Notes
image from: babycentre.co.uk
Description
- In shoulder dystonia, the anterior shoulder of the baby is unable to pass under the maternal pubic arch.
Etiology
- Shoulder dystocia is associated with advanced maternal age, diabetes maternal obesity, large baby (macrosomia), postdate pregnancy, and multiparity.
Pathophysiology
- The plane of the fetal shoulders aligns perpendicular to the pubis instead of at an angle. This causes the shoulder to become wedged under the pubic arch.
Assessment Findings
1. Associated findings. The birth process may seem unnecessarily prolonged.
2. Clinical manifestations
- The fetal head retracts against the mother’s perineum as soon as the head is delivered. This is known as the “turtle sign.”
- External rotation does not occur.
Nursing Management
- Identify shoulder dystocia and assist with management.
1. Place the client in the McRobert’s position (ie, thighs pulled up against the abdomen with hips abducted).
- The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve. A supported squat has a similar effect and adds gravity to her pushing efforts.
Image credit to: foamem.com
2.Apply suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis. Fundal pressure should not be used, because it will push the anterior shoulder more firmly against the mother’s symphysis.
Nursing Care Plan
Dysfunctional/Dystocia Nursing Care Plans
Risk For Fluid Volume Deficit
Risk for fluid volume deficit: At risk for experiencing vascular, cellular, or intracellular dehydration.
Risk factors
- Hypermetabolic state.
- Vomiting.
- Profuse diaphoresis.
- Restricted oral intake.
- Mild diuresis associated with oxytocin administration
Possibly evidenced by
- [Not applicable].
Desired Outcomes
- Patient will maintain fluid balance, as evidenced by moist mucous membranes, appropriate urine output, and palpable pulses.
- Patient will be free of complications.
| Nursing Interventions | Rationale |
|---|---|
| Monitor vital signs. Note reports of dizziness with change of position. | Increased pulse rate and temperature, and orthostatic BP changes may indicate decrease in circulating volume. |
| Assess lips and oral mucous membranes and degree of salivation. | Dry oral mucous membranes/lips and decreased salivation are further indicators of dehydration. |
| Note abnormal FHR response. | May reflect effects of maternal dehydration and decreased perfusion. |
| Keep accurate intake/output, test urine for ketones, and assess breath for fruity odor. | Decreased urine output and increased urine specific gravity reflect dehydration. Inadequate glucose intake results in a breakdown of fats and presence of ketones. |
| Encourage oral fluids as appropriate. | Clear liquids such as fruit juices and broths provide not only fluids but also calories for energy production. Note: PO fluids are not recommended if surgical intervention is contemplated. |
| Review laboratory data, e.g.: Hb/Hct, serum electrolytes, and serum glucose. | Increased Hematocrit suggests dehydration. Serumelectrolyte levels detect developing imbalances; serum glucose levels detect hypoglycemia. |
| Administer fluids intravenously. | Parenteral solutions containing electrolytes and glucose can correct or prevent maternal and fetal imbalances and may reduce maternal exhaustion. |
Risk For Maternal Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Risk factors
- Alteration of muscle tone/contractile pattern.
- Maternal fatigue.
- Mechanical obstruction to fetal descent.
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- Patient will accomplish cervix dilation at least 1.2 cm/hr for primipara, 1.5 cm/hr for multipara in active phase, with fetal descent at least 1 cm/hr for primipara, 2 cm/hr for multipara.
