CNE
An Overview
of Shoulder
Dystocia
The Nurse’s Role
Barbara Camune,
CNM, WHNP, DrPH
Mary C. Brucker,
CNM, PhD, FACNM
INTRODUCTION
Objectives
Upon completion of this activity, the learner will
be able to:
1. Discuss risk factors for shoulder dystocia.
2. Describe fetal position at the time of a
shoulder dystocia.
3. Describe actions to be undertaken when a
shoulder dystocia occurs.
Continuing Nursing Education (CNE) Credit
A total of 2 contact hours may be earned as CNE
credit for reading “An Overview of Shoulder
Dystocia: The Nurse’s Role” and for completing
an online post-test and evaluation.
To take the test and complete the evaluation,
please visit http://JournalsCNE.awhonn.org. Certiﬁcates of completion will be issued on receipt of
the completed evaluation form, application and
processing fees. Note: AWHONN contact hour
credit does not imply approval or endorsement of
any product or program.
AWHONN is accredited as a
provider of continuing nursing education by the American
Nurses Credentialing Center’s
Commission on Accreditation.
AWHONN also holds California and Alabama
BRN numbers: California CNE provider #CEP580
and Alabama #ABNP0058.
Barbara Camune, CNM, WHNP, DrPH, is a clinical associate professor
and program coordinator of Midwifery and Women’s Health Nursing at
the University of Illinois at Chicago. Mary C. Brucker, CNM, PhD, FACNM, is a professor and director of graduate programs at Baylor University
Louise Herrington School of Nursing in Dallas, TX. The authors report no
conflicts of interest or financial relationships relevant to this article.
DOI: 10.1111/j.1751-486X.2007.00231.x
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© 2007, AWHONN
Shoulder dystocia can be defined in many ways. The most frequently used definition is “inability to birth the shoulders of
the infant whether it be anterior, posterior or both, after the
head has been delivered” (Collins & Collins, 2001). No one will
question that failure to birth the shoulders is a true shoulder
dystocia. However, some providers may use the term when the
shoulders are “tighter” than usual. Others employ it when they
perform any change in positioning to facilitate birth. Therefore, the actual prevalence is difficult to ascertain with any certainty; however, it has been estimated to occur in 0.2 percent
to 3 percent of births in the U.S. (Gherman, 2002). Because the
entrapment of the infant in the birth canal is an emergent situation, it’s imperative that the obstetric team is familiar with the
actions/interventions required to achieve the best outcome for
both mother and infant. This article will review risk factors
for shoulder dystocia and nursing strategies for managing it.
RISK FACTORS
Because increased birth weight is associated with shoulder dystocia, the nurse should recognize factors associated with a larger baby. A history of large infants in the family, a discrepancy
between the size of parents or a history of gestational diabetes
in a previous pregnancy should alert the prenatal care provider
about the possibility of a large infant. Genetics also play a role
in fetal growth. A different father in past pregnancies can negate
historical risk for the current pregnancy. Early glucose testing
and follow-up should be performed to ameliorate uncontrolled
growth of the fetus.
It is well-known that gestational diabetes is a risk factor for
a large fetus (Nesbitt, Gilbert, & Herrchen, 1998). Pregnancy itself induces metabolic changes that control fetal growth. When
a mother develops gestational diabetes, the growth of the fetal
chest circumference exceeds the typical growth pattern found
in non-diabetic exposure (Nesbitt, Gilbert, & Herrchen, 1998).
In addition, although the overall body weight of the infant of a
mother with gestational diabetes is larger than the average 3,500
grams, the body length does not increase in proportion. This
phenomenon makes the infants appear short and chubby. Often the chest of an infant of a mother with diabetes will be the
largest area of the body to pass through the birth canal, rather
than the head. Soft sutures and fontanels allow for the head to
mold and adapt to the dimensions of the passage, but the infant’s shoulders do not. Thus the infant’s shoulders are dependent upon position and rotation to navigate the birth canal.
There exists debate about what constitutes “macrosomia.”
The American College of Obstetricians and Gynecologists
(ACOG) defines a macrosomic infant as one who weighs 4,500
grams (9 lbs., 1 oz.) or more (ACOG, 2000). Others define it as
4,000 grams (8 lbs., 13 oz.) (Acker, Sachs, & Friedman, 1986).
Regardless of the definition used, evidence suggests that the
larger the infant, the greater risk of shoulder dystocia occurring
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IMPORTANT SIGNS
At the time of birth, there are two signs that are used to diagnose a shoulder dystocia event. “Turtling” occurs when the
head emerges and then pulls back tight against the perineum,
like a turtle in its shell. The other sign involves failure of spontaneous external rotation and restitution. In many cases, the
fetal head wiggles from side to side and doesn’t rotate into the
oblique parameter. These signals should be recognized by the
person at the perineum (physician, midwife or nurse) and be
communicated to the other team members. Inability to continue the birth of the fetal shoulders after the head with gentle
pressure alone indicates shoulder dystocia.
