Nursing Maneuvers for Shoulder Dystocia

Though relatively uncommon, shoulder dystocia can cause serious complications if it is not addressed quickly and effectively. To protect the health of both mothers and children, obstetric care teams must have a robust shoulder dystocia management plan in place and continuously strive to improve their shoulder dystocia preparation and management skills. Through regular drills and continuing education (CE), these teams can help facilitate smooth, safe deliveries.

What Is Shoulder Dystocia?

Shoulder dystocia is a birthing complication that occurs when either one or both of the baby’s shoulders becomes trapped in the mother’s pelvis during labor, preventing the baby from exiting the birth canal. While shoulder dystocia is a relatively uncommon complication—shoulder dystocia statistics show it occurs in only 0.2-3.0% of births—it can cause health problems for the mother and baby if interventions aren’t swiftly implemented.

Studies indicate that better outcomes are directly tied to a prompt response from care teams, making the nurse’s role in shoulder dystocia a particularly vital one. Unfortunately, there are not many shoulder dystocia warning signs,meaning healthcare professionals often have little time to respond in cases of shoulder dystocia. In addition, shoulder dystocia is neither predictable nor preventable according to the American College of Obstetricians and Gynecologists, making it even more important for labor and delivery nurses to anticipate that this medical emergency could occur with any delivery.

To ensure the best possible outcomes for mothers and children, education and teamwork-simulation training are an absolute must. Nurses must also be armed with a robust knowledge base of shoulder dystocia nursing interventions as well as best practices for supporting the provider during the shoulder dystocia delivery process.

What Causes Shoulder Dystocia?

While it is unclear what causes shoulder dystocia, there are a few risk factors. Shoulder dystocia risk factors include gestational diabetes, fetal macrosomia, prior instances of shoulder dystocia, late labor and delivery, induced labor, maternal obesity, and pregnancy with multiples.

When multiple risk factors are present, doctors may preemptively recommend a cesarean section to ensure the complication does not occur. This typically only happens if the fetus weighs 11 pounds or more or if the mother has diabetes and the baby weighs at least nine pounds, 15 ounces. In the majority of cases, shoulder dystocia management decisions are made once labor is in progress.

What Are the Complications of Shoulder Dystocia?

Brachial plexus injury (BPI) occurs in 2.3-16.0% of shoulder dystocia cases and is the most common complication of shoulder dystocia for infants. BPI occurs when the brachial plexus nerves—the nerves that run from the spinal cord down through the arm—are damaged, often as a result of stretching due to excessive traction applied by the delivering provider. BPI can result in paralysis or weakness in the arm or shoulder and is a permanent and devastating injury.

Less frequent complications of shoulder dystocia include fractures in the fetal humerus and clavicle. In some cases, these fractures may be caused intentionally by the obstetrics team to help release the infant’s shoulders from the pelvis. Asphyxia is also a fetal complication of shoulder dystocia, but it is extremely rare. Asphyxia occurs when the shoulder is not released in a timely manner and the neonate is deprived of oxygen, resulting in brain injury or death. Studies report asphyxia in only 0.4% of shoulder dystocia cases.

For mothers, the complications of shoulder dystocia can include postpartum hemorrhage, tearing of the perineum (the area between the vagina and the rectum), and uterine rupture.

How Do You Manage Shoulder Dystocia?

Healthcare professionals managing shoulder dystocia have one goal: to safely release the infant’s shoulder(s) from wherever they are trapped in the mother’s pelvis. Vaginal and cesarean deliveries are both viable birthing options after shoulder dystocia is treated. It is the responsibility of the delivering provider to choose whichever method will ensure the baby is delivered quickly and safely.

In terms of how to treat shoulder dystocia, familiarity with a series of evidence-based maneuvers is required. The specific maneuvers deployed and the order in which they are deployed are determined by the infant’s position in the pelvis and the clinician’s experience. Healthcare providers must be able to recognize when a maneuver is not working and quickly move on to the next one.

In most cases, clinicians are encouraged to spend approximately 30 seconds on each maneuver. This leaves enough time to attempt all available maneuvers within a three- to five-minute window and increase the chances of a safe delivery. Identifying the time between the delivery of the head and the shoulder dystocia diagnosis—as well as the time between each maneuver—ensures the provider and their team remain continuously aware of how much time has elapsed, helping them avoid the chance of acidosis or asphyxia.