| Nursing Interventions | Rationale |
|---|---|
| Review the history of labor, onset, and duration. | Helpful in identifying possible causes, needed diagnostic studies, and appropriate interventions. Uterine dysfunction may be caused by an atonic or a hypertonic state. Uterine atony is classified as primary when it occurs before the onset of labor (latent phase) or secondary when it occurs after well-established labor (active phase). |
| Note timing/type of medication(s). Avoid administration of narcotics or of epidural block anesthetics until the cervix is 4 cm dilated. | A hypertonic contractile pattern may occur in response to oxytocin stimulation; sedation/analgesia given too early (or in excess of needs) can inhibit or arrest labor. |
| Note the condition of cervix. Monitor for signs of amnionitis. Note elevated temperature or WBC; odor and color of vaginal discharge. | A rigid or unripe cervix will not dilate, impending fetal descent/labor progress. Development of amnionitis is directly related to length of labor, so that delivery should occur within 24 hr after rupture of membranes. |
| Assess uterine contractile pattern manually (palpation) or electronically via external, or internal monitor with internal uterine pressure catheter (IUPC). | Dysfunctional contractions lengthen labor increasing the risk of maternal/fetal complications. A hypotonic pattern is reflected by frequent, mild contractions measuring less than 30 mm Hg via IUPC or “soft as chin” per palpation. A hypertonic pattern is reflected by increased frequency, an elevated resting tone per palpation or greater than 15 mm Hg via IUPC, and possibly decreased intensity of contractions. Note: Intensity of contractions cannot be measured by an external monitor. |
| Evaluate the current level of fatigue, as well as activity and rest prior to onset of labor. | Excess maternal exhaustion contributes to secondary dysfunction, or may be the result of prolonged labor/false labor. |
| Note effacement, fetal station, and fetal presentation. | These indicators of labor progress may identify a contributing cause of prolonged labor. For example, breech presentation is not as effective a wedge for cervical dilation as is vertex presentation. |
| Evaluate degree of hydration. Note amount and type of intake. | Prolonged labor can result in a fluid-electrolyte imbalance as well as depletion of glucose reserves, resulting in exhaustion and prolonged labor with increased risk of uterine infection, postpartal hemorrhage, or precipitous delivery in the presence of hypertonic labor. |
| Graph cervical dilation and fetal descent against time (i.e., Friedman curve). | May be used on occasion to record progress/ prolongation of labor. |
| Review bowel habits and regularity of evacuation | Bowel fullness may hinder uterine activity and interfere with the fetal descent. |
| Encourage client to void every 1–2 hr. Assess for bladder fullness over symphysis pubis. | A full bladder may inhibit uterine activity and interfere with the fetal descent. |
| Place client in lateral recumbent position and encourage bed rest or sitting position/ambulation,as tolerated. | Relaxation and increased uterine perfusion may correct a hypertonic pattern. Ambulation may assist gravitational forces in stimulating normal labor pattern and cervical dilation. |
| Have emergency delivery kit available. | May be needed in the event of a precipitous labor and delivery, which are associated with uterine hypertonicity. |
| Remain with the client if possible, arrange for the presence of doula as appropriate; provide a quiet environment as indicated. | Decrease external stimuli may be important to allow sleep after administration of medication to a client in the hypertonic state. Also helpful in decreasing the level of anxiety, which can contribute to both primary and secondary uterine dysfunction. |
| Palpate the abdomen of thin client for the presence of pathological retraction ring between uterine segments. (These rings are not palpable through the vagina or through the abdomen, in the obese client). | In obstructed labor, a depressed pathological ring (Bandl’s ring) may develop at the juncture of lowerand upper uterine segments, indicating an impending uterine rupture. |
| Investigate reports of severe abdominal pain. Note signs of fetal distress, cessation of contractions, presence of vaginal bleeding. | May indicate developing uterine tear/acute rupture necessitating emergency surgery. Note: Hemorrhage is usually occult since it is intraperitoneal with hematomas of the broad ligament. |
| Prepare client for amniotomy, and assist with the procedure, when the cervix is 3–4 cm dilated. | Rupture of membranes relieves uterine overdistension (a cause of both primary and secondary dysfunction) and allows presenting part to engage and labor to progress in the absence of cephalopelvic disproportion (CPD). Note: Active management of labor (AML) protocols may support amniotomy once presenting part is engaged to accelerate labor/help prevent dystocia. |
| Administer narcotic or sedative, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for sleep as indicated. | May help distinguish between true and false labor. With false labor, contractions cease; with true labor, a more effective pattern may happen following a rest. Morphine helps promote heavy sedation and eliminate hypertonic contractile pattern. A period of rest conserves energy and reduces utilization of glucose to relieve fatigue. |
| Use nipple stimulation to produce endogenous oxytocin or initiate infusion of exogenous oxytocin (Pitocin) or prostaglandins. | Oxytocin may be necessary to increase or institute myometrial activity for a hypotonic uterine pattern.It is usually contraindicated in hypertonic labor pattern because it can accentuate the hypertonicity, but may be tried with amniotomy if the latent phase is prolonged and if CPD and malpositions are ruled out. |
| Prepare for forceps delivery, as necessary. | Excessive maternal fatigue, resulting in ineffective bearing-down efforts in stage II labor, necessitates the use of forceps. |
| Assist with preparation for cesarean delivery, as indicated, e.g., malposition, CPD, or Bandl’s ring. | Immediate cesarean birth is indicated for Bandl’s ring or fetal distress due to CPD. Note: Once labor is diagnosed, if delivery has not occurred within 12 hr, and amniotomy and oxytocin have been used appropriately, then a cesarean delivery is recommended by some protocols. |
Risk For Fetal Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Risk Factors
- Abnormalities of the maternal pelvis.
