Clinical Scenario: Dystocia (Shoulder Dystocia) 

Assessment Diagnosis Planning Intervention Rationale Evaluation

Risk for After 30 minutes After 30 minutes of

Subjective: maternal of nursing effective nursing
“Pahilab hilab na injury related intervention, the This is helpful in intervention, the
yung tiyan ko, di na to mechanical patient will 1. Review the patient identifying causes, patient was able to
nga ako mapakali obstruction as maintain safety history of labor, needed diagnosis maintain safety and
kapag humihilab” manifested by and participate onset and duration and appropriate participate in 
as verbalized by fetal chin fixed in measures intervention. measures that protect
the patient  in the that will protect herself during the
perineum  herself during delivery as
the delivery Shoulder dystocia manifested by patient
Objective: may cause the statement
2. Assess the
patient to have “Maginhawa na ang
patient’s risks for
vaginal bleeding due pakiramdam ko” and
vaginal tearing and
 Fundal to the unnatural the baby was
bladder damage
height: 40 position of the baby successfully
cm during delivery delivered, thus the
goal was met

 Cervix
Dilation: Heavy vaginal
10cm 3. Monitor the bleeding may result
patient’s level of to hypotension and
consciousness lower level of
using AVPU Scale consciousness
 Fetal chin
(Alert, Voice, Pain
appeared Stimuli,
fixed in the Unconciousness)
perineum

4. Assist in performing
the McRobert’s The McRobert’s
Maneuver maneuver is a
position where the
legs are pulled
towards the
stomach. It
promotes the
rotation of the pelvis
to let the baby pass
through easily.
5. Prepare the
patient for
immediate surgical An episiotomy is
intervention to when an incision is
deliver the baby  made on the
perineum which is
the area between
the vagina and
anus. It prevents
tearing and opens
the birth canal
allowing more room
for the baby to pass
6. Evaluate  through
degree of
hydration. Note
amount and type of
intake. Prolonged labor can
result in a fluid
electrolyte
imbalance and
prolonged labor with
increased risk of
uterine infection,
postpartum
hemorrhage, or
precipitous delivery
in the presence of
hypertonic labor