Case Analysis

SHOULDER
DYSTOCIA
NCM 109-Skills Lab
March 10, 2021

Matza, Kurt Rovic

Vale, Virgene Marie Blessa
GROUP 7
 CASE ANALYSIS OVERVIEW
This case analysis shows a 35-year old woman,
gravida 3 para 2, who was admitted with spontaneous
rupture of the membranes 12 hours ago, at 40 weeks
gestation. She had 2 previous healthy infants, each by
spontaneous vaginal delivery, with birth weights of 8 lbs.
(about 3,700 grams). Her weight is 195 pounds, with a
BMI of 30, but her blood sugar screen was normal.
 RATIONALE
Shoulder dystocia results from a size
discrepancy between the fetal shoulders and the
pelvic inlet. In normal labor, after internal
rotation, the biparietal diameter rests in a
transverse position with the bisacromial
diameter in an oblique angle.
 2. PATIENT’S PROFILE
Demographic profile
Name: Maria Zapanta
Age: 35 years old
Gender: Female
Address: San Jose St., Goa, Camarines Sur
Date of Birth: March 9, 1986
Educational level: College Graduate
Ocupation: Housewife
Nationality: Filipino
Marital Status: Married
Health history (Past and Present history)

Family Health History

N/A
Obstetric history
G3P2 with spontaneous rupture of the membranes 12 hours ago, at 40 weeks
gestation
2 previous healthy infants, each by spontaneous vaginal delivery

Diagnosis/ Impression
Risk for Altered Uteroplacental Tissue Perfusion related to shoulder dystocia

Date of admission/ Discharge

March 9, 2021
 Laboratory results
Oral glucose tolerance test (OGTT) was the gold standard for making the diagnosis of type 2 diabetes. It is still
commonly used during pregnancy for diagnosing gestational diabetes. With an oral glucose tolerance test, the person
fasts overnight (at least 8 hours, but not more than 16 hours).

Diagnostic Purpose Result Implication to the

Procedure case presented
Oral Glucose The glucose test The blood sugar It can tell whether you
Tolerance Test measures your body's screen was normal. are at risk for diabetes
(OGTT) response to sugar or if you already have
(glucose). The glucose it. A shorter version of
challenge test is done an OGTT checks for
during pregnancy to diabetes during
screen for gestational pregnancy.
diabetes — diabetes
that develops during When you're pregnant,
pregnancy. a blood glucose level
of 140 mg/dL or higher
is abnormal. Your
doctor will recommend
that you take a 3-hour
OGTT.
3. Anatomy and Physiology

As the accompanying diagram shows, the maternal

pelvis is composed of a series of bones forming a circle
protecting the pelvic organs. The front-most bone is the
symphysis pubis. It is on this structure that a baby's
anterior shoulder gets caught during a delivery complicated
by shoulder dystocia. The bone at the back of the maternal
pelvis is the sacrum. Because of its shape, it generally
serves as a slide over which a baby's posterior shoulder can
descend freely during labor and delivery. However
sometimes a baby’s posterior shoulder can get caught on
its slight projection into the pelvis. The side walls of the
maternal pelvis, although very important in determining
how smoothly the process of labor will go, usually do not
contribute to shoulder dystocia.
3. Anatomy and Physiology

Shoulder dystocia refers to a situation

where, after delivery of the head, the
anterior shoulder of the fetus
becomes impacted on the maternal
pubic symphysis, or (less commonly)
the posterior shoulder becomes
impacted on the sacral promontory.
 4. Pathophysiology
Etiology
Shoulder dystocia is associated with advanced maternal age,
diabetes maternal obesity, large baby (macrosomia), postdate pregnancy,
and multiparity.

Pathophysiology
Shoulder dystocia results from a size discrepancy between the fetal
shoulders and the pelvic inlet. In normal labor, after internal rotation, the
biparietal diameter rests in a transverse position with the bisacromial
diameter in an oblique angle. Extension and restitution result in the occiput
returning to the anteroposterior plane. It is speculated that a persistent
anteroposterior location of the fetal shoulders at the pelvic brim occurs
when there is increased resistance between the fetal skin and vaginal walls
(e.g., with macrosomia), with a large fetal chest relative to the biparietal
diameter, and when truncal rotation does not occur (e.g. precipitous labor).
When this occurs, the anterior shoulder impacts behind the symphysis
pubis. Shoulder dystocia also may occur from impaction of the posterior
fetal shoulder on the maternal sacral promontory.
 5. Medical/
Surgical
Intervention
 Medical Intervention
Drug Classification Indication Action Dosage Nursing
Responsibilities
Analgesic anti- reduce fever blocking pain
inflammatory and relieve signals to the 325 to 500 mg Assessing for
drugs mild to brain or and managing
moderate pain interfering with side effects of
the brain's the medication
interpretation
of those
signals.

