Last updated on May 18th, 2022 at 10:26 am
Shoulder Dystocia Nursing Care Plans Diagnosis and Interventions
Shoulder Dystocia NCLEX Review and Nursing Care Plans
Shoulder dystocia is a medical emergency which occurs when the baby’s shoulder is caught on the mother’s pubic bone during delivery. It is sometimes referred to as “turtle sign” due to its presentation.
The head is delivered but the shoulder gets stuck so the head pops back into the birth canal, imitating a turtle’s head.
It is commonly the anterior aspect of one shoulder that gets caught in one of the mother’s pelvic bones.
Shoulder dystocia carries the risk of maternal and infant mortality; hence, immediate action is necessary as soon as it is identified.
The longer the shoulder remains stuck on the mother’s pelvis, the higher the risk of developing complications for the baby and the mother.
Signs and Symptoms of Shoulder Dystocia
Shoulder dystocia can only be identified once the head is already delivered.
The most common presentation that leads midwives and clinicians to suspect it is the retraction of the head back into the birth canal.
The repeated retraction of the head is called “turtle sign” as it mimics a turtle popping its head in and out of its shell.
Causes and Risk Factors of Shoulder Dystocia
The exact cause of shoulder dystocia is unknown.
It could be difficult for a health care provider to diagnose it prior to labor and delivery as it cannot be predicted.
However, there are risk factors associated with it. They are as follows:
- The mother has gestational diabetes which can cause macrosomia or large birth weight baby
- The mother has a small stature, which usually suggests she may have smaller pelvic bones and birth canal.
- History of previous delivery with shoulder dystocia
- History of giving birth to a large birth weight baby
- Having induction of labor
- Being overweight
- Deliveries past due date
- History of having assisted delivery
- Multiple pregnancies
Though these risk factors have been identified to be related to shoulder dystocia, there are still a number of cases not involving any of these risk factors.
Complications of Shoulder Dystocia
Shoulder dystocia is considered a medical emergency because of the risk of mortality on both the infant and the mother.
It is recorded that less than 10% of cases recorded have permanent complications to the newborn.
Complications to the baby are as follows:
- Reduced oxygen supply. When the shoulder gets stuck in the mother’s pelvis, the umbilical cord can also get caught, causing an impeded flow of blood to the baby. At this stage, the baby still gets his/her oxygen supply from the blood flowing through the umbilical cord. Therefore, obstructed flow in the umbilical cord means reduced oxygen supply to the body and most importantly, to the baby’s brain, which can lead to brain damage.
- Injuries to the collarbone, shoulder, or arm. In some cases, damages to these areas are recorded.
- Damage to the nerves in the affected arm
- Risk of paralysis
Complications to the mother include the following:
- Excessive bleeding
- Vaginal tearing
- Damage to the bladder
Diagnosis of Shoulder Dystocia
Midwives and health care workers will not necessarily know that shoulder dystocia will happen until it is happening.
After the delivery of the baby’s head, the rest of the body usually follow straight after.
However, when the midwife or doctor notices the retraction of the head into the birth canal, the doctor will make the diagnosis straightaway and act fast to correct it.
During the prenatal visits, risk factors may be identified that may lead the midwife or the doctor to the possibility of shoulder dystocia happening, but again, they cannot be certain.
Ultrasound prior to delivery can suggest the baby’s measurement and options for a different method of delivery may then be discussed.
Treatment of Shoulder Dystocia
Once shoulder dystocia is identified and diagnosed, the health care workers and midwives will need to act fast. The following mnemonic is what they usually follow in the treatment of shoulder dystocia – HELPERR.
H – Help. Shoulder dystocia is a medical emergency, therefore, more intensive monitoring and assistance will be needed. Asking for an extra hand is usually the health care worker’s first move.
E – Episiotomy. The midwife or doctor will need to evaluate the need for an episiotomy. An episiotomy is when an incision is 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 through.
L –Legs. The midwife or doctor may ask the mother to assume a position where the legs are pulled towards the stomach. It is also known as the McRoberts maneuver. It promotes the rotation of the pelvis to let the baby pass through easily.
P – Pressure. Pressure may be placed on the suprapubic area of the mother to encourage baby’s shoulder to change position and rotate.
E – Enter maneuver. The doctor may need to assist the baby’s shoulder to rotate through certain maneuvers. It can also be called internal rotation.
R – Remove posterior arm from the birth canal. It may be helpful if the doctor can push and free up on of the baby’s arms from the birth canal to ease the shoulder’s passage.
R – Roll the patient. Asking the mother to position herself on all fours can help the baby to pass through easily.
