Never apply fundal pressure for shoulder dystocia; it worsens the impaction.
Before you read
Test yourself first: 2 questions
Question 1 of 2
A nurse is teaching a client newly diagnosed with gestational diabetes about fetal risks. Which complication should the nurse identify as most directly associated with poor maternal glucose control?
Answer: B. Maternal hyperglycemia drives fetal hyperinsulinemia, producing macrosomia (large for gestational age). Macrosomia increases the risk of shoulder dystocia and birth trauma. Growth restriction is more typical of vascular or placental insufficiency, not uncontrolled gestational diabetes.
Question 2 of 2
A client with a new permanent pacemaker is taught to:
Answer: B. Monitor pulse daily and report a rate below the set rate, avoid strong electromagnetic fields/MRI unless cleared, carry the device ID card, and avoid heavy lifting/raising the arm above the shoulder on the insertion side initially.
Keep the streak going with more questions like these, each with a full rationale.
What is shoulder dystocia?
It is unpredictable and can cause neonatal brachial plexus injury, clavicle fracture, hypoxia, and maternal hemorrhage or tears. Rapid, coordinated maneuvers are needed to relieve the impaction.
Key points to remember
- The 'turtle sign' (the fetal head retracts tightly against the perineum) signals shoulder dystocia.
- Risk factors include fetal macrosomia, maternal diabetes, obesity, and a prolonged second stage.
- The McRoberts maneuver (sharp hyperflexion of the mother's thighs onto her abdomen) plus suprapubic pressure is the first-line response.
- Suprapubic (not fundal) pressure is applied to dislodge the anterior shoulder; fundal pressure worsens impaction.
- Brachial plexus injury (Erb palsy) and clavicle fracture are common neonatal complications.
- Maternal complications include postpartum hemorrhage and perineal/vaginal lacerations.
Nursing priorities
- Call for help immediately and note the time; mobilize the obstetric emergency team.
- Perform the McRoberts maneuver (hyperflex maternal hips/thighs) and apply suprapubic pressure as directed.
- Assist with documentation of maneuvers, times, and personnel.
- After birth, assess the neonate for arm movement, clavicle integrity, and respiratory effort.
- Assess the mother for hemorrhage and lacerations postpartum.
Patient teaching
- Explain to the laboring woman the leg-positioning maneuver and the need to follow rapid directions.
- Reassure parents that brachial plexus injury is often temporary and that follow-up will assess arm movement.
- Counsel diabetic clients on glucose control to reduce macrosomia risk in future pregnancies.
Red flags: report now
- Never apply fundal pressure for shoulder dystocia; it worsens the impaction.
- Report the turtle sign and absent restitution/delivery of the body promptly.
- Report neonatal arm weakness/asymmetry or respiratory distress and maternal heavy bleeding after delivery.
References
Clinical references for this topic