EXPECTANT MANAGEMENT
Recognizing a shoulder dystocia and implementing proper
interventions and timely delivery are the goals of the medical
team in emergencies such as shoulder dystocia. Communication among the birth attendant, the nursing team and the
parents is of utmost importance. Accurate knowledge of the
skills and interventions that can be used in resolving shoulder
dystocia along with skillful hands-on techniques is essential in
obtaining the best outcome for both mother and infant.
Before the mother delivers the baby, she optimally needs
to have an empty bladder, and so she may need to be straight
catherized. If an indwelling catheter is present, it needs to be
removed as the head crowns. If the mother does not have an
Because increased birth weight is
associated with shoulder dystocia,
the nurse should recognize factors
associated with a larger baby.
epidural, local anesthesia instruments and xylocaine (1 to 2
percent) should be readily available if an episiotomy becomes
necessary. A common misconception is that an episiotomy is a
valid treatment for shoulder dystocia. Because shoulder dystocia is not a soft tissue factor, an incision into the perineum is
not the answer; an episiotomy may be helpful after the delivery of the head if there is not enough room for the hands of
the birth attendant to perform internal maneuvers (Gherman,
2005; Gurewitsch, Donithan, & Stallings, 2004).
If at all possible, there should be some product to slide under the buttocks of the mother to provide a firm surface from
which to work. This can be a CPR board under the mattress
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factor in shoulder dystocia. But because the majority of shoulder dystocias occur in average-sized infants, providers should
be alert that shoulder dystocia can occur at any birth.
CNE
during that birth (Nesbitt, Gilbert, & Herrchen, 1998). This increased risk occurs because there is less room within the pelvis
to accommodate the cardinal movements of labor that help to
propel the infant forward in the birth canal. It’s also more work
for the uterine muscles to squeeze and propel the infant through
the birth process. Any delay in the infant descending or rotating
should be a cautionary warning, although it’s still impossible to
predict which infant will exhibit shoulder dystocia.
Assisted delivery with either forceps or vacuum extraction
has been associated with a higher risk of shoulder dystocia
(McFarland, Raskin, Daling, & Benedetti, 1986). The association may be explained by the interruption of the mechanisms
of labor related to internal rotation. Prolonged second stage of
labor—greater than two hours (or three hours with an effective
epidural in place) in a primigravida—signals the increased risk
for shoulder dystocia to occur. A second stage greater than one
hour should increase suspicion for a multiparous woman to
have a shoulder dystocia.
There are other factors associated with shoulder dystocia
in addition to high birthweight. Even a multiparous woman
who arrives at the hospital with an average-sized infant and a
completely dilated cervix, who might be expected to give birth
momentarily and without difficulty, could also experience
shoulder dystocia. In this situation, laxity of the birth canal
or the intense forces of the uterus can prevent the infant from
completing the internal rotation that normally occurs. Then the
infant’s shoulders don’t become aligned in an oblique position
to pass through and under the symphysis pubis. This illustrates
the need to be vigilant in care.
Although many risk factors have been identified in the literature, there is little consensus about predicting the event of shoulder dystocia. The factor most often suggested to be predictive is
that of reoccurrence. A woman who has experienced shoulder
dystocia in a previous pregnancy has a higher than average risk
of experiencing it again (Gherman, 2005). Similarly, a woman
whose infant had a fractured clavicle at birth may have experienced a shoulder dystocia that resolved without any outward
sign of impingement. Thus, she also is at greater risk of a shoulder dystocia and/or another infant with a clavicular fracture.
Authorities agree that most shoulder dystocias cannot be
predicted. However, the issue of fetal weight is often mentioned
as a potential factor. For some, this is a confusing situation.
When birthweights are categorized by pounds, the most cases
of shoulder dystocia occur among infants who weigh between 7
and 8 pounds; most babies born in North America fall into this
weight category (Doublet, Benson, & Nadel, 1997). However,
for babies who weigh 9 pounds or more, a higher percentage
will be found with shoulder dystocias (Acker, Sachs, & Friedman, 1986). In other words, the more the baby weighs, the
greater the risk for shoulder dystocia. Large infants are relatively predictable, and because of the potential association with
shoulder dystocia, a high birthweight often is discussed as a
or bed linens. In some instances, infants expected to weigh
greater than 10 pounds are born on traditional delivery tables in a delivery room rather than birthing beds, in order to
have the hard surface as well as room for additional health
care providers.
The neonatology team needs to be present for the birth
and not “on call,” even if they could arrive within minutes after the birth. Full resuscitation equipment should be ready to
use immediately. While equipment set-up is important for any
birth, possible shoulder dystocia requires a “be prepared” attitude. The nursery personnel also should be made aware of a
possible complicated delivery.
