EVIDENCE- Shoulder Dystocia: Staff Education

BASED CARE
SHEET What We Know
Shoulder dystocia (SD) during childbirth requires additional maneuvers following failure
of gentle downward traction on the fetal head to deliver the shoulders. It is often an
unpredictable and unpreventable obstetric emergency(1,3,4)
SD occurs when the anterior fetal shoulder is stuck behind the maternal pubis symphysis
or when the posterior fetal shoulder cannot pass the sacral promontory. Failure of the
shoulders to emerge spontaneously during delivery places both the mother and fetus/
infant at risk for injury and other complications.(1,4) (For general information on SD, see
Quick Lesson About ... Dystocia, Shoulder )
Potential injuries and complications to the infant as a result of SD include brachial
plexus damage, fracture of the clavicle, hypoxia, and death(1,4)
- Staff member knowledge about the management of SD reduces the occurrence of
birth injuries, including brachial plexus injury(3)
Potential maternal complications include hemorrhage and laceration(1,4)
The incidence of SD in vertex presentation vaginal birth is 0.61.4%.(1,3,4)The incidence
of SD began to increase in the United States in the 1980s, not long after the start of the
use of active management of the birthing process(2)
Antenatal risk factors are maternal obesity or diabetes; maternal history of large
ICD-9 infants, difficult delivery, or previous SD; a large fetus; and postdate (i.e., past the
predicted due date) pregnancy(1,3,4)
660.4

ICD-10
O66.0
Authors
Amy E. Beddoe, RN, PhD
Cinahl Information Systems, Glendale, CA
Debra Balderrama, RN, MSCIS
Glendale Adventist Medical Center,
Glendale, CA
Reviewers
Darlene Strayer, RN, MBA
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
January 20, 2017
Intrapartum risk factors are dysfunctional labor, prolonged first and/or second stage
of labor, cephalopelvic disproportion, slow progress or advancement in vertex
presentation, use of oxytocics, and an instrumental delivery(1,3,4)
Signs of SD are the fetal head retracting with the chin tight against the perineum after
delivery of head, the fetal head not spontaneously realigning with the body after delivery
of the head (called restitution), and the fetal shoulders failing to descend
Several maneuvers have been developed to release the affected shoulder during delivery.
Fewer birth injuries occur when fetal maneuvers are used initially(1,3,4)
Common fetal maneuvers include the Rubin maneuver, the Woods screw maneuver, and
the Zavanelli maneuver(4)
Common maternal maneuvers include the McRoberts maneuver, suprapubic pressure,
and the Gaskin maneuver(1,3,4)
Maneuvers should be performed immediately, one after the other, until delivery is
complete(1,3,4)
Education, training, and simulations can prepare staff for an SD emergency(1,3,4)
Proper training, education, and simulation is associated with improved maternal and
fetal outcomes. It improves confidence levels and clarifies roles and the sequence of
appropriate outcomes during an SD emergency
The roles of team members during a delivery involving SD should be considered and
reviewed; teamwork is essential