- Cephalopelvic disproportion (CPD).
- Fetal malpresentation.
- Tissue hypoxia/acidosis.
- Prolonged labor.
Possibly evidenced by
- [Not applicable].
Desired Outcomes
- Patient will participate in interventions to improve labor pattern and/or reduce identified risk factors.
- Patient will display FHR within normal limits, with good variability, no late decelerations noted.
| Nursing Interventions | Rationale |
|---|---|
| Assess FHR manually or electronically. Note variability, periodic changes, and baseline rate. If in the free standing birth center, check Fetal heart tone between contractions using a Doptone. Count for 10 min, break for 5 min, and count again for 10 min. Continue this pattern throughout the contraction to midway between it and the following contraction. | Detects abnormal responses, such as exaggerated variability, bradycardia, and tachycardia, which may be caused by stress, hypoxia, acidosis, or sepsis. |
| Note frequency of uterine contractions. Notify physician if the frequency is 2 min or less. | Contractions occurring every 2 min or less do not allow for adequate oxygenation of intervillous spaces. |
| Note uterine pressures during resting and contractile phases via intrauterine pressure catheter, if available. | Resting pressure greater than 30 mm Hg or contractile pressure greater than 50 mm Hg reduces or compromises oxygenation within intervillous spaces. |
| Identify maternal factors such as dehydration, acidosis, anxiety, or vena caval syndrome. | Sometimes, simple procedures (such as turning client to lateral recumbent position) can increase circulating blood and oxygen to uterus and placenta and may prevent or correct fetal hypoxia. |
| Monitor fetal descent in birth canal in relation to ischial spines. | Descent that is less than 1 cm/hr for a primipara, or less than 2 cm/hr for a multipara, may indicate CPD or malposition. |
| Assess for malpositioning using Leopold’s maneuvers and findings on internal examination (location of fontanelles and cranial sutures). Review results of ultrasonography. | Determining fetal lie, position, and presentation may identify factor(s) contributing to dysfunctional labor. |
| Arrange transfer to aacute care setting if malposition is detected in client in a free-standing birth center without adequate surgical/high-risk neonatal capabilities. | Risk of fetal/neonatal injury or demise increases with vaginal delivery if presentation is other than vertex. |
| Prepare client for the most expedient method of delivery if fetus is in brow, face, or chin presentation. | Such presentations increase the risk of CPD, owing to a larger diameter of the fetal skull entering the pelvis (11 cm in brow or face presentation, 13 cm in chin presentation, versus 9.5 cm for vertex presentation), often necessitating assisted delivery via forceps or vacuum, or cesarean delivery because of failure to progress and ineffective labor pattern. |
| Assess for deep transverse arrest of the fetal head. | Failure of the vertex to rotate fully from an OP to an occiput OA position may result in a transverse position, arrested labor, and the need for cesarean delivery. |
| Note color and amount of amniotic fluid when membranes rupture. | Excess amniotic fluid causing uterine over distention is associated with fetal anomalies. Meconium-stained amniotic fluid in a vertex presentation results from hypoxia, which causes vagal stimulation and relaxation of the anal sphincter. Noting characteristics of amniotic fluid alerts staff to potential needs of newborn, e.g., airway/ventilatory support. |
| Observe for visible cord prolapse when membranes rupture, and occult cord prolapse as indicated by variable decelerations on monitor strip, especially if fetus is in breech presentation. | Cord prolapse is more likely to occur in breech presentation, because the presenting part is not firmly engaged, nor is it totally blocking the os, as in vertex presentation. |
| Note odor and change in color of amniotic fluid with prolonged rupture of membranes. | Ascending infection and sepsis with accompanying fetal tachycardia may occur with prolonged rupture of membranes. |