Nursing Diagnosis for Shoulder Dystocia
Shoulder Dystocia Nursing Care Plan 1
Nursing Diagnosis: Risk for Altered Uteroplacental Tissue Perfusion related to shoulder dystocia
Desired Outcome: The baby will maintain efficient tissue perfusion and will be delivered successfully.
| Shoulder Dystocia Nursing Interventions | Rationales |
| Ask for help. Ensure that there are enough members of the team to support the delivery of the baby with dystocia. | Shoulder dystocia is a medical emergency, therefore, more intensive monitoring and assistance will be needed. Asking for an extra hand is usually the health care worker’s first move. |
| Consider the need for an episiotomy. | An episiotomy is when an incision is 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 through. |
| Assist the mother to assume the McRoberts maneuver. | The McRoberts 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. |
| Place pressure on the suprapubic area of the mother. | To encourage baby’s shoulder to change position and rotate. |
| Support the doctor or midwife in performing internal rotation. | The doctor may need to assist the baby’s shoulder to rotate through certain maneuvers. |
| Remove posterior arm from the birth canal. | It may be helpful if the doctor can push and free up on of the baby’s arms from the birth canal to ease the shoulder’s passage. |
| Roll the patient. | Asking the mother to position herself on all fours can help the baby to pass through easily. |
Shoulder Dystocia Nursing Care Plan 2
Nursing Diagnosis: Risk for Deficient Fluid Volume related to heavy bleeding during delivery
Desired Outcome: Post-delivery, the mother will re-establish a functional body fluid volume and a balanced input and output status.
| Shoulder Dystocia Nursing Interventions | Rationale |
| Post-delivery, assess vital signs, conduct physical examination, and commence daily weight monitoring. | Edema, headaches, low blood pressure, and pain are associated with the patient’s blood loss. Fluid retention may be evident if the patient has an unexplained weight gain. |
| Start input and output monitoring. | To monitor circulatory blood volume. To ensure that the patient has adequate oral hydration or if there is a need to commence IV hydration therapy. |
| Speak to the patient and family about the need for hospitalization for the treatment of serious hemorrhage. | To treat the vaginal bleeding and deficient fluid volume related to shoulder dystocia in the appropriate setting. |
| Prepare for blood transfusion as required. | To increase blood volume. |
| Encourage the patient to have a low salt intake. | Consuming salt between 2 to 4 g per day is ideal as a high salt intake may lead to dehydration. |
Shoulder Dystocia Nursing Care Plan 3
Nursing Diagnosis: Risk for Maternal Injury
Desired Outcome: The patient will maintain safety and participate in measures that will protect self during the treatment.
| Shoulder Dystocia Nursing Interventions | Rationale |
| Assess the patient’s risks for vaginal tearing and bladder damage. | Shoulder dystocia may cause the patient to have vaginal bleeding due to the unnatural position of the baby during delivery. |
| Monitor the patient’s level of consciousness using AVPU. Heavy vaginal bleeding may result to hypotension and lower level of consciousness. Using AVPU scale (i.e. Alert, Voice, Pain stimuli, or Unresponsive/unconscious) can help determine the urgency of surgical treatment and increased risk for maternal injury. | |
| Prepare the patient for immediate surgical intervention to deliver the baby with shoulder dystocia. | An episiotomy is when an incision is 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 through. |
| Post-delivery, place the patient in complete bed rest if there is evidence of severe bleeding. | To help regain energy, and keep the patient safe |
Shoulder Dystocia Nursing Care Plan 4
Risk for Fetal Injury
Nursing Diagnosis: Risk for Fetal Injury related to shoulder dystocia secondary to cephalopelvic disproportion (CPD) and fetal malpresentation,
Desired Outcomes:
- The mother will be able to participate in calculated interventions that will improve labor pattern.
- The mother will be able to display normal fetal heart rates, with noted good variability and the absence of late decelerations.