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 All staff members should know their roles and responsibilities; nurses should be able and prepared to take either of the
nursing roles
- One nurse is dedicated to recording delivery events
- Two nurses assist with the McRoberts position and suprapubic pressure or other position changes, as needed
- An obstetric or other trained clinician (e.g., midwife, family medicine clinician) delivers the baby
- Pediatricians/neonatologists, a neonatal intensive care team, and an anesthesiologist are often part of the team
Communication between the delivering clinician, nurses, and patient/parentsis essential(1,3,4)
Learn to clearly communicate in order to elicit maternal cooperation
- Speak to the mother/parents in simple lay terms with simple instructions (e.g., We are moving your legs to give the
baby more room, I am helping to get the babys shoulder lined up for birth, Dont push until we say to)
The chain of events leading to SD during the delivery process should be considered and reviewed(1,3,4)
Before the emergency, if labor is not progressing or the fetus is not descending,
- empty the maternal bladder (e.g., straight catheterization might be needed)
- have local anesthesia, instruments, and lidocaine ready so an episiotomy can be quickly performed if necessary
- have all emergency equipment available and ready for use
When the potential for SD is identified, state the problem to colleagues clearly when calling for help
- Call the neonatologist or pediatrician, notify the nursery, and prepare the neonatal resuscitation equipment for immediate
use
Treatment of SD when the mother is on her back involves the following steps:(1,3,4)
An episiotomy can facilitate delivery of the shoulders by providing room for the hands of the clinician to perform
additional internal maneuvers if needed
To institute the McRoberts maneuver, two staff members hyperflex the mothers legs onto the abdomen; the mothers legs
should remain held in this position until the baby is delivered or the clinician delivering the baby gives other directions; this
is usually the first intervention performed in SD
The McRoberts maneuver increases the pelvic diameter by 1 centimeter and allows the clinician more room to work,
elevates the anterior shoulder, and reduces the amount of traction required to free the shoulder
The mother in the McRoberts position should be instructed to release the tension in her legs and let the nurses hold them
in the hyperflexed position to make more room for the baby. She should also be instructed to push only when directed to
do so
Performance of the McRoberts maneuver requires a minimum of two staff members to safely and evenly hyperflex both
of the mothers legs
During the maneuver, one of the two assisting staff members also applies firm suprapubic pressure
- Suprapubic pressure is gentle downward pressure with the palm or heel of the hand against the area above the pubic
arch; it puts pressure on the fetal back to direct the pressure to the fetal midline. Fundal pressure should never be
applied
- The clinician directs the baby first downward, then slightly upward following the pelvic curve. The McRoberts
maneuver combined with suprapubic pressure results in the resolution of SD in 90% of cases
If the McRoberts maneuver does not free the anterior shoulder, the clinician might instruct the mother to squat or move to
her hands and knees. These positions can help free the shoulder but are not possible if the mother has had an epidural
The hands and knees position increases the pelvic diameter by 1 centimeter
The next maneuver is the Woods screw maneuver, which is performed by the delivering clinician and consists of manually
applying pressure to the posterior fetal shoulder and gently rotating the infant though a 180 counterclockwise turn in order
to free the anterior shoulder
Never use traction or pull on the babys head and neck , which increases the risk of morbidity and mortality
The next maneuver is the reverse Woods screw maneuver, which is performed by the delivering clinician and consists of
manually applying pressure to the posterior fetal shoulder and gently rotating the infant though a 180 clockwise turn in
order to free the anterior shoulder
Documenting SD includes recording all birth details in the delivery medical record in real time, including time at
identification of SD, maneuvers used and effects, maternal or newborn injury, and physical findings at birth, including the
infants ability to move the arms(1,3,4)
What We Can Do
Become knowledgeable about SD during childbirth so you can accurately assess your patients personal characteristics and
health education needs; share this information with your colleagues
Collaborate with your facilitys nursing education department and other nursing colleagues to develop an SD training
program, which should include(1,3,4)
goals and objectives for the training
clarity about when and how the training will be performed
Options for training locations include the labor and delivery unit or a simulation center
- Simulation centers have high-tech mannequins, a prepared curriculum, and experienced staff educators; simulation
centers can improve individual performance during an SD emergency
- In-house training can teach teamwork
- Force monitors that measure pressure on maternal/fetal mannequins can be particularly helpful
clear SD protocols and a curriculum
A common management protocol includes the seven components of assessing the problem, calling for help, performing
an episiotomy, performing the McRoberts maneuver, applying suprapubic pressure, birth of the posterior shoulder, and
performing the Woods screw maneuver
Another management protocol is called HELPERR, which stands for call for h elp, e valuate for episiotomy, position
the l egs (in the McRoberts maneuver), apply suprapubic p ressure, perform e nter maneuvers (e.g., internal manual
rotation by the treating clinician, such as the Woods screw maneuver), r emove the posterior arm, and r oll the mother
(e.g., position the patient on her hands and knees)
a list of roles to be performed during an SD emergency
requirements for staff attendance; plan to assess staff knowledge/competence before and after the training
how the course will be evaluated
Staff members need multiple practice sessions to develop SD management and team skills

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
1. Allen, R. H., & Gurewitsch, E. D. (2016, August 22). Shoulder dystocia. Medscape. Retrieved October 22, 2016, from http://emedicine.medscape.com/article/1602970-overview
(RV)
2. Iffy, L., Varadi, V., & Papp, Z. (2014). Epidemiologic aspects of shoulder dystocia-related neurological birth injuries. Archives of Gynecology and Obstetrics, 291(4), 769-777.
doi:10.1007/s00404-014-3453-8 (R)
3. Jenkins, L. (2014). Managing shoulder dystocia: Understanding and applying RCOG guidance. British Journal of Midwifery, 22(5), 318-324. doi:10.12968/bjom.2014.22.5.318
(GI)
4. Draycott, T. J., Crofts, J. F., Ash, J. P., Wilson, L. V., Yard, E., Sibanda, T., & Whitelaw, A. (2008). Improving neonatal outcome through practical shoulder dystocia training.
Obstetrics and Gynecology, 112(1), 14-20. (G)