| Have client assume hands-and-knees position, or lateral Sims’ position on side opposite that to which fetal occiput is directed, if fetus is in OP position. | These positions encourage anterior rotation by allowing fetal spine to fall toward the client’santerior abdominal wall (70% of fetuses in OP position rotate spontaneously). |
| Administer antibiotic to client, as indicated. | Prevents/treats ascending infection and will protect fetus as well. |
| If fetus fails to rotate from OP to OA position (faceto pubis), prepare for delivery in posterior position.Alternatively, apply vacuum extractor as indicated. | Delivering the fetus in a posterior position results in a higher incidence of maternal lacerations. Vacuum extractor may be used to rotate and expedite delivery of fetus. |
| Prepare for cesarean delivery of breech presentationif fetus fails to descend, labor progress ceases, or CPD is identified. | Vaginal delivery of an infant in breech position isassociated with injury to the fetal spinal column, brachial plexus, clavicle, and brain structures, increasing neonatal mortality and morbidity. Risk of hypoxia caused by prolonged vagal stimulation with head compression, and trauma such as intracranial hemorrhage, can be alleviated or prevented if CPD is identified and surgical intervention follows immediately |
Ineffective Individual Coping
Ineffective Individual Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.
May be related to
- Inadequate/exhausted support systems.
- Personal vulnerability.
- Situational crisis.
- Unrealistic expectations/perceptions.
Possibly evidenced by
- Verbalizations and behavior indicative of inability to cope (loss of control, inability to problem-solve and/or meet role expectations), irritability, reports of tension/fatigue.
Desired Outcomes
- Patient will verbalize understanding of what is happening.
- Patient will identify/use effective coping techniques.
| Nursing Interventions | Rationale |
|---|---|
| Determine progress of labor. Assess degree of pain in relation to dilation/effacement. | Prolonged labor with resultant fatigue can reduce the client’s ability to cope/manage contractions. Increasing pain when the cervix is not dilating/ effacing can indicate developing dysfunction. Extreme pain may indicate developing anoxia of the uterine cells. |
| Acknowledge reality of client’s reports of pain/discomfort. | Discomfort and pain may be misunderstood in the presence of lack of progression that is not recognized as a dysfunctional problem. Feeling listened to and supported can help client relax, reducing discomfort and enhancing ability to cope with situation. |
| Determine anxiety level of client and partner. Note evidence of frustration. | Excess anxiety increases adrenal activity/release of catecholamines, causing endocrine imbalance. Excess epinephrine inhibits myometrial activity. Stress also depletes glycogen stores, reducing glucose available for adenosine triphosphate (ATP) synthesis, which is needed for uterine contraction. |
| Discuss possibility of discharge of client to home until active labor is established. | Too early admission fosters a sense of longer/ prolonged labor for client. Client may be able to relax better in familiar surroundings. Provides opportunity to divert/refocus attention and to attend to tasks that may be contributing to level of anxiety/frustration. |
| Provide encouragement for client/couple efforts to date. | May be useful in correcting misconception that client is overreacting to labor or is somehow to blame for alteration of anticipated birth plan. |
| Provide comfort measures and reposition client/encourage ambulation as appropriate. Demonstrate/encourage use of relaxation techniques, including patterned breathing. | Reduces anxiety, promotes relaxation and sense of control, assisting client to cope positively with the situation. |
| Give factual information about what is happening. | Reduces the “unknowns” to assist with reduction of anxiety and provides data necessary to make informed decisions. |