Republic of the Philippines

CATANDUANES STATE UNIVERSITY

Virac, Catanduanes
College of Health Sciences

A Case of:
SHOULDER DYSTOCIA

Submitted by:
Soriao, Lovely Rose V.
BSN 4C (Group 2)

Submitted to:
Janette S. Garcia, RN
Clinical Instructor
SCENARIO 7:

● Patient: Laura, 32-year-old second-time mother.

● Issue: Laura’s baby’s head was delivered, but the shoulders became stuck
behind the mother’s pelvis, causing an obstetrical emergency.
● Intervention: Dr. Johnson quickly employs various maneuvers to dislodge the
baby’s shoulders, including the McRoberts maneuver and suprapubic pressure,
successfully delivering the baby.

I. DEMOGRAPHIC PROFILE

Name: Laura
Age: 32-year-old
Gender: Female
Nationality: Filipino
Civil Status: Married
Date of Birth: February 1, 1990
Religion: Roman Catholic
Admitting Physician: Dra. Ob
Date of Admission: October 9, 2023
Room No: 210

II. NURSING HEALTH HISTORY

A. History of Present Illness:

● Patient’s blood glucose result was 180 mg/dl. She was diagnosed with
gestational diabetes at 26 weeks and was prescribed Metformin 500 mg
PO TID. An ultrasound was done two weeks ago (at 37 weeks.) because
her fundic height was 36 cm. Her ultrasound result showed that the
estimated fetal weight was 35000 grams. Upon internal examination the
patient presents the following findings

Time Cervical Dilatation Effacement Station

8:30 AM 5cm cervical 90% effaced +1 station

dilatation

9:30 AM Fully dilated cervix Completely effaced +1 station

B. Past Health History:

● History of gestational diabetes in the previous pregnancy.

● Overweight
 III. PHYSICAL ASSESSMENT

Vital Signs:
● Blood Pressure: 140/90 mmHg
● Pulse Rate: 100bpm
● Respiratory Rate: 21cpm
● Temperature: 36.7
● Oxygen Saturation: 96%

Assessment Body Part Norms Actual Analysis and

Method Used Findings Interpretation

Inspection and Head and EYES - Visual acuity AS, PPC, no Anicteric sclera
Palpation Hair is intact; sclera is CLADS means that the white
non-icteric. part of your eye is
Conjunctivae are white and healthy in
clear without appearance.
exudates. No signs of
nystagmus. Posterior polar
cataract (PPC) is a
THROAT/MOUTH - unique form of
Oral mucosa is pink congenital cataract,
and moist with good which results in
dentition. No buccal defective distance
nodules or lesions and near vision and
noted. affects the patient's
daily activities.

Auscultation Chest and No abnormal SCE, no rets, No retractions

lungs curvature of the CBS
spine. Full range of
motion, no muscle
spasm or tenderness.

No rales, rhonchi,
wheezes, or rubs.
Vocal and tactile
fremitus normal.

Auscultation Heart The external chest is AP, NRRR, no A normal

normal in appearance murmurs Anterior-Posterior
without lifts, heaves, Diameter means that
or thrills. Heart rate there is no significant
and rhythm are enlargement of the
normal. heart.

The heart is at the

normal rate and, has
a regular rhythm.
Inspection and Abdomen The abdomen is soft, Flat, NABS, Normal Active Bowel
Palpation symmetric, and soft, and Sound.
non-tender without non-tender.
distention. There are The absence of
no visible lesions or tenderness suggests
scars. that the patient did
not experience
pain/discomfort when
pressure was applied
to various areas of
the abdomen.

Palpation Extremities No asymmetry or FEPP, warm Normal CRT - normal

muscle atrophy, full extremities, blood volume and
ROM of all joints. CRT <2secs perfusion; no edema
Normal skin
temperature, no
edema.

IV. LABORATORY/DIAGNOSTICS

Blood Glucose: 180 mg/dl

ULTRASONOGRAPHY RESULT:

Last Menstrual Period: January 2, 2023

Expected Date of Delivery: October 9, 2023

Impression: Single, Live uterine pregnancy with normal and regular cardiac activity
Presentation: Cephalic
Amniotic Fluid: Normal
Fetal Movements: Present
Fetal Weight: 3500 grams
Gestational Age: 37 weeks
Fetal Heart Rate: 140 beats/minute
 V. MEDICAL INTERVENTION (DRUG STUDY)

Name of Drug Action Indication Contraindicati Adverse Nursing

on Effects Responsibilities

METFORMIN Biguanide oral Metformin is a ● Severe renal Lactic acidosis, Do not use with
hyperglycemic medication impairment a serious and renal
Classification: agent. Unlike used to control or elevated potentially fatal dysfunction,
Hormones & sulfonylureas, blood glucose serum condition metabolic
Synthetic biguanides do levels in creatinine caused by the acidosis, or
Substitutes; not stimulate the people who levels buildup of lactic ketoacidosis.
antidiabetic release of the have type 2 ● Hypersensiti acid in the
agent; insulin from the diabetes. It is vity or blood Monitor urine or
Biguanides beta cells of the sometimes allergy to Low blood serum glucose
pancreas. used together metformin sugar, which levels frequently
Route: Oral Mechanism of with insulin or ● Acute or can cause to determine
action is thought other chronic symptoms such effectiveness of
Dosage: to be due to medications, metabolic as dizziness, drug and
500mg tab both increasing but it is not for acidosis, sweating, dosage.
the binding of treating type 1 including hunger, and
Frequency: insulin to its diabetes. diabetic confusion.
TID receptor and Unlike insulin, ketoacidosis
potentiating metformin ● Congestive
insulin action. doesn't cause heart failure
weight gain requiring
and may help pharmacolog
with weight ic treatment
loss.