Many clinicians attempt to deliver the baby in one motion
and routinely do not wait for external rotation or restitution
before continuing the birth sequence. This technique can be
helpful in some instances, but does not always prevent the
shoulder from becoming impacted. Other clinicians stop after
the head is born to reduce a nuchal cord, suction the baby,
and then assist in turning the head before proceeding with
the birth (Beall, Spong, & Ross, 2003). If the mother is pushing well and the shoulders have rotated, the birth can be accomplished with gentle traction by the birth attendant. If the
shoulders have not rotated, the pelvic outlet is small, the infant
is malpositioned (nuchal hand or arm), or the shoulders and
chest are a larger circumference than the head, it’s probable
that shoulder dystocia will occur (Gherman, 2005).
Positioning of the mother is important in all births but
even more so when a large baby is expected and shoulder dystocia is more likely than usual. The mother of a macrosomic
infant may push more effectively on either side, but at the time
of birth the mother should either be squatting, on her hands
and knees, or semi-sitting. This enables the physician or midwife to attempt to continue the delivery of the head and shoulders in one motion, rather than spending time stopping for a
contraction, cutting the cord or suctioning the baby.
Finally, an extra pair of nursing hands is essential until the infant is born. In an emergency situation, at least two nurses need
to be assisting the physician or midwife; more than two nurses
might even be necessary. Ideally, the increase in staff enables
the following actions to be performed quickly and smoothly:
McRoberts maneuver (Figure 1), suprapubic pressure, support
of the mother, time keeping and care of the neonate.
MANAGEMENT TECHNIQUES
McRoberts Maneuver
Once the infant’s head has delivered but the shoulders will not
follow, shoulder dystocia is occurring. The physician or midwife
should recognize this and alert the nurse. It’s not necessary to
say, “I have a shoulder dystocia” or “the shoulders are stuck.”
The birth attendant can communicate the message by asking
for McRoberts maneuver to be executed or the mother’s legs to
be pulled back. Two people need to hyperextend the legs of the
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FIGURE 1 MCROBERTS MANEUVER
AND SUBRAPUBIC PRESSURE
When fetal shoulders become impacted under the maternal symphis pubis, the nurse should ﬁrst initiate McRoberts maneuver by
hyperextending the birthing woman’s legs onto her abdomen and
simultaneously providing suprapubic pressure to assist the fetus
in adducting the arms closer to the body in an attempt to release
the impacted shoulders. The birth attendant should be directing
the birth of the baby ﬁrst downward, and then slightly upward, following the curve of the pelvis (Curve of Carus). These actions are
usually sufﬁcient to remedy mild cases of shoulder dystocia.
mother onto the abdomen. This is known to enlarge the pelvis
by approximately one centimeter (Poggi et al., 2004). A family
member can be used to hold the leg if needed, as long as the
directive is coming from the nurse. The nurse is responsible for
placing the legs in proper position to avoid causing harm to the
hips and ligaments of the mother and to accomplish the McRoberts maneuver successfully. Once the McRoberts maneuver is
employed, the mother’s legs should remain in this position until
the infant is fully delivered (Gonik, Stringer, & Held, 1983).
Suprapubic Pressure
Just as the positioning of the mother is essential, so is the position of the nurse when a shoulder dystocia occurs. The nurse
may need to use a step-stool or chair to attain a position above
the woman in order to apply suprapubic pressure. In some institutions, when the birth attendant asks the nurse if a stepstool is ready, it’s an alert to the nurse that the risk of a shoulder
dystocia is higher than normal. Suprapubic pressure may be
needed along with the McRoberts maneuver to loosen the
trapped shoulders. Suprapubic pressure applied immediately
above the symphysis pubis may assist the infant in adducting
the arms closer to the body and releasing the impacted shoulder. Suprapubic pressure can also be employed to sweep the
shoulder externally into an oblique position in the pelvis that
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Occasionally, the physician or midwife will ask for assistance
with other positioning. Research indicates that having the
mother on her hands and knees enlarges the pelvis by approximately one centimeter (Bruner, Drummond, Meenan, &
Gaskin, 1998). Even a mother with an active epidural can assume this position with assistance. Often, the turning of the
mother from the semi-fowlers position to the hands-and-knees
position is enough to dislodge the shoulders. The infant will be
born with the posterior shoulder first in this position. A disadvantage of the hands-and-knees position is inability to provide
suprapubic pressure.
Another maternal position that may be helpful is squatting.
Many a midwife has described squatting as “McRoberts with
gravity.” Suprapubic pressure, although somewhat awkward,
can be provided to the woman in a squatting position.
Another position that may be requested is for the woman to
lie supine. Even with the head delivered, the mother’s vena cava
can cause bradycardia in the infant. If the nurse must place the
mother flat, the woman should still be placed in a pelvic tilt.
