Shoulder dystocia

[mormor]

Hi All!

I have been doing a lot of reading about shoulder dystocia but have yet (knock on wood) to assist in a dystocia delivery. I would be very interested in hearing about such an experience, what worked/didn't work, what the most critical issues were and how they were handled. Do protocols differ greatly between hospitals or physicians?I so much want to be prepared as shoulder dystocia is often so unpredictable! Thank you!

[johwiklundRN]

The McRoberts maneuver is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled. The technique is effective in about 42% of cases

Rubin II or posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the lady parts

Woods' screw maneuver which leads to turning the anterior shoulder to the posterior and vice versa (somewhat the opposite of Rubin II maneuver)

Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled.

Gaskin maneuver, named after Certified Professional Midwife, Ina May Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.

Zavanelli's maneuver, which involves pushing the fetal head back in with performing a cesarean section, or internal cephalic replacement followed by Cesarean section

maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.

I have also heard of skilled Midwife intentionally manually fracturing the baby's clavicle to facilitate shoulder dystocia.

I would presume that the conservative methodology would involve surgical intervention, but to skilled hands belong many alternatives.

[MKS8806]

At our hospital, we have small step stools that are stored in every labor room. If we know that the mom has any risk factors that would put her at risk for shoulder dystocia, we get the stool out in anticipation. This just allows the nurse to get a little higher to apply that suprapubic pressure. Then we also do the McRoberts maneuver.

I've been in on some mild dystocias that were delivered with these methods. I haven't had one that we had to implement the others listed (knock on wood as well ), but I have heard of some at my facility. We have had some clavicles fractured, but not intentionally. Can be a scary situation though!

[miss81, BSN, RN]

The McRoberts maneuver is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled. The technique is effective in about 42% of cases

Rubin II or posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the lady parts

Woods' screw maneuver which leads to turning the anterior shoulder to the posterior and vice versa (somewhat the opposite of Rubin II maneuver)

Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled.

Gaskin maneuver, named after Certified Professional Midwife, Ina May Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.

Zavanelli's maneuver, which involves pushing the fetal head back in with performing a cesarean section, or internal cephalic replacement followed by Cesarean section

maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.

I have also heard of skilled Midwife intentionally manually fracturing the baby's clavicle to facilitate shoulder dystocia.

I would presume that the conservative methodology would involve surgical intervention, but to skilled hands belong many alternatives.

Stole my answer! hahaha! Great one at that... Our educator just did a great presentation on these techniques!

[mormor]

Thank you all! Very helpful!

[HeartsOpenWide, RN]

McRoberts and superpubic pressure. You press the shoulder in the direction depending on where the head is rotating. The docs tell us which way to push by looking/feeling the fontenells and sutures. Essentially you are trying to push the babys shoulder inwards from behind and pop the shoulder under the pubic bone. We have stools for the nurses to stand on in all of our rooms. One thing you NEVER do is fundal pressure.

[johwiklundRN]

Provided the mother does not have an epidural, and the OB or Midwife does't object to women changing position while giving birth, I have personally seen great results with the Gaskin Maneuver. Mothers deliver their babies on the hands and knees arching their back with pushes. Gravity is working with you

[klone, MSN, RN]

We have step stools too, but as a not large nurse (5'5"), I find it easier to just jump onto the bed when I have to do supra-pubic pressure. You really have to just jam your fist in there from above, getting all your weight into it. Don't forget to yank the knees back.

[NurseNora, BSN, RN]

Always be ready for a shoulder dystocia; most women with risk factors deliver without dystocia, while some women without risk factors do develop dystocia. Before each delivery be sure the standing stool is handy. Make it a part of your usual check to be sure you're ready any emergency.

Check the time when the head is delivered on all deliveries. That way, you know how long it takes for the body to deliver. Most of the time you don't need this information, but if the shoulder does get stuck, time slows down or speeds up. It's really hard to give a good estimate if you haven't checked.

Let the doc know how long it's been because time has moved into a different dimension for him too. He may realize he's been doing one procedure long enoug and that it's time to try something else.

Call for help. There is a lot to do and think about in a very short period of time.

Let the charge nurse know there's a problem. Call Peds if you don't already have them there. In large hospitals that may just be a call to the nursery. In a small rural hospital it may involve getting the Peds doc in from home. Be sure anesthesia knows and is available. Same with the OR crew.

[klone, MSN, RN]

Check the time when the head is delivered on all deliveries. That way, you know how long it takes for the body to deliver. Most of the time you don't need this information, but if the shoulder does get stuck, time slows down or speeds up. It's really hard to give a good estimate if you haven't checked.

Totally. The worst dystocia I experienced was as a very new nurse. It was a private hospital where the physicians were not on premises (we called them in for delivery), and it was an RN delivery (well, the head, anyway). It was an 11lb. baby on a 4'11" woman, and it felt like the head was stuck for about 5 minutes (or forever). I had absolutely NO concept of the length of time that elapsed before the doc got there and how long the dystocia actually lasted.

[mormor]

These posts are so helpful, as I'm familiar with the maneuvers but as of yet haven't had the opportunity to use them - I know that there are no stepping stools in our L&D rooms. I'm going to bring this up with our director when I go in on Wednesday. The timing of the delivery of the head is also a very helpful piece of advice. The most important objective is of course the safe delivery of the baby and the well-being of the mother. But I'm also concerned that if such an experience results in a lawsuit, that I've done exactly what I'm supposed to have done. I rely heavily on the wise advice of experienced nurses! Thank you all!

[ischialspines]

We have shoulder dystocia drills at our facility. Everything mentioned above is in it. Also - using the CPR latch to quickly drop the HOB for McRoberts, and don't forget to call for extra hands!