Shoulder dystocia is an obstetric emergency that occurs when the anterior shoulder of the fetus cannot pass below the pubic symphysis after delivery of the head. This nursing diagnosis focuses on identifying risk factors, managing the emergency, and preventing complications for both mother and baby.
Causes (Related to)
Shoulder dystocia can occur due to various maternal and fetal factors that increase the risk of this obstetric emergency:
- Maternal factors including:
- Gestational diabetes
- Maternal obesity (BMI > 30)
- Post-term pregnancy
- Previous shoulder dystocia
- Advanced maternal age
- Small or abnormal pelvic structure
- Fetal factors including:
- Macrosomia (estimated fetal weight > 4000g)
- Post-term gestation
- Male gender
- Abnormal fetal position
- Labor-related factors including:
- Prolonged second stage of labor
- Instrumental delivery (forceps or vacuum)
- Epidural anesthesia
- Labor induction or augmentation
Signs and Symptoms (As evidenced by)
The recognition of shoulder dystocia requires careful observation of specific signs during delivery.
Subjective: (Mother reports)
- Intense pressure during pushing
- Inability to push the baby out despite strong contractions
- Increased pain or discomfort
- Anxiety and distress
Objective: (Nurse assesses)
- Turtle sign (retraction of the fetal head against perineum)
- Failed restitution of fetal head
- Failed delivery with routine traction
- Failure of shoulders to descend
- Need for additional maneuvers beyond routine delivery
- Prolonged head-to-body delivery time
Expected Outcomes
Successful management of shoulder dystocia is indicated by:
- Successful delivery of the infant within 5-7 minutes of diagnosis
- Minimal or no maternal trauma
- Minimal or no fetal injury
- Mother demonstrates understanding of potential future pregnancy risks
- Complete documentation of the event and interventions
- Appropriate follow-up care for both mother and infant
Nursing Assessment
Risk Factor Identification
- Review prenatal records
- Assess maternal history
- Monitor fetal size estimates
- Evaluate pelvic adequacy
- Document risk factors
Labor Progress Monitoring
- Track labor progression
- Assess contraction patterns
- Monitor fetal descent
- Evaluate pushing effectiveness
- Document delivery progress
Emergency Preparedness
- Verify emergency equipment availability
- Ensure team readiness
- Review HELPERR mnemonic
- Position emergency supplies
- Confirm communication systems
Maternal Assessment
- Monitor vital signs
- Assess pain levels
- Check psychological status
- Evaluate tissue integrity
- Document intervention responses
Fetal Assessment
- Monitor fetal heart rate
- Assess fetal position
- Check for signs of distress
- Document fetal responses
- Track delivery progress
Nursing Care Plans
Nursing Care Plan 1: Risk for Maternal/Fetal Injury
Nursing Diagnosis Statement:
Risk for Maternal/Fetal Injury related to mechanical forces during shoulder dystocia management as evidenced by the presence of risk factors and emergency delivery situation.
Related Factors:
- Mechanical forces during delivery
- Emergency interventions
- Anatomical constraints
- Time pressure during delivery
Nursing Interventions and Rationales:
- Position mother appropriately (McRoberts maneuver)
Rationale: Helps flatten sacrum and increase pelvic diameter - Apply suprapubic pressure as ordered
Rationale: Assists in rotating anterior shoulder under pubic bone - Monitor fetal heart rate continuously
Rationale: Detects fetal compromise early
Desired Outcomes:
- Successful delivery without maternal injury
- Minimal or no fetal trauma
- Effective emergency response implementation
- Complete documentation of interventions
Nursing Care Plan 2: Anxiety
Nursing Diagnosis Statement:
Anxiety related to emergency situation and fear for maternal/fetal wellbeing as evidenced by expressed concerns and physiological stress responses.
Related Factors:
- Emergency situation
- Uncertain outcomes
- Loss of control
- Fear for baby’s safety
Nursing Interventions and Rationales:
- Provide clear, concise communication
Rationale: Reduces anxiety through understanding - Maintain a calm, professional demeanor
Rationale: Helps reduce patient anxiety - Explain interventions briefly but clearly
Rationale: Promotes cooperation and reduces fear
Desired Outcomes:
- Reduced anxiety levels
- Improved cooperation with interventions
- Better understanding of the situation
- Positive coping mechanisms demonstrated
Nursing Care Plan 3: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to mechanical forces and emergency interventions as evidenced by the potential for tissue trauma during delivery.
Related Factors:
- Mechanical pressure
- Emergency maneuvers
- Tissue stretching
- Instrumental delivery
Nursing Interventions and Rationales:
- Assess perineal integrity frequently
Rationale: Early detection of tissue damage - Document any tears or lacerations
Rationale: Ensures proper follow-up care - Implement perineal care protocols
Rationale: Promotes healing and prevents infection
Desired Outcomes:
- Minimal tissue trauma
- Early identification of complications
- Appropriate healing progression
- Effective pain management
Nursing Care Plan 4: Risk for Ineffective Breathing Pattern (Newborn)
Nursing Diagnosis Statement:
Risk for Ineffective Breathing Pattern related to potential birth trauma and delayed delivery as evidenced by risk for respiratory compromise.
Related Factors:
- Prolonged delivery
- Potential nerve injury
- Respiratory compromise
- Birth trauma
Nursing Interventions and Rationales:
- Prepare resuscitation equipment
Rationale: Ensures immediate availability if needed - Assess newborn breathing immediately
Rationale: Early detection of respiratory issues - Monitor oxygen saturation
Rationale: Ensures adequate oxygenation
Desired Outcomes:
- Effective respiratory function
- Normal oxygen saturation levels
- Successful transition to extrauterine life
- No signs of respiratory distress
Nursing Care Plan 5: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to understanding of shoulder dystocia and future pregnancy implications as evidenced by questions about recurrence risks and prevention.
Related Factors:
- Complex medical situation
- Lack of previous experience
- Information overload
- Stress during event
Nursing Interventions and Rationales:
- Provide post-event education
Rationale: Increases understanding and preparation for future - Review risk factors for future pregnancies
Rationale: Promotes informed decision-making - Discuss preventive measures
Rationale: Empowers patient with knowledge
Desired Outcomes:
- Understanding of shoulder dystocia
- Knowledge of future pregnancy risks
- Awareness of preventive measures
- Ability to verbalize concerns
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Chauhan SP, Gherman RB. Shoulder Dystocia: Challenging Basic Assumptions. Obstet Gynecol Clin North Am. 2022 Sep;49(3):491-500. doi: 10.1016/j.ogc.2022.02.005. PMID: 36122981.
- Hill MG, Cohen WR. Shoulder dystocia: prediction and management. Womens Health (Lond). 2016;12(2):251-61. doi: 10.2217/whe.15.103. Epub 2016 Feb 22. PMID: 26901875; PMCID: PMC5375046.
- Menticoglou S. Shoulder dystocia: incidence, mechanisms, and management strategies. Int J Womens Health. 2018 Nov 9;10:723-732. doi: 10.2147/IJWH.S175088. PMID: 30519118; PMCID: PMC6233701.
- Olson, D. N., Logan, L., & Gibson, K. S. (2021). Evaluation of multidisciplinary shoulder dystocia simulation training on knowledge, performance, and documentation. American Journal of Obstetrics & Gynecology MFM, 3(5), 100401. https://doi.org/10.1016/j.ajogmf.2021.100401
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
