How Competent Are You (or Your Staff) with Shoulder Dystocia?

Shoulder dvstocia-when the fetal head retracts or recoils against the maternal perineum ( “ttirtle sign ”)

and external rotation is not accomplished-occws in approximately 1 of every 200 deliveries. It ’.s often

diagnosed after the emergence of the fetal head when deliverv is prevented bji impaction of the fetal shoul-

ders within or above the maternal pelvis. When it occur.^, shoulder dystocia is an ohtetric emergency.

Although there are identifiable risk factors for shoulder dystocia, 89 percent occurs in birth weight infants below 4000 g. When shoulder dystocia occurs, it’s an obstetric emergency requiring immediate recog- nition and prompt treatment. With shoulder dystocia, there is difficulty in delivering the anterior shoulder from underneath the symphysis. Time becomes critical. Benedetti and Gabbe (1995) reported that fetal acid-base balance starts to deteriorate after 5 minutes in a previously non-compromised fetus. When this situation exists, every obstetric provider needs to be prepared to manage shoulder dystocia, and the intrapartum nurse needs to respond immediately with appropriate assistance. The goal of care is optimal maternal and fetal outcomes.

Mary Wright, MSN, RNC, is an instructor of Parent-Child Nursing at The University of New Mexico, Health Sciences Center College of Nursing in Albuquerque, NM. Patricia Grant Higgins, PhD, RN, is also a professor of Parent-Child Nursing at The University of New Mexico, Health Sciences Center College of Nursing in Albuquerque, NM.

February/March 1999 A W H O N N L i f e l i n e s 35

Preparing for Shoulder Dystocia Intrapartum nurses need to be able to recognize and report associated risk factors for shoulder dystocia, such as macrosomia, protracted deceleration phase, and arrested descent in labor. Additionally, labor and deliv- ery nurses must know two of the most important meth- ods of assistance during a shoulder dystocia emergency (for good illustrations of these methods, see “The Nurse’s Role in the Identification of Risks and Treatment of Shoulder Dystocia” (Hall, 1997).

McRoberts Maneuver Applying Suprapubic Pressure The McRoberts maneuver is best known and most com- monly used (Piper & McDonald, 1994). It involves sharp hyperflexion of the mother’s legs against the abdomen, which straightens the sacrum in relation to the lumbar spine with cephalad rotation of the symph- ysis pubis. This results in a decreased angle of inclina- tion of the symphysis compared with the lithotomy position. This maneuver doesn’t change the dimensions of the true pelvis but the superior rotation of the sym- physis may allow expanded room for the anterior shoul- der and acts to disimpact the anterior fetal shoulder from behind the symphysis.

Assessing Risk An increased risk of shoulder dystocia is found with (Penney & Perlis, 1992):

Intraparturn nurses need to be- abk to recognize and report associated risk factors for shoul- der dystocia, such as macrosomia protracted deceleration phase, and arrested descent in labor.

Suprapubic pressure may then be applied using one of two techniques: the Rubin or the more popular Mazzanti technique. The Rubin technique requires the nurse to apply pressure posteriorly against the anterior shoulder to move the shoulder laterally into an oblique position (Hall, 1997). In the Mazzanti technique, the nurse applies direct pressure, posteriorly and laterally, above the symphysis pubis (Hall, 1997). This dislodges the anterior shoulder and rotates it underneath the sym- physis. The Mazzanti technique is the one most often used in shoulder dystocia.

By being prepared to implement the McRoberts maneuver and suprapubic pressure, intrapartum nurses can provide calm support and physical assistance to

women, their fetus, and the physician or midwife dealing with the dystocia (Hall, 1997). One way of preparing for shoulder dystocia is a training drill for intrapartum nurses on a regular basis. The training drill facilitates preparation

Prolonged second stage labor (more than 2 hours in primigravidae and more than 1 hour in multigravidae)

Macrosomia (infant larger than 4000 g)

Midpelvic instrumental delivery

Other risk factors include previous macrosomic infant, prolonged gestation, prolonged deceleration phase, prolonged second stage, and arrested descent. Piper and McDonald (1 994) identified addi- tional risks that may influence the frequency of shoulder dystocia: short maternal stature, abnormal pelvic morphology such as the platypelloid shape, and generally reduced pelvic size. The most consistent risk factors for shoulder dystocia are newborns weighing more than 4000 g and maternal diabetes.

The risk, for increased birth weight, is clearly higher in women who have diabetes. Acker, Sachs, and Friedman (1985) observed a 1 O-percent rate of shoulder dystocia in newborns weighing between 4000 and 4499 g. Also, they reported a 22.6-percent rate of shoulder dystocia in newborns weighing over 4500 g. In diabetes, these rates were 23.1 and 50 percent, respectively.

Despite identified risk factors, shoulder dystocia usually occurs without warning. Morrison, Sanders, Magann, and Wiser (1 992) reported that 89 percent of shoulder dystocia occurred in infants weighing below 4000 g at birth. Piper and McDonald (1 994) describe macrosomia as an “anthropometric disproportion in an individual fetus, resulting in the body growing significantly larger than the head and thus may occur at any weight”. However, only 11 percent of cases of shoulder dystocia occurred when risk fac- tors were present.

by reviewing and practicingthe-steps necessary to perform the McRoberts maneuver and suprapubic pressure. It also includes a review of the physiology underlying shoulder dystocia to assist the intrapartum nurses in understand- ing how the McRoberts maneuver and suprapubic pressure facilitate birth when shoulder dystocia occurs. This training drill can be used to assist in developing competency for the intra- partum nursing staff.

Case Example The nurses on the labor and delivery unit at Presbyterian Hospital in Albuquerque, New Mexico, identified the need to learn how to assist care providers when shoulder dystocia is diagnosed. The nursing staff request- ed a shoulder dystocia competency be developed.