Emergency Measures
Emergency measures, such as oxygen by mask at 10 liters,
checking for a patent IV access and keeping track of heart tones
with either a doppler or fetoscope are essential. Electronic fetal
monitoring is limited, as application of a new scalp electrode
will impede manipulation and the external fetal monitor does
not pick up fetal heart rate (FHR) well under the symphysis
pubis. If the cord has not been clamped and cut, the infant is
still able to receive some oxygen transfer from the mother.
Maternal Pushing
During the time of these manipulations, either the physician or
midwife should direct the mother to either breath or push. If the
shoulder is mildly stuck, McRoberts maneuver and suprapubic
pressure will generally loosen the shoulder and the mother will
assist in pushing the infant out (Penney & Perlis, 1992). In a
mild case this may seem to take a long time, but it’s usually less
than two minutes in its entirety. It’s the nurse’s responsibility to
document time on the perineum (after the head delivers until
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Communicating With Parents
The parents should be apprised of the situation by the nurse
if the physician or midwife does not communicate with them.
The statement, “We are moving your legs to give the baby more
room,” is a simple explanation that can be understood by all.
Suprapubic pressure can be explained as “helping to get the
shoulders lined up for birth.” If a mother is to breathe through
contractions, the nurse can coach her nose-to-nose. This helps
keep the mother concentrating. If she needs to push, the nurse
is there to encourage her. Comprehensive and honest information about the situation needs to occur after the infant is born
and stabilized.
Emergency Management
Shoulder dystocia can also occur with an emergency delivery. A
nurse who cannot obtain assistance from a physician or midwife
will have to deliver the infant. Once the head is delivered, the
clock starts ticking regarding fetal hypoxemia and acidosis. It’s
believed that a newborn can survive for approximately six minutes before irreversible brain and organ damage occurs (Goodwin, 1999). Unless the help is in the hospital and due to arrive
within a minute, the nurse should proceed with the birth.
If the shoulders will not come with gentle traction on the
head in accompaniment with the mother pushing, the nurse
should instruct the woman to stop all pushing activity. The
nurse should immediately call for assistance and have the responders apply McRoberts maneuver and suprapubic pressure.
The next step is to have the mother push again to see if the
shoulder has loosened. If it has, the anterior shoulder should be
gently guided under the symphysis pubis by angling down until
the top of the shoulder is out and then lifting up for the posterior shoulder. Once the shoulders are born, the rest of the body
should slide out with gentle guidance. Hands should never be
placed around the baby’s neck or under the chin at any time
while the shoulders are guided, as this can injure the infant.
Once the baby is born, the cord should be promptly clamped
and cut so that the infant can be cared for by others. The nurse
should remain with the mother to watch for hemorrhage or
delivery of the placenta. At no time should the nurse pull on the
placenta before it is expelled spontaneously.
Other Maneuvers
If the shoulders are not released with McRoberts maneuver and
suprapubic pressure, the nurse should try to rotate the shoulders (Rubin maneuver, see Figure 2) (Gurewitsch et al., 2005).
Placing a hand within the vagina, the nurse should push the
shoulders from behind the scapula toward the face of the infant. Often this will rotate the shoulders into oblique diameter
and birth will ensue. If this does not work, the nurse should
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Maternal Position
the body arrives) for the delivery. The physician or midwife will
not be watching the clock. Any resuscitation measures and a
thorough examination of the infant should be documented.
CNE
allows for delivery. The nurse needs to be knowledgeable about
hand placement and the purpose of this technique. Open or
closed hand can be used (Beall, Spong, & Ross, 2003). If the
nurse is unsure of the technique, another nurse should do it.
Incorrect hand placement can delay the birth, rupture the
uterus or cause the shoulder to become further impacted. Any
fundal pressure on the abdomen in the area of the uterine fundus or above the umbilical area could produce harm to both
the mother and infant. Although some physicians were trained
to use fundal pressure in the past, current evidence has shown
that this kind of manipulation is harmful, and should not be
employed (Hankins, 1998).
try to rotate the shoulders in the opposite direction. This
maneuver, called the Wood’s Screw Maneuver (Figures 3
and 4), can be used to work the infant out slowly. It requires
pushing the shoulders forward, then pushing the shoulders
back and twisting the body as it turns (Gurewitsch et al.,
2005). These maneuvers have been compared with rotating
a tight cork out of a bottle. Note that it is never proper to
pull on the shoulders simultaneously.
Another maneuver that can be useful is the removal
of the posterior arm (Figure 5). Most likely, the infant has
arms at the sides or across the chest. The nurse should place
her/his hand in the vagina at the 6 o’clock position and follow the arm past the elbow to find the infant’s hand. Grasping the hand, the arm can be moved gently in a sweeping
motion toward the center of the body with the hand passing
over the head as it exits the vagina. This action has been likened to a cat sweeping its paw over its chest up to its mouth.
