What are shoulder dystocia precautions?

From the Guidelines

Shoulder dystocia precautions involve identifying risk factors and implementing specific maneuvers during delivery to prevent complications when a baby's shoulders become stuck after the head has emerged, with the most recent and highest quality evidence recommending the use of the McRoberts maneuver as the first line of intervention 1. The risk factors to monitor include maternal diabetes, previous shoulder dystocia, excessive maternal weight gain, post-term pregnancy, and estimated fetal weight over 4000g. During labor, healthcare providers should be prepared with a clear emergency protocol, including the HELPERR mnemonic:

• call for Help
• Evaluate for episiotomy
• Leg hyperflexion (McRoberts maneuver)
• suprapubic Pressure
• Enter maneuvers (internal rotation)
• Remove the posterior arm
• Roll the patient. The McRoberts maneuver, which involves sharply flexing the mother's thighs against her abdomen, is typically the first intervention as it has high success rates and minimal complications, as suggested by the most recent guidelines 1. Suprapubic pressure applied in the appropriate direction can help dislodge the anterior shoulder. These maneuvers work by changing the relationship between the fetal shoulders and the maternal pelvis, increasing the functional size of the pelvis or decreasing the bisacromial diameter of the fetus. Proper documentation of all interventions and timely neonatal assessment after delivery are essential components of shoulder dystocia management. It is also important to note that screening for gestational diabetes mellitus can help identify women at risk for shoulder dystocia, as it is associated with an increased risk of macrosomia and shoulder dystocia 1. However, the most recent and relevant evidence for shoulder dystocia precautions is focused on the management of the condition during delivery, rather than screening for gestational diabetes mellitus 1.

From the Research

Definition and Risks of Shoulder Dystocia

• Shoulder dystocia is defined as a vaginal delivery in cephalic presentation that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed 2.
• It complicates 0.5-1% of vaginal deliveries and increases the risks of brachial plexus birth injury, clavicle and humeral fracture, perinatal asphyxia, hypoxic-ischemic encephalopathy, and perinatal mortality 2.

Risk Factors for Shoulder Dystocia

• The main risk factors for shoulder dystocia are previous shoulder dystocia and macrosomia, but both are poorly predictive 2.
• Other risk factors include maternal diabetes, fetal macrosomia, and maternal history of previous delivery of a large infant 3.
• However, most cases of shoulder dystocia occur without warning, and more than 50% of cases occur in instances without identifiable risk factors 3.

Precautions and Management of Shoulder Dystocia

• Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for shoulder dystocia 2.
• In obese women, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy 2.
• Women with gestational diabetes require diabetes care to reduce the risk of macrosomia and shoulder dystocia 2.
• Induction of labor is recommended in cases of impending macrosomia if the cervix is favorable at a gestational age of 39 weeks or more 2.
• Cesarean delivery is recommended before labor in certain situations, such as estimated fetal weight >4500g in women with diabetes or >5000g in women without diabetes 2.
• The McRoberts maneuver, with or without suprapubic pressure, is recommended as the first line of treatment for shoulder dystocia 2, 4.
• Nurses play a vital role in obtaining assistance during a shoulder dystocia, keeping time, assisting with maneuvers, and documenting the dystocia management 5.

Institutional Protocols and Training

• Institutional protocols and algorithms for the prevention and management of shoulder dystocia have become mainstays for clinicians 6.
• Regular drills and case reviews help build nursing shoulder dystocia management skills 5.
• Training and simulation exercises improve physician and team performance when shoulder dystocia occurs 4.