Oxytocin induction of Oxytocin stimulates

powerful contractions 0.25 to 5 IU of Assess uterine tone
and vaginal bleeding.
labor in that help to thin and
open (dilate) the cervix,
oxytocin Monitor for adverse
reactions of water
patients with a move the baby down intoxication, such as
and out of the birth lightheadedness,
medical canal, push out the nausea, vomiting,
indication for placenta, and limit
bleeding at the site of
headache, and malaise.

the initiation of the placenta.

labor
 Surgical Intervention
Procedure Classification Indication
Maneuver McRoberts maneuver there are no specific indicators for the use For nurses, managing shoulder dystocia begins with alerting all
of McRobert's maneuver
Symphysiotomy Trapped head of a breech baby, shoulder
dystocia which does not resolve with
routine manoeuvres, and obstructed labor
at full cervical dilation when there is no
option of a caesarean section.
Cleidotomy Cephalic presentation producing
obstructed labour with dead fetus
Hydrocephalus even in a living fetus
Interlocking head of twins
Nursing Responsibilities
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.
-Shave the incision site; swab the pubic and perineal region with 10%
povidone iodine.
-Place a sterile fenestrated drape over the symphysis.
-Insert the Foley catheter, which allows location of the urethra
throughout the procedure.
-Local anaesthesia: 10 ml of 1% lidocaine, infiltrating the skin and
subcutaneous tissues superior, anterior, and inferior to the symphysis,
along the midline, down to the cartilage. Infiltrate the episiotomy
region as well.
-Exploration of the utero-vaginal canal must be done to exclude
rupture of the uterus or lacerations on the vagina or any genital injury.
-A self retaining catheter is put inside specially following craniotomy
for a period of 3-5 days or until the bladder tone is regained.
-Dextrose saline drip is to be continued till dehydration is corrected.
-Blood transfusion may be given if required
 Nursing Care Plan
Cues Nursing Background Goals Nursing Intervention Rationale Evaluation
(Subjective or Diagnosis knowledge
Objective data) Long term Short term Ideal Actual

SUBJECTIVE Risk for Altered Shoulder The baby will The baby will be INDEPENDENT:
DATA Uteroplacental dystocia refers maintain delivered -Goal was met
-Patient Tissue Perfusion to a situation efficient tissue successfully. 1.) Ask for help. 1.) Ask for 1. ) Shoulder and the patient
complaining of related to where, after perfusion Ensure that help. Ensure dystocia is a verbalized that
abdominal pain. shoulder delivery of the there are that there are medical she has been
enough enough emergency, feeling good
- “ Masakit tiyan dystocia head, the therefore, more and
members of the members of relieved
ko ” as anterior intensive
verbalized by shoulder of the team to support the team to monitoring and from pain.
the delivery of support the assistance will Also, she said
the patient. fetus becomes that we don’t
impacted on the baby with delivery of be needed. feel any pain
the maternal dystocia. the baby with Asking for an from her
OBJECTIVE pubic dystocia. extra hand is abdomen. Her
usually the vital signs are
DATA symphysis, or
health care normal, Skin is
BP: 120/90 (less worker’s first smooth
mmHg commonly) the 2.) Always 2.) Always move. and
not clammy.
PR: 80 posterior monitor for the monitor for
Skin tone is
beats/min shoulder vital sign of the the vital sign 2.) So that we back to normal
RR: 20 becomes patient. of the patient. can provide the and warm to
baseline of
breaths/min impacted on
data for touch.
Temp: 36.5 C the sacral
comparison
promontory. and evaluation
in response to
the
intervention.
 Nursing Care Plan
Cues Background Goals Nursing Intervention Rationale Evaluation
(Subjective or knowledge
Objective data) Long term Short term Ideal Actual

3.) Monitor the 3.) Monitor the 3.) By means of

intake and output intake and monitoring we
of the patient output of the can ensure that
patient the patient has
proper intake
and output.
4.) Place 4.) To
4.) Place pressure pressure on encourage
on the suprapubic the suprapubic
area of the mother. area of the baby’s shoulder
to change
mother. position and
rotate.

COLLABORAT
COLLABORATIVE IVE 1. The doctor
may need to
1.Support the 1.Support the assist the
doctor or midwife doctor or
baby’s shoulder
in performing midwife in
to rotate
internal rotation. performing
internal through certain
rotation. maneuvers.
 B. Discharge Plan

1. Documentation of the appropriate use of maneuvers to relieve shoulder

dystocia demonstrates standard of care practice, thereby decreasing the
potential for successful malpractice allegations.

2. Nurses can assist mothers and families to review the shoulder dystocia
and any newborn injuries in the postpartum period, thereby reducing
confusion and anxiety.
Conclusion/ Implication of the case to student’
learning
Shoulder dystocia is an infrequent obstetric
emergency that often occurs without warning and can
lead to serious neonatal and maternal morbidity. When
the risk factors of fetal macrosomia, maternal diabetes,
postdatism, maternal obesity, previous history of
macrosomia and shoulder dystocia, second-stage
abnormalities, and operative vaginal delivery are
present, an even higher index of suspicion must be
present. Proper management of this disorder should be
aimed toward minimizing fetal and maternal morbidity
through an organized and expeditious clinical approach.
All obstetricians should frequently review the
management of shoulder dystocia.