The whole arm will be delivered. Then the infant can be
turned by using the Rubin maneuver again. Most likely the
infant will come easily in conjunction with mother’s pushing (Gherman, 2002; Gherman, 2005).
It’s important to note that the mother should not push,
except when instructed to and only when it’s believed the
shoulder has been released. If the mother continues to
push, her uterus could rupture and the shoulder could be
impacted more tightly with bruising.
By the time that the above actions have been taken, it’s
likely that additional assistance will have arrived. If shoulder dystocia remains unresolved at this point, it’s time for
the maneuvers of last resort. These are best undertaken by
an experienced provider and include deliberate clavicular
fracture or performance of the Zavanelli maneuver, which
consists of cephalic replacement of the fetal head by rotating it into a direct occiput anterior position and pushing
it back into the pelvis until a cesarean section can be performed. The Zavanelli maneuver should not be performed
by a labor nurse.
BRACHIAL PLEXUS INJURY
As mentioned before, a shoulder dystocia can result in a
major disruption in oxygen transfer, resulting in impaired
neurological development. In addition to that neonatal risk,
shoulder dystocia can cause birth trauma. Brachial plexus
injury is the most common consequence of shoulder dystocia and can occur through bruising, stretching or avulsion
of the nerve networks in the upper spine. Nerve palsies are
named by the level of spinal involvement. The most common, Erb’s Palsy, involves the C4–6 nerve roots, while ErbDuChenne-Klumpke involves the entire brachial plexus.
A third type, Klumpke, involves the C8–T1 area. A combination of injuries and scar tissue development impact the
optimal recovery and use of the affected arm. Avulsion of
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FIGURE 2 RUBIN MANEUVER
Several maneuvers exist to attempt to rotate the fetal shoulders into
a deliverable position. These maneuvers are designed to rotate the
baby—NOT to pull on the shoulders, which is not only unlikely to
be successful, but may result in birth trauma. The Rubin maneuver
is accomplished by placing ﬁngers behind the anterior scapula and
attempting to rotate the baby forward so that the shoulders are more
likely to be in an oblique position.
FIGURE 3 WOODS SCREW MANEUVER
If the Rubin maneuver alone is unsuccessful, the Woods Screw
maneuver can be perfomred by placing ﬁngers from the other hand in
front of the fetal arm of the other side, to promote rotation in the same
direction.
FIGURE 4 REVERSE WOODS SCREW MANEUVER
If neither the Rubin nor the Woods Screw is successful, the birth
attendant would employ the Reverse Woods Screw maneuver, which
attempts to rotate the fetal body in the opposite direction by placing
the ﬁngers behind the posterior scapula.
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In some situations, the professional can reach the fetal arm and follow
it past the elbow to the hand. Grasping the hand, the arm is moved
gently in a sweeping motion across the fetal chest, over the head and
outside the vagina. This maneuver changes the fetal diameters and
often enables a subsequent manual rotation to be successful. The delivery of the posterior arm should be performed in a smooth manner
without roughness.
LEGAL REALITIES
Shoulder dystocia with resulting brachial plexus injury is one
of the most common birth events precipitating litigation. It’s
alleged that the only mechanism of injury is the improper use
of extreme lateral traction on the fetal head/neck while the
shoulders are impacted (Allen, Bankoski, Butzin, & Nagey,
1994). However, case reports have described brachial plexus
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IMPLICATIONS FOR NURSING PRACTICE
Everyone working in labor and delivery should be knowledgeable in their roles and prepared for all emergencies. Communication with the physician or midwife ahead of time about the
delivery plan for an at-risk infant makes the difference between
smooth interventions or potential chaos. Being proactive during
BOX 1 BE CALM MNEMONIC
B: Breathe, do not push. Encourage the woman
to breathe or even pant in order not to push;
the nurse should also remember to breathe
herself.
E: Elevate the legs into a McRoberts position.
C: Call for help, because this is an event that will
require more than two hands.
A: Apply suprapubic pressure (but NOT fundal
pressure).
L: Enlarge the vaginal opening with an episiotomy when additional hand room is needed.
(Remember, this does not treat the actual
problem.)
M: Maneuvers (e.g., Rubin and Woods; remove
the posterior arm; reposition the woman on
hands and needs).
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nerve roots produces the most severe deformities (flaccid, abducted arms; claw hands; and loss of shoulder use) (Carson,
Woolridge, Colletti, & Kilgore, 2006).
Mild injuries usually resolve by three months of age, with no
residual effect. It’s impossible to predict or diagnose the prognosis in the newborn period. A physical therapist needs to be
consulted promptly. Exercises must be initiated by parents in the
days following birth. Frequent follow-up is warranted with both
the pediatric provider and physical therapist. Current practices
favor referral to a neurologist between 6 and 12 months for evaluation of continuing weakness or movement problems. Ability
to move the fingers of the affected arm may be construed as “a
good sign”; however, it does not predict future abilities (Gherman, Ouzounian, Miller, Kwok, & Goodwin, 1998; Piatt, 2005).
