Though relatively rare, shoulder dystocia can cause serious complications if not addressed quickly and effectively. To protect the health of both parents and infants, obstetric care teams must have a robust shoulder dystocia management plan in place. They must also continuously improve their shoulder dystocia preparation and management skills. In this article, we’ll review nursing maneuvers for shoulder dystocia and the key role nurses play in shoulder dystocia cases.
What is shoulder dystocia?
Shoulder dystocia is a complication that occurs when either one or both of a baby’s shoulders become trapped in the birthing parent’s pelvis during labor, preventing the baby from exiting the birth canal. While shoulder dystocia is not a common occurrence — statistics show it occurs in only up to 2% of births — it can cause complications for the parent and baby without rapid intervention.
Studies indicate that better outcomes are directly tied to a prompt response from care teams, making the nurse’s role in shoulder dystocia a vital one. Unfortunately, there are few shoulder dystocia warning signs, meaning healthcare professionals often have little time to respond. 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 this medical emergency.
Education and teamwork simulation training can help ensure the best outcomes. Nurses must have a robust knowledge of nursing maneuvers for shoulder dystocia and best practices for supporting the provider during the shoulder dystocia delivery process.
In an uncomplicated birth, the infant’s shoulders move freely through the birth canal.
What causes shoulder dystocia?
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 more than one risk factor is present, doctors may preemptively recommend a cesarean section to ensure that shoulder dystocia complications do 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 most cases, shoulder dystocia management decisions are made once labor is in progress.
How do care teams manage shoulder dystocia?
Obstetric care teams managing shoulder dystocia have one goal: to safely release the infant’s shoulder(s) from where they are trapped in the birthing parent’s pelvis. A vaginal or cesarean delivery can then safely occur. It is the responsibility of the provider to choose the method that will ensure that the baby is delivered quickly and safely.
Use of shoulder dystocia maneuvers
Care teams must be familiar with a series of evidence-based maneuvers to successfully treat shoulder dystocia. The specific maneuvers and the order in which they are used depend on the infant’s position in the pelvis and the provider’s knowledge and experience. Healthcare providers must 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 three to five minutes and increases the chances of a safe delivery. Identifying the time between the delivery of the head and the diagnosis of shoulder dystocia — and the time between each maneuver — ensures that the provider and team are continuously aware of how much time has elapsed. By doing this, they can avoid the chance of acidosis or asphyxia.
Nurses’ responsibilities
For nurses specifically, managing shoulder dystocia includes:
- Alerting all appropriate members of the obstetric care team for situational awareness
- Applying primary maneuvers
- Assisting the provider as necessary with secondary maneuvers
- Regularly communicating the time to the team
- Briefing and debriefing with the team to thoroughly and accurately document the shoulder dystocia treatment, including the order of maneuvers and their timing
Nurses also play a vital role in helping reduce confusion and anxiety among mothers and families during the peripartum and postpartum periods. Every facility should have a detailed shoulder dystocia nursing management and care plan in place to help nurses perform these duties successfully.
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 nursing maneuvers for shoulder dystocia
Nurses may need to apply these primary maneuvers.
McRoberts Maneuver This maneuver is often attempted first because it is simple and effective. In fact, the McRoberts maneuver has been reported successful for about 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.
Suprapubic pressure: 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.
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Secondary nursing maneuvers for shoulder dystocia
Providers typically are the ones to perform these secondary maneuvers.
Rubin Maneuver: 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. This 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 Wood’s screw maneuver, the clinician pushes on the posterior surface of the posterior shoulder in a corkscrew fashion to try to release the trapped anterior shoulder and minimize the diameter of the shoulder girdle.
Gaskin maneuver: During this 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.
Episiotomy: The American College of Obstetricians and Gynecologists (ACOG) recommends against universally performing an episiotomy in shoulder dystocia cases. However, it may help if the delivering provider believes that it will aid the performance of secondary maneuvers.
Additional nursing maneuvers for shoulder dystocia
If these maneuvers fail, desperation maneuvers may be needed. These include:
Clavicle fracture: An intentional fetal clavicle fracture performed by the clinician can reduce the diameter of the infant’s shoulders so they can pass through more easily.
Zavanelli maneuver: This 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.
Abdominal rescue: This involves performing a low transverse hysterotomy to allow the fetal shoulder to be dislodged and manually rotated through the transabdominal incision. A vaginal delivery then follows this maneuver.
Symphysiotomy: This maneuver is considered a last resort when other measures have failed or an operating room is unavailable. 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.
Be prepared for shoulder dystocia
While shoulder dystocia is 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 minutes to safely deliver the baby and protect the mother.
Keeping up-to-date with obstetric best practices is integral to shoulder dystocia preparedness. With regular simulations and continuing education (CE), healthcare teams can help facilitate smooth, safe deliveries. Relias’ advanced training and education help nurses understand the actions they must take to manage shoulder dystocia and facilitate smooth, safe deliveries.
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