| Shoulder Dystocia Nursing Interventions | Rationale |
| Evaluate the fetal heart rate, taking note of the variability, any sporadic changes, and the baseline fetal heart rate. When using a doppler machine, ensure to check for the fetal heart tone in between contractions. The manner of counting should be for 10 minutes, with breaks of 5 minutes and resuming for 10 minutes. Follow through with this counting pattern during the contraction to midway between it and the next contraction. | Monitoring for the fetal heart tones is essential to detect abnormal results such as exaggerated variability, bradycardia, and tachycardia that may be induced by stress, sepsis, acidosis, or hypoxia. |
| Observe the frequency of uterine contractions. Inform the healthcare team or the physician if the frequency is 2 minutes or less. | Having a two-minute or less contraction would indicate inadequate oxygenation to the fetal intervillous spaces that would compromise the status of both the patient and the fetus. |
| Recognize maternal factors that may worsen fetal health such as dehydration, anxiety, acidosis, or vena cava syndrome. | Some procedures, such as the simple turning of the patient to the lateral recumbent position, can promote better circulating oxygen-rich blood to the uterus and placenta that may correct or prevent fetal hypoxia. s |
| Observe the descent of the fetus in the birth canal, with regards to the ischial spines of the pelvis. | The fetus descending at a rate of 1 cm/hr (for primipara) or less than 2 cm/hr (for a multipara) would indicate cephalopelvic disproportion (i.e., the baby’s head is too big for the birth canal) or malposition (i.e., the shoulder is presenting instead of the fetal head.) |
| Evaluate for malpositioning utilizing Leopold’s maneuvers and correlate with the internal examination, such as the location of fontanelles and cranial sutures. Double-check the findings by ultrasound. | Finding the fetal lie, position, and presentation will assist in identifying contributing factors that may lead to dysfunctional labor. |
| Once fetal malposition is determined, especially in a free-standing birthing center, arranging for transfer to a facility with a higher level of care capabilities is necessary. | Fetal presentations other than the vertex increases the injury or death risk of the fetus when delivering the baby via the vaginal route. |
| Make the client ready for the most advantageous delivery method if the fetus is found out to be on either brow, face, chin, or shoulder presentation. | Fetal presentations such as brow, face, chin or shoulders increase the risk of CPD due to the unnaturally large diameter of the fetal skull (or shoulder) entering the pelvis as the mother gives birth. Furthermore, unusual presentations would need a forcep or vacuum-assisted delivery of the fetus. If these procedures are unsuccessful, a cesarean delivery is necessary due to the failure of labor progress and ineffective labor pattern. |
| Observe and assess the color and amount of amniotic fluid once membranes rupture. | Fetal anomalies have been associated with the presence of excessive amniotic fluid that has caused uterine overdistention. The staining of the amniotic fluid with meconium, especially on a vertex presentation, can cause hypoxia by stimulating vagal response and anal sphincter relaxation. Observing for deviations in the amniotic fluid can assist the healthcare team to anticipate the potential needs of the newborn (e.g., airway support). |
| Note for the presence of visible cord prolapse when membranes rupture. Variable decelerations in the monitoring strip, especially on breech presentations, would indicate cord prolapse. | Cord prolapse is more likely on breech presentations, due to the poor engagement of the presenting fetal part. |
| Anticipate for cesarean delivery of the breech presentation especially if CPD is identified, the fetus fails to descend, or if labor progress stops. | A vaginal delivery of a fetus in a breech position is related to increased risk of injury to the spine, brachial plexus, clavicle, and brain structures. Immediate surgical intervention should be facilitated to decrease neonatal morbidity and mortality rates, risk of hypoxia, and unnecessary fetal trauma. |
Shoulder Dystocia Nursing Care Plan 5
Ineffective Individual Coping
Nursing Diagnosis: Ineffective Individual Coping related to situational crisis secondary to shoulder dystocia as evidenced by verbalizations and behavior on inability to cope, irritability, and manifestations of tension and fatigue.
Desired Outcomes:
- The patient will be able to express understanding of her current state and situation.
- The patient will be able to correctly identify and utilize effective coping strategies and techniques in relation to the current situation.
| Shoulder Dystocia Nursing Interventions | Rationale |
| Ascertain the progress of the patient’s labor. Evaluate the patient’s level of pain in relation to the dilation and effacement of the cervix. | The mother on prolonged labor with associated fatigue can decrease her ability to manage contractions. Likewise, increasing pain in the absence of the cervix not dilating or effacing may indicate the start of a dysfunction. Extreme pain could be an indication of the anoxia (i.e., absence of oxygen) on the cells of the uterus. |
| Help the patient to accept the reality of the experienced pain and discomfort and provide comfort measures as required. | In instances of lack of progression in the delivery process, having pain and discomfort may be interpreted as not part of a dysfunctional problem. The health care team, taking the time to acknowledge the patient’s feelings can help the patient feel reassurance and comfort, thereby decreasing discomfort and promoting her ability to cope with the current situation. |
| Assess the patient’s anxiety levels, including her significant others. Consider feelings of frustration regarding the situation. | Excessive anxiety levels heighten adrenal activity and the release of catecholamines and consequently, resulting to various endocrine imbalance. The overflow of epinephrine impedes myometrial activity and uterine contractions. Undue stress will reduce available glucose, which is needed for adenosine triphosphate (ATP) synthesis, and in turn, is necessary for good uterine contraction. |
| Explain the probability of discharging the patient home until active labor is apparent. | A patient too early to be admitted contributes to instances of a long labor process for the mother. The need to place the patient in a familiar environment is needed to promote relaxation. Likewise, doing so will give the patient ample time to refocus attention and attend to tasks that are worsening the level of her anxiety and frustration. |
| Support and give encouragement to the efforts of the client or couple. | Giving support and encouragement is a valuable tool for the healthcare team to utilize in correcting client misconceptions about an overreaction to labor or self-blame for deviations on the scheduled birth plan. |
| Offer comfort measures and client repositioning as needed. Consider ambulation for the patient as appropriate. Help the patient by using relaxation techniques such as deep-breathing exercises, etc. | Relaxation and diversional techniques help in reducing patient anxiety. It also encourages relaxation and establishes a sense of control for the patient. Considering these options can assist the patient to positively cope with the current situation. |
| Provide information and data on the current situation. | Providing the patient with the current data address issues on the “unknowns” and helps assist in decreasing anxiety. It also provides an opportunity for the patient to make an informed decision in light of the current situation. |
Shoulder Dystocia Nursing Care Plan 6
Anxiety
Nursing Diagnosis: Anxiety related to situational crisis secondary to shoulder dystocia as evidenced by increased tension, and display of restless and fearful behavior.