Because most infants are born in the left occiput anterior
position, the anterior shoulder and injured side are commonly
on the right as it is the right shoulder that comes under the symphysis in this birth position. It’s also possible to have a left-sided
injury due to posterior arm impaction on the sacral promontory
of the pelvis. Occasionally, both sides have been affected (Carson,
Woolridge, Colletti, & Kilgore, 2006; Hankins & Clark, 1995).
injuries with spontaneous deliveries and no shoulder dystocia; fractured clavicles with no evident shoulder dystocia; Erb’s palsy with cesarean births and malpresentations
in utero (Allen, 2005; Gherman, Ouzounian, & Goodwin,
1999; Hankins, 1998; Hankins & Clark, 1995). A study of
1,611 cases of brachial plexus found that 47 percent of them
occurred after a birth that had no indication of a shoulder
dystocia (Gilbert, Nesbitt, & Danielson, 1999).
Obstetricians and nurse-midwives explain the ordinary
force needed to assist the birth as “gentle traction.” Gentle
traction is used to direct the baby in maneuvering the pelvic curve of Carus as the rest of the body is expelled. “Gentle traction” is an experience-derived skill, learned through
practice on models and at actual births. Because labor and
delivery nurses do not routinely deliver babies, it’s harder
for the nurse or inexperienced clinician to have this “gentle
touch.” Most importantly, if the anterior shoulder does not
deliver with maternal pushing and downward guidance
of the fetal head, the nurse must stop and then reassess.
According to Simpson & Knox (2003), the most common
reason for nurses to be named in shoulder dystocia cases is
proceeding with improper techniques (fundal pressure, incorrectly applied suprapubic pressure, or invasive maneuvers without training).
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FIGURE 5 DELIVERY OF THE POSTERIOR ARM
BOX 2 THE HELPERR ALGORITHM
Prompt recognition of
a shoulder dystocia
Stop pushing
Call for Help
Consider an Episiotomy
Elevate the Legs (McRoberts)
Provide P ressure (suprapubic)
Success
No success
Enter maneuvers (Rubin and Woods)
Success
No success
Remove posterior arm
During a shoulder dystocia, the nurse must chart accurately
and in detail about the times at which assistance/maneuvers
were performed. The physician or midwife should write what
they did in their own progress notes. It’s wise to review the
times among all involved so that all notes reflect the same chronology. Involve parents as members of the team by giving them
simple explanations as the event progresses. The nurse should
discuss any concerns with the person who delivered the infant
and should not speculate about what happened and what was
done. Nurses should chart only what was seen. Internal maneuvers and strength of traction are not data that anyone can
document with certainty, except the person performing them
(Dunn, Gies, & Peters, 2005).
When a shoulder dystocia event occurs, follow-up with the
parents is essential. There is no need to apologize, but sincere
sharing of care and hope that the injury will improve (if there
was one) can be therapeutic for the parents and the nursing staff.
Not all injuries can be avoided. However, with the best preparation and knowledge, both the infant and mother will have less
trauma, both physical and psychological, surrounding the event.
CONCLUSION
Success
No success
Roll the woman (reposition)
Success
No success
Maneuvers of last resort
In summary, birth is a normal event. Untoward events should
not be expected nor conveyed in such a manner that parents and
providers are afraid of the normal physiological event. Alternatively, unusual events do occur. Among them are potentially
catastrophic ones that include shoulder dystocias. Understanding how shoulder dystocias occur, present and are treated can
enable nurses to promptly and appropriately intervene (see
Boxes 3 and 4 for further information for nurses). NWH
REFERENCES
labor can be invaluable. The nurse should encourage the woman to empty her bladder regularly. Attention to a prolonged labor or observation of a high estimated birthweight can help the
nurse identify women at potential risk.
Nurses routinely practice CPR as part of their professional
responsibilities. Nurses in obstetrics should routinely practice
“shoulder dystocia drills.” For example, a nurse can practice
McRoberts maneuvers and suprapubic pressure on models
or even on a colleague. Identifying the location of necessary
equipment, such as a step-stool, can save a nurse precious time
during an emergency. Performing the delivery hand positions
on models with the supervision of a physician or midwife can
prepare a nurse for the actual event.
Although no magic sequence of techniques seems to exist,
it’s wise that each institution or birth site develops a set pattern
that can be followed. A mnemonic that may be of aid would be
BE CALM (see Box 1).
Another mnemonic is HELPERR (see Box 2), as advocated
by the American Academy of Family Physicians (AAFP, 2000).
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Acker, D., Sachs, B., & Friedman, E. (1986). Risk factors for shoulder dystocia in the average weight infant. Obstetrics and Gynecology, 67, 614–661.