The recent JOGNN article by Hall (1 997) entitled, “The Nurse’s Role in the Identification of Risks and Treatment of Shoulder Dystocia,” was identified and used as part of this com- petency. In the article, Hall summa- rized the risk factors, management, and nursing implications of shoulder

36 A W H O N N L i f e l i n e s Volume 3, issue 1

dystocia. This article provided the necessary information regarding the underlying physiology of shoulder dystocia. It also described and illus- trated how to perform both the McRoberts maneuver and suprapu- bic pressure.

on the labor and delivery unit at Presbyterian Hospital developed a competency packet, which includes:

/OGNN article, “The Nurse’s Role in the Identification of Risks and Treatment of Shoulder Dystocia” (Hall, 1997) a written post-test on risk identifi- cation for shoulder dystocia based on this article (see “Assessing Competency)

positioning for the McRoberts maneuver correct application of suprapubic pressure

A clinical nurse specialist (CNS)

skills demonstration of the correct

The CNS pilot-tested the compe- tency with expert labor and delivery staff who had already been designat- ed as the educator resource nurses for the unit. Each shift had two edu- cator resource nurses assigned to assist with nursing education needs under the supervision of the CNS. They distributed the shoulder dysto- cia competency packets to the nurs- ing staff. Each nurse read the article and completed the written post-test, which covered risk factors for shoul- der dystocia, recognition of shoulder dystocia, and recognition that docu- mentation of details related to the management of shoulder dystocia is a nursing responsibility. The CNS recommended that the post-test emphasize how and what to docu- ment. This could be accomplished by the inclusion of a case study of shoulder dystocia with each nurse completing a sample documentation of the case study.

After passing the post-test, each nurse then completed a demonstra- tion of the McRoberts maneuver. A nurse partner played the role of the mother with shoulder dystocia by positioning herself in stirrups in a birthing bed. The nurse demonstrat- ing McRoberts maneuver then had to lower the head of the bed, remove legs from the stirrups, and demon- strate hyperflexion of the legs against the abdomen. The hyperflexion of the legs needed to match the illustra-

Assessing Competency: Nurses’ Role in Identifying Risks and Treating Shoulder Dystocia

Part 1. After reading the designated materials, complete the following post-test.

Part 2. Requires return demonstration and validation by designated personnel.

Part I: Identifying Risks and Treatment of Shoulder Dystocia

I. Shoulder dystocia may occur in the absence of any identified risk factors. a. - True b. - False

a. b.

2. List three risk factors for shoulder dystocia.

C.

3. After delivery of the fetal head with shoulder dystocia, a

4. After implementation of the McRoberts maneuver, the nurse

deterioration in fetal acid-base occurs within minutes.

applies fundal pressure to facilitate delivery of the fetal shoulder. a. - True b. ___ False

5. Shoulder dystocia is recognized during the delivery when: a. b.

6. Documentation of details related to the occurrence and management of dystocia in a delivery is the responsibility of the obstetrician only. a. - True b. - False

be an accurate predictor of macrosomia. a. - True b. - False

7. Measure of estimated fetal weight by ultrasound is shown to

Part 2 Skills Demonstration for Shoulder Dystocia

(legs are removed from stirrups/footrests; head of bed is lowered; maternal knees are hyperflexed against the abdomen by assistants on each side).

1. Demonstrates correct positioning for the McRoberts maneuver

Yes No

2. Demonstrates correct application of suprapubic pressure (the nurse applies downward pressure above the symphysis pubis; pressure is applied using fingers, palms, or fist).

Yes No

Date: Validator:

February/March 7999 A W H O N N L i f e l i n e s 37

By being prepared to implemen, the McRoberts maneuver and suprapubic pressure, intra- parturn nurses can provide cah support and physical assistance to women, their fetus, and the physician or midwife dealing with the dystocia

tion in the Hall article. Suprapubic pressure was also demonstrated on the nurse partner by locating the suprapubic bone and then placing the hands in the cor- rect position. Again, the positioning needed to match the illustrations in the Hall article. No pressure was used; however, the correct positioning of the hands was evaluated. To make the skills portion more realist, the education resource nurses purchased an abdominal pal- pation model for future skill demonstration sessions. The model includes a fetal model; therefore, demon- stration of correct positioning along with some pressure could be applied, making the simulation experience more realistic. Use of a model allowed for developing and differentiating the differences between the Rubin and the Mazzanti techniques.

ed by the educator resource nurse who then signed off that the skills were performed correctly. These return demonstrations occurred during quiet periods at work, thereby saving extra trips to the hospital. The less-expe- rienced staff appreciated learning from their more-expe- rienced peers. + References

The skill demonstrations were observed and evaluat-

Acker, D. B., Sachs, B. P., & Friedman, E. A. (1985). Risk fac- tors for shoulder dystocia. Obstetrics and Gynecology,

Barone, P., & Perlis, D. W. (1992). More methods for manag- ing shoulder dystocia. Maternal-Child Care Nursing,

66(6), 762-768.

17(4), 276-277.

Benedetti, T. J., & Gabbe, S. G. (1978). Shoulder dystocia: A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstetrics and Gynecology, 52(5), 526-529.

Hall, S. P. (1997). The nurse's role in the identification o f risks and treatment of shoulder dystocia. JOGNN, 26( I ) , 25-32.

Penny, D. S., & Perlis, D. W. (1992). Shoulder dystocia: When to use suprapubic or fundal pressure. Maternal-Child Care Nursing, 17(1), 34-36.

Piper, D. M., & McDonald, P. (1994). Management of antici- pated and actual shoulder dystocia: Interpreting the litera- ture. Journal of Nurse-Midwifery, 39(2), Supplement, 91 5-1055.

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