Desired Outcomes:
- The patient will be able to utilize breathing and relaxation techniques effectively
- The patient will be able to collaborate with the healthcare team in preparation for rapid delivery.
- The patient will be able to follow instructions for a safe and efficient delivery process.
| Shoulder Dystocia Nursing Interventions | Rationale |
| Ensure to promote a calm environment. Give out clear and condensed instructions. Offer explanations to the patient. | In instances wherein the delivery is extremely complicated and occurring outside the hospital setting, it could prove daunting and anxiety-provoking for both the patient and spouse, especially for those who expected an orderly labor and delivery process. When the actual experience is far from their expectations, patient reactions may present with either fear, hostility, or disappointment. At these times, the decorum and approach of the healthcare team are necessary to avoid or allay unnecessary anxiety. |
| Ensure to have the patient stay in a quiet and calm environment, with privacy maintained as appropriate. Ensure proper positioning of the patient to promote comfort. | A calm and quiet environment decreases unnecessary distraction and discomfort, thereby giving the patient the time to focus. It further decreases needless anxiety from others thereby supporting modesty and a sense of self-respect. |
| Allow the significant other to stay with the patient in order to provide comfort, support, and assistance. | The patient’s significant other being present enhances self-esteem. Furthermore, it promotes closer family ties and reduces needless apprehension. With this, it assists the healthcare team controls the situation in order to deliver the best possible care. |
| Utilize therapeutic touch (if the patient consents), active listening, use of presence, and calm demeanor in order to establish to the patient that they are not alone with the process of a complicated delivery. Encourage self-expression or clarifications of concerns, needs, and patient queries. | Showing support to the patient in stressful situations promotes improved communication between patient and caregiver, thereby facilitating a better care experience. |
| Inquire and utilize the patient’s use of coping techniques that she has previously used and found effective previously. | Previous experiences in controlling anxiety can help the patient address the apprehension about the current situation. It also provides a sense of mastery and renewed confidence |
| Stay with the patient. Supply the patient with the needed information, considering the ongoing labor progression and eventual delivery of the baby. | Offering to stay with the patient promotes positive coping and cooperation for the patient. Furthermore, it decreases unnecessary apprehension and anxiety that could affect the labor and delivery process. |
| Support the patient to utilize appropriate relaxation or diversional methods. | Relaxation and diversional techniques have been proven to assist with stressful and anxiety-inducing situations. It aids in establishing a sense of control over the situation. Furthermore, it improves the participation of the patient and significant other in the whole labor and delivery process. |
| Organize for professional help, medical or nursing staff assistance, as necessary. Tell the patient that assistance has been requested to address her needs. | The patient knowing that additional assistance has been brought will ensure better management of the stressful situation. It also keeps the patient or couple from feeling more apprehensive and increases security. |
| Facilitate the delivery process in a calm manner as much as possible. Ensure to and give out continuous information about the current situation. | Maintaining a calm decorum will help the patient remain calm and focus on the birthing process. It also allows for the patient to listen and follow through with the instructions better. |
| Position the newborn on the mother’s abdomen as soon as good respirations are established. Have the patient’s spouse cradle the newborn. | Placing the newborn on the mother’s abdomen promotes mother-baby bonding after the birthing process. It gives a positive experience for the patient, newborn, and the family after a successful delivery. |
More Shoulder Dystocia Nursing Diagnosis
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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