Allen, R. H. (2005). Temporary Erb-Duchenne palsy without
shoulder dystocia or traction to the fetal head. Obstetrics and
Gynecology, 105(Pt 2), 1210–1212.
Allen, R. H., Bankoski, B. R., Butzin, C. A., & Nagey, D. A. (1994).
Comparing clinician applied loads for routine, difficult, and
shoulder dystocia deliveries. American Journal of Obstetrics and
Gynecology, 171, 1621–1627.
American Academy of Family Physicians. (2000). Shoulder dystocia. In Advanced life support in obstetrics (ALSO). Leawood, KS:
Author.
American College of Obstetricians & Gynecologists. (2000). Fetal
macrosomia: Practice bulletin no. 22. Washington, DC: Author.
Beall, M. H., Spong, C., & Ross, M. G. (2003). A randomized controlled trial of prophylactic maneuvers to reduce head-to-body
delivery time in patients at risk for shoulder dystocia. Obstetrics
and Gynecology, 102, 31–35.
Bruner, J. P., Drummond, S. B., Meenan, A. L., & Gaskin, I. M.
(1998). All-four maneuver for reducing shoulder dystocia during labor. Journal of Reproductive Medicine, 43, 439–443.
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The basic code is 660.4.
The ﬁfth digit is used to designate severity:
660.40 = Unspeciﬁed
660.41 = Mild
660.42 = Moderate
660.43 = Severe
BOX 4 TIPS FOR CARING FOR A WOMAN
WITH HIGHER THAN AVERAGE RISK OF
SHOULDER DYSTOCIA
1. PROVIDE ANTICIPATORY GUIDANCE TO THE
WOMAN AND HER FAMILY: For example, talk
about techniques to stop pushing.
2. EQUIP THE APPROPRIATE BIRTH SITE: Make
certain that there is adequate room for additional
personnel should a shoulder dystocia occur; verify
resuscitation equipment is available and operational; and ﬁnd the step stool.
3. COORDINATE WITH COLLEAGUES: Communicate plans with other nurses, midwives, physicians, etc. Verify comfort and skill level
of colleagues.
4. ATTEND TO THE WOMAN IN LABOR: Support and observe labor closely. Promote frequent
emptying of the bladder and position changes.
Carson, S., Woolridge, D. P., Colletti, J., & Kilgore, K. (2006). Pediatric upper extremity injuries. Pediatric Clinics of North America,
53, 41–67.
Collins, J. H., & Collins, C. L. (2001). What is shoulder dystocia?
Journal of Reproductive Medicine, 46, 148–149.
Doublet, P. M., Benson, C. B., & Nadel, A. S. (1997). Improved
birth weight table for neonates developed from gestations
dated by early ultrasonography. Journal of Ultrasound Medicine, 16, 241–244.
Dunn, P. A., Gies, M. L., & Peters, M. A. (2005). Perinatal litigation and related nursing issues. Clinics in Perinatology, 32,
277–290.
Gherman, R. B. (2002). Shoulder dystocia: An evidenced-based
evaluation of the obstetric nightmare. Clinical Obstetrics and
Gynecology, 45, 345–362.
October
November 2007
Gherman, R. B., Ouzounian, J. G., Miller, D. A., Kwok, L., & Goodwin, T. M. (1998). Spontaneous vaginal delivery: A risk factor for
Erb’s palsy? American Journal of Obstetrics and Gynecology, 178,
423–427.
Gilbert, W., Nesbitt, T., & Danielson, T. (1999). Associated factors
in 1611 cases of brachial plexus injury. Obstetrics and Gynecology,
93, 536–544.
Gonik, B., Stringer, C. A., & Held, B. (1983). An alternate mechanism for management of shoulder dystocia. American Journal of
Obstetrics and Gynecology, 145, 882–884.
Goodwin, T. M. (1999). Clinical implications of perinatal depression. Obstetric and Gynecologic Clinics of North America, 26,
711–723.
Gurewitsch, E. D., Donithan, M., & Stallings, S. P. (2004). Episiotomy versus fetal manipulation in managing severe shoulder dystocia: A comparison of outcomes. American Journal of Obstetrics
and Gynecology, 191, 911–916.
Gurewitsch, E. D., Kim, E. J., Yang, J. H., Outland, K. E., McDonald,
M. K., & Allen, R. H. (2005). Comparing McRobert’s and Rubin’s
maneuvers for initial management of shoulder dystocia an objective evaluation. American Journal of Obstetrics and Gynecology,
192, 153–160.
Hankins, G. D. V. (1998). Lower thoracic spinal cord injury: A
severe complication of shoulder dystocia. American Journal of
Perinatology, 15, 443–444.
Hankins, G. D. & Clark, S. L. (1995). Brachial plexus palsy involving
the posterior shoulder at spontaneous vaginal delivery. American
Journal of Perinatology, 12, 44–45.
