Shoulder Dystocia: A Comprehensive Guide for Nurses

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted behind the maternal pelvis after the head has delivered, preventing further descent of the fetus. It requires prompt, coordinated interventions to prevent maternal and neonatal complications. Nurses play a vital role in recognizing the condition, assisting during the delivery, and providing post-delivery care.

Definition

Shoulder dystocia is defined as failure to deliver the fetal shoulders spontaneously after the head has emerged during a vaginal delivery, often requiring additional obstetric maneuvers.

Risk Factors

Maternal Factors:

• Maternal obesity.
• Diabetes mellitus (gestational or pre-existing).
• Excessive weight gain during pregnancy.
• Post-term pregnancy.

Fetal Factors:

• Macrosomia (birth weight >4000–4500 g).
• Previous delivery with shoulder dystocia.

Labor and Delivery Factors:

• Prolonged second stage of labor.
• Operative vaginal delivery (e.g., forceps or vacuum extraction).
• Induction or augmentation of labor.

Pathophysiology

During delivery, the fetal anterior shoulder becomes lodged behind the maternal pubic symphysis, or the posterior shoulder is trapped against the sacral promontory. This impedes the descent of the fetus, requiring specific maneuvers to resolve the impaction.

Clinical Presentation

Signs During Delivery:

• Turtle Sign: Retraction of the fetal head against the perineum after delivery of the head.
• Failure of the fetal shoulders to descend despite maternal pushing and standard obstetric maneuvers.

Complications

Neonatal Complications:

• Brachial Plexus Injury: Erb’s palsy or Klumpke’s palsy.
• Clavicle or Humerus Fracture.
• Hypoxia or Acidosis: Due to prolonged delivery.
• Stillbirth: In severe cases.

Maternal Complications:

• Postpartum Hemorrhage: Due to uterine atony or trauma.
• Perineal, vaginal, or cervical lacerations.
• Uterine rupture.
• Emotional trauma or anxiety in subsequent pregnancies.

Management of Shoulder Dystocia

Goals:

• Safely deliver the baby.
• Minimize neonatal and maternal trauma.
• Provide prompt, clear communication among the healthcare team.

Initial Steps:

• Call for Help: Alert additional team members, including obstetricians, pediatricians, and anesthesiologists.
• Positioning: Place the patient in the McRoberts maneuver (hips flexed and abducted against the abdomen) to widen the pelvic outlet.
• Avoid Excessive Traction: Use gentle downward pressure on the fetal head to prevent brachial plexus injury.

Delivery Maneuvers:

McRoberts Maneuver:

• First-line maneuver to flatten the sacrum and increase pelvic dimensions.

Suprapubic Pressure:

• Apply firm, downward pressure above the pubic symphysis to dislodge the fetal anterior shoulder.

Rubin Maneuver:

• Insert a hand into the vagina to rotate the fetal anterior shoulder inward.

Wood’s Corkscrew Maneuver:

• Rotate the posterior shoulder 180° to dislodge the anterior shoulder.

Delivery of the Posterior Arm:

• Reach into the vaginal canal, locate the posterior arm, and gently deliver it to reduce the shoulder diameter.

Gaskin Maneuver:

• Turn the patient onto her hands and knees to create more pelvic space.

Last-Resort Measures:

• Zavanelli Maneuver: Reinsert the fetal head into the vagina and proceed with an emergency cesarean section.
• Symphysiotomy: Surgical division of the pubic symphysis (rarely performed).
• Intentional Fracture of the Clavicle: Performed to reduce the fetal shoulder diameter and facilitate delivery.

Nursing Interventions

During Delivery:

• Assist with Positioning: Support the mother in achieving and maintaining the McRoberts position.
• Apply Suprapubic Pressure: Coordinate with the provider to apply pressure effectively.
• Maintain Communication: Reassure the mother and provide clear instructions to reduce anxiety.

After Delivery:

• Monitor the Neonate: Assess for injuries such as clavicle fractures or brachial plexus injury.
• Monitor for Hypoxia: Watch for signs of neonatal distress.
• Monitor the Mother: Observe for signs of postpartum hemorrhage or lacerations.
• Provide Pain Relief and Emotional Support: Address physical and emotional needs.

Documentation:

• Record all maneuvers performed, the time elapsed, and the condition of the mother and baby.

Post-Delivery Care and Education

Neonatal:

• Monitor for brachial plexus injury or other birth trauma.
• Arrange follow-up for pediatric evaluation and physical therapy if needed.

Maternal:

• Provide postpartum counseling to address emotional impact.
• Educate about future pregnancy risks and the potential need for cesarean delivery.

Prevention of Shoulder Dystocia

Risk Assessment:

• Identify high-risk pregnancies (e.g., macrosomia, diabetes).

Labor Management:

• Avoid unnecessary labor induction or augmentation in high-risk patients.

Consider Elective Cesarean Section:

• For patients with significant risk factors, such as a history of shoulder dystocia with neonatal injury.

Conclusion

Shoulder dystocia is a critical obstetric emergency that requires swift, coordinated action. Nurses are integral to the management team, providing physical support during delivery and emotional support afterward. By employing evidence-based practices and maintaining effective communication, healthcare teams can minimize complications and improve outcomes for both mother and baby.