OXYTOCIN Causes potent Induction of ● Hypersensiti CV: Assess uterine

and selective labor in vity to Hypertention, tone
Classification: stimulation of patients with a oxytocin or increase heart and vaginal
Uterine-active uterine and medical any rate, systemic bleeding.
agents mammary gland indication for component venous returns, Monitor for
smooth muscle. the initiation of of the cardiac output adverse
Dosage: labor formulation. GI: Nausea and reactions of
0.25 to 5 IU of Vomiting water
oxytocin ● Significant Repiratory: intoxication, such
cephalopelvi Anoxia, as
c Asphyxia lightheadedness,
Route: IV disproportion Others: Low nausea,
or APGAR score vomiting,
unfavorable at 5 mins. headache, and
fetal malaise
positions or
presentation
s that are
undeliverabl
e without
conversion
before
delivery.
 VI. SURGICAL INTERVENTION

Procedure Classification Indication Nursing Responsibilities

Manuever McRoberts There are no For nurses, managing shoulder

Maneuver specific indicators dystocia begins with alerting all
for the use of the appropriate members of the obstetrics
McRoberts care team (situational
maneuver. 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.

VII. 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.
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.

VIII. 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.
 IX. NURSING CARE PLANS

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

SUBJECTIVE: Risk for Short-term: INDEPENDENT: INDEPENDENT Goal met

Altered The baby
“Masakit ang Uteroplacental will be 1. Ask for help. 1. Shoulder
tiyan ko ” as Tissue delivered Ensure that there dystocia is a
verbalized by Perfusion successfully. are enough medical
the patient. r/t shoulder members of the emergency,
dystocia team to support the therefore, more
OBJECTIVE Long-term: delivery of the intensive
DATA: The baby baby with dystocia. monitoring and
will maintain assistance will be
BP: 140/90 efficient 2. Always monitor needed. Asking for
mmHg tissue for the vital signs of an extra hand is
PR: 100bpm perfusion the patient. usually the
RR: 21cpm healthcare
T: 36.7 3. Monitor the worker’s first
O2: 96% intake and output move.
of the patient
2. So that we can
4. Place pressure provide the
on the suprapubic baseline of data for
area of the mother comparison and
evaluation in
COLLABORATIVE response to the
intervention.
1. Support the
doctor or midwife 3. By means of
in performing monitoring we can
internal rotation ensure that the
patient has proper
intake and output.

4. To encourage
the baby’s
shoulder to change
position and rotate.

COLLABORATIVE

1. The doctor may

need to assist the
baby’s shoulder to
rotate through
certain maneuvers.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

SUBJECTIVE: Risk for fetal Within 15-30 1. Establish 1. This will help After 15-30
and maternal minutes of rapport with the in performing the minutes of
“Masakit ang injury related to nursing patient. following nursing
tiyan ko ” as Cephalopelvic interventions, interventions interventions,
verbalized by Disproportion the mother 2. Assess fetal more easily. the mother
the patient. (CPD) will heart rate. Count successfully
successfully for 10 minutes, 2. Continue this delivered the
OBJECTIVE deliver the break for 5 pattern baby and
DATA: baby and will minutes, and throughout the does not
not count again for 10 contraction. This experience
BP: 140/90 experience minutes. detects any health
mmHg any health abnormal complications;
PR: 100bpm complications 3. Assist in responses which and the baby
RR: 21cpm ; and the performing may be caused is free of
T: 36.7 baby will be episiotomy. by stress, trauma, injury,
O2: 96% free of hypoxia, and other
trauma, 4. Assist the acidosis, or complications
injury, and mother in the sepsis. and has
other position of displayed
complications McRoberts’ 3. An episiotomy normal fetal
and will maneuver prevents tearing heart rate with
display and opens the no late
normal fetal birth canal to decelerations
heart rate allow more room noted.
with no late for the baby to
decelerations pass through.
noted
4. This
maneuver is a
position in which
the mother is
lying on her back
with her legs
pushed towards
her tummy. This
can help widen
the birth canal

X. DISCHARGE PLAN

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

demonstrates the standard of care practice, thereby decreasing the potential for
successful malpractice allegations.
2. Nurses can assist mothers and families in reviewing the shoulder dystocia and
any newborn injuries in the postpartum period, thereby reducing confusion and
anxiety