McFarland, L. V., Raskin, M., Daling, J. R., & Benedetti, T. J. (1986).
Erb/Duchenne’s palsy a consequence of fetal macrosomia and
method of delivery. Obstetrics and Gynecology, 68, 784–788.
Nesbitt, T. S., Gilbert, W. M., & Herrchen, B. (1998). Shoulder dystocia and associated risk factors with macrosomic infants born
in California. American Journal of Obstetrics and Gynecology, 179,
476–480.
Penney, D. S. & Perlis, D. W. (1992). Shoulder dystocia when to use
suprapubic pressure. MCN: The American Journal of Maternal
Child Nursing, 17, 34–36.
Piatt, J. H. (2005). Birth injuries of the brachial plexus. Clinics in
Perinatology, 32, 39–59.
Poggi, S. H., Allen, R. H., Patel, C. R., Ghidini, A., Pezzullo, J. C.,
& Spong, C. Y. (2004). Randomized trial of McRobert’s versus
lithotomy positioning to decrease the force that is applied to the
fetus during delivery. American Journal of Obstetrics and Gynecology, 191, 874–878.
Simpson, K. R. & Knox, G. E. (2003). Common areas of litigation
related to care during labor and birth recommendations to promote patient safety and decrease risk exposure. Journal of Perinatal and Neonatal Nursing, 17, 110–118.
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http://JournalsCNE.awhonn.org
The code for an affected fetus or newborn is 763.1.
Gherman, R. B., Ouzounian, J. G., & Goodwin, T. M. (1999). Brachial plexus palsy an in utero injury? American Journal of Obstetrics and Gynecology, 180, 1303–1307.
CNE
BOX 3 CODING FOR
A SHOULDER DYSTOCIA
Gherman, R. B. (2005). Shoulder dystocia prevention and management. Obstetrics and Gynecology Clinics of North America, 32,
297–305.
CNE
Post-Test Questions
Instructions: To receive contact hours for this learning
activity, please complete the online post-test and evaluation
at http://JournalsCNE.awhonn.org. CNE for this activity
is available online only; written tests submitted to
AWHONN will not be accepted.
8. With continuing weakness after brachial plexus
injury, current practice favors referral to a neurologist
during which age range?
a. 1 to 2 weeks
b. 3 to 5 months
c. 6 to 12 months
http://JournalsCNE.awhonn.org
9. Which of the following equipment should be
available when shoulder dystocia is discovered?
1. When birthweights are categorized by pounds, the
most cases of shoulder dystocia occur among infants
in which of the following weight categories?
a. 6 to 7 pounds
b. 7 to 8 pounds
c. 8 to 9 pounds
2. The physiology of gestational diabetes can cause the
fetus to:
a. Delay long bone growth
b. Develop a broad chest circumference
a. Forceps/vacuum
b. Full resuscitation equipment
c. Sling for the arm
10. To be proactive during the second stage of labor
when a large infant is expected, the nurse should
perform which following intervention?
a. Make sure the mother’s bladder is empty
b. Move the mother to the delivery room
c. Use McRoberts maneuver while the mother is
pushing
c. Have polycystic kidney problems
3. The McRoberts maneuver is used to:
11. The best way for the nurse to prepare for shoulder
dystocia is to:
a. Apply pressure to the uterus
a. Avoid epidural anesthesia for obese mothers
b. Elevate the fetal head
b. Develop a plan with team members
c. Enlarge the pelvic diameter
c. Suggest delivery by cesarean section
4. How is suprapubic pressure properly applied?
a. At the fundus of the uterus
12. A very important role for the labor nurse during a
shoulder dystocia event is to:
b. In the lower left quadrant
a. Assign the Apgar score
c. Over the symphysis pubis
b. Assist perineal repair
c. Charts times maneuvers were performed
5. A nurse who is managing an emergency delivery with
shoulder dystocia should:
13. The “A” in the BE CALM mnemonic stands for:
a. Instruct the woman to stop pushing
a. Apply fundal pressure
b. Try to hold the head back
b. Apply no pressure
c. Turn the mother to her side and tell her to push
c. Apply suprapubic pressure
6. The Rubin maneuver involves:
a. Pulling the shoulders simultaneously
14. Which of the following may faciliate internal
maneuvers after the head is delivered?
b. Rotating the shoulders
a. An episiotomy
c. Twisting the abdomen to the posterior position
b. Fundal pressure
c. More pushing by the mother
7. It is possible to accurately diagnose which fetus will
encounter shoulder dystocia at birth by:
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15. The “L” in the HELPERR algorithm stands for:
a. Aggregating risk factors
a. Elevate the legs
b. Referring to past delivery weights
b. Left side–lying
c. Watching for a sign of “turtling”
c. Lower the legs
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