For nurses specifically, managing shoulder dystocia begins with alerting all appropriate members of the obstetrics care team (situational awareness), applying primary maneuvers, assisting the provider as necessary with secondary maneuvers, regularly communicating the time to the team, and briefing and debriefing with the team to thoroughly and accurately document the dystocia treatment measures, including the order of maneuvers, their timing, etc.

Nurses also play a vital role in helping reduce confusion and anxiety among mothers and families during the peripartum and postpartum periods. To help nurses perform these duties successfully, every facility should have a detailed shoulder dystocia nursing management and care plan in place.

How Do You Perform Shoulder Dystocia Maneuvers?

There are two main categories of shoulder dystocia maneuvers: primary maneuvers and secondary maneuvers. All clinicians managing shoulder dystocia must have a strong understanding of both sets of maneuvers.

Primary and secondary maneuvers of shoulder dystocia include:

McRoberts Maneuver

The McRoberts Maneuver is often attempted first because it is simple and effective. In fact, the McRoberts maneuver has been found to single-handedly resolve between 39% and 42% of shoulder dystocia cases. During the McRoberts maneuver, two assistants pull the mother’s leg back towards her abdomen to flatten and rotate her pelvis and help free the impacted shoulder. In some cases, suprapubic pressure—pressure applied above the pubic bone using a palm or fist—may be applied at the same time to further help dislodge the infant’s shoulder.

Rubin Maneuver I

The first Rubin maneuver uses suprapubic pressure to rotate the infant’s anterior shoulder. This maneuver is commonly used in conjunction with the McRoberts maneuver.

Rubin Maneuver II

The second Rubin maneuver is not used unless the first Rubin maneuver has failed. In this maneuver, the clinician inserts their fingers into the vaginal canal to try to manually rotate the baby’s shoulder toward their chest, reducing the diameter of the shoulder girdle. The second Rubin maneuver is typically more successful when combined with suprapubic pressure.

Wood’s Screw Maneuver

This procedure is considered the opposite of the Rubin maneuver. During the Wood’s Screw maneuver, the clinician pushes on the posterior surface of the posterior shoulder in a corkscrew fashion in an attempt to release the trapped anterior shoulder and minimize the diameter of the shoulder girdle.

Gaskin Maneuver

During the Gaskin maneuver, the mother moves onto her hands and knees so that gravity can help release the baby’s posterior arm from the birth canal, leaving more space for the baby’s shoulders to pass through. This maneuver can also help widen the pelvic outlet.

When all of these maneuvers fail, desperation maneuvers are applied. These include:

  • Maternal Symphysiotomy: In this procedure, the pubic bone’s connective tissue is broken to widen the pelvis by up to two centimeters. This maneuver should be performed in combination with vacuum extraction.
  • Clavicle Fractures: Intentional clavicle fractures performed by the clinician reduce the diameter of the infant’s shoulders so they can pass through more easily.
  • Zavanelli Maneuver: This maneuver is only performed after all other options have been exhausted. It involves pushing the infant’s head back in and then performing a cesarean section.

Be Prepared for Shoulder Dystocia

While shoulder dystocia remains a relatively rare birthing complication, every member of the obstetrics team must be well-versed in managing it. The moment shoulder dystocia is identified, healthcare professionals have mere minutes to safely deliver the baby and protect the mother.

Remaining up-to-date with obstetrics best practices is an integral part of shoulder dystocia preparedness. With CE in shoulder dystocia management and documentation, the quality of care increases while delivery risks decrease. Relias’ advanced training and educational courses help nurses understand the actions they must take to manage shoulder dystocia and facilitate smooth, safe deliveries.

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Lora Sparkman

Clinical Effectiveness Consultant, Relias

Lora Sparkman, MHA, BSN, RN, is a Clinical Effectiveness Consultant for Relias. She provides internal and external consulting, thought leadership, and strategic guidance on the use and optimization of Relias clinical solutions related to improving patient safety and creating high reliability in some of the highest risk areas in healthcare: Obstetrics and Emergency Department as well as other clinical areas with the acute care setting. Prior to Relias, Lora worked for Ascension as a Director of Clinical Excellence. In her role, she had the opportunity to work with clinical leaders and innovators from across the country in improving the delivery of care demonstrating results in patient outcomes and reducing the cost of risk. Lora is a registered nurse, holds a Master of Health Administration from Lindenwood University, a Bachelor of Science in Nursing from the University of Missouri, and a Diploma in Nursing from Barnes Hospital School of Nursing.

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