indicated by provided)
В„ Fundal pressure (only upon provider request)
В„ All-fours
В„
Support mother about bearing down when instructed by provider
49
If vaginal birth is not successful:
В„
Prepare for immediate surgical birth
В„
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)
В„
Assess for
В„
В„
В„
В„
В„
Hematoma
Uterine atony
Excessive bleeding
Bladder injury
Rectal injury
В„
Provide explanations to family as needed
В„
Document birth events
54
В„
Neonatal
В„
Neonatal resuscitation as needed
В„
Assess for broken clavicle
В„
Assess for brachial plexus injury
55
Broken Clavicle Management
В„
Minimize pain or discomfort
В„ Immobilize
the affected arm
56
Brachial Plexus Injuries
В„
Weakness or total paralysis of muscles
innervated by the brachial plexus C5 to C8
and T1
В„
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
ErbвЂ™s Palsy
В„
Involves C5 and C6 +/- C7 which results
in proximal muscle weakness
В„
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
В„
В„
ErbвЂ™s palsy
В„
Grasp reflex present
В„
Moro abnormal
Total plexus palsy
В„
Paralysis extends into hand and grasp reflex is
absent
(Mouser, 1997)
63
Traumatic lesions associated with brachial
plexus injuries
В„
Fractured clavicle (10%)
В„
Fractured humerus (10%)
В„
Subluxation of cervical spine (5%)
В„
Cervical cord injury (5-10%)
В„
Facial palsy (10-20%)
(Mouser, 1997)
64
Brachial Plexus Injury Management
В„
Prevent contractures (PT and/or OT consults)
В„
Immobilize limb gently across abdomen for first week
В„
Start passive range of motion exercises at all joints of the
limb
В„
Use supportive wrist splints
В„
Surgery may be necessary if significant functional
recovery does not happen by 3 to 4 months of age
(Mouser, 1997)
65
Suggestions for
Medical Record
Documentation
Source: Simpson, K. (1999) Shoulder Dystocia Nursing
Interventions and Risk-Management Strategies. MCN,
24(6), 305-311.
В„
Narrative note summarizing the series of
interventions and clinical events
67
В„
Attempt to closely approximate time
interval between delivery of fetal head and
body
68
В„
Note that nursing assistance with
maneuvers was under direction of
physician or CNM
69
В„
Correctly note if suprapubic or fundal
pressure was used
70
В„
Include times for calls for assistance and
when other providers arrived
71
В„
Describe resuscitation efforts and those
who attended the newborn
72
В„
Make sure umbilical cord blood gasses
become part of the record if they were
obtained
73
В„
Include notes of discussions between the
physician or CNM and the woman and her
family about the shoulder dystocia
74
Public Internet Resources
В„
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
В„
http://www.shoulderdystocia.com/
Shoulder Dystocia & Brachial Plexus Informational Web Site
В„
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)
В„ Be
aware of maternal risk factors
for shoulder dystocia
78
В„ Keep
in mind that shoulder
dystocia is unpredictable
79
В„ Be
prepared to assist if shoulder
dystocia occurs
80
В„ Stay
calm and call for help as
needed
81
В„ Avoid
use of fundal pressure
(except as noted)
82
В„ Have
a neonatal resuscitation
team available at the birth
83
В„ Document
the sequence of events
with time frames as accurate as
possible
84
В„ Provide
emotional support to the
woman and her family
85
В„ Be
prepared for emergency
with вЂњshoulder dystocia drillsвЂќ
86
Shoulder Dystocia
Drills
Component Suggestions
В„
Review article(s)
В„
Shoulder Dystocia: Nursing
Interventions and RiskManagement Strategies by
Kathleen Rice Simpson in MCN,
Vol. 24, No. 6
В„
Shoulder Dystocia Drill Video
(AVL103) вЂ“ William Young, MD
(ACOG)
В„
Written Post-Test
В„
Demonstration of correct
application of suprapubic
pressure and McRoberts
Maneuver
(November/December 1999)
В„
The NurseвЂ™s Role in the
Identification of Risks and
Treatment of Shoulder Dystocia
by Sharon P. Hall in JOGNN, Vol.
26, No. 1 (January/February 1997)
88
Source: http://www.gaumard.com/html/hnp20.html
89
References
В„
Hall, S. P. (1997). The nurseвЂ™s role in the identification of risks
and treatment of shoulder dystocia. JOGNN, 26(1), 25-32.
В„
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.
В„
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.
В„
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
В„
Penny, D. S. & Perlis, D. W. (1992). Shoulder dystocia: When to use
suprapubic or fundal pressure. MCN, 17(1), 34-36.
В„
Piper, D. & McDonald, P. (1994). Management of anticipated and actual
shoulder dystocia-interpreting the literature. Journal of Nurse-Midwifery,
39(2-Supplement), 91S-105S.
В„
Simpson, K. (1999). Shoulder dystocia nursing interventions and riskmanagement strategies. MCN, 24(6), 305-311.
В„
Simpson, K. & Creehan, P. (2001). Perinatal Nursing, Second Edition.
Lippincott, Philadelphia.
В„
Wright, M. & Higgins, P. (1999). How competent are you (or your staff)
with shoulder dystocia. Lifelines, February/March.
92

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