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"Haurdunaldia 7. hilabetean (1)" by Naiaaizpurua, used under CC BY-SA 4.0/Cropped from original
Birth Injury Help Center (2020, January 9). 3 Most Dangerous Childbirth Complications: https://www.youtube.com/watch?v=Mln7RkmVn8Q
Shoulder Dystocia
Shoulder Dystocia
Shoulder dystocia is a condition in which the head is born, but the anterior shoulder cannot pass under the pubic arch. Disproportion related to excessive fetal size (more than 4000 g) or maternal pelvic abnormalities can cause shoulder dystocia.
Other risk factors for shoulder dystocia include:
Maternal diabetes (risk for macrosomia)
History of shoulder dystocia with a previous birth
Prolonged second stage of labor
Signs of shoulder dystocia include:
Slowing of the progress of the second stage of labor
Formation of a caput succedaneum that increases in size
Retraction of the fetal head against the perineum immediately following its emergence (turtle sign)
External rotation does not occur
Fetal injuries may be caused by:
Asphyxia
Trauma; the most common complications related to trauma include:
Fracture of the humerus or clavicle
Unilateral brachial plexus injuries
Giorux, M. (2019, January). Intrapartum Care: Shoulder Dystocia OBGYNAcademy. https://obgynacademy.com/intrapartum-care/
Care Management
The McRoberts maneuver and suprapubic pressure are usually the first-line interventions for shoulder dystocia. In the McRoberts maneuver, the woman’s legs are hyperflexed on her abdomen. This causes the sacrum to straighten, and the pelvis and symphysis pubis to rotate toward the mother’s head allowing for a slightly increased opening of the pelvis. Suprapubic pressure will potentialy dislodge the anterior shoulder from behind the pubic bone. There is also the Gaskin maneuver, in which the woman moves to a hands-and-knees position.
Fundal pressure is NEVER used - it will only further impact the shoulder into the pubic bone.
Other maneuvers that are done by the provider include Wood's Screw Maneuver (rotation of the infant's shoulder from under the pubic bone), delivery of the infant's posterior shoulder, breaking the infant's clavicle, and Zavenelli maneuver (return infant to uterus and deliver by cesarean section).
Newborn assessment should include examination for fracture of the clavicle or humerus as well as brachial plexus injuries and asphyxia.
Maternal assessment should focus on early detection of hemorrhage and trauma to the vagina, perineum, and rectum.
McRobert's Maneuver (1)
Suprapubic Pressure (2)
"McRoberts Maneuver" by geraldbaeck, used under CC0/Cropped from original
Be aware that the video in this module contain images of an actual labor care and vaginal delivery.
Surgery 101 (2019, May 1). Shoulder Dystocia: https://www.youtube.com/watch?v=BvkKMwDaryg
Global Health Media Project (2022, March 27). Stuck Shoulders: https://globalhealthmedia.org/videos/stuck-shoulders/
Prolapsed Umbilical Cord
Prolapsed Umbilical Cord
Prolapse of the umbilical cord is when the cord lies below the presenting part of the fetus. It may be occult (hidden, rather than visible) at any time during labor.
Care Management
Care Management
Prompt recognition of a prolapsed umbilical cord is important because fetal hypoxia resulting from prolonged cord compression (i.e., occlusion of blood flow to and from the fetus for more than five minutes) usually results in CNS damage or death of the fetus.
Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off the umbilical cord.
Alternative positions include:
Modified Sims
Trendelenburg
Knee-chest
Birth Injury Help Center (2020, January 17). Umbilical Cord Prolapse: https://www.youtube.com/watch?v=ni621ZlVxUE
Uterine Rupture
Uterine Rupture
Uterine rupture is symptomatic disruption and separation of the layers of the uterus or previous scar. This most commonly occurs during a TOL for VBAC. Factors that increase the risk for uterine rupture include:
Prior uterine rupture
Trauma
Abortion
Instrumentation injury
Uterine perforation
Grand multiparity
Uterine overdistension
"Rupture Transverse" by Khcnrc01, used under CC BY SA 4.0/Cropped from original
Uterine Dehiscence
Uterine Dehiscence
Uterine dehiscence, or incomplete uterine rupture, is separation of a prior scar. It may go unnoticed unless the woman undergoes a subsequent cesarean birth or other uterine surgery.
Signs and symptoms vary with the extent of the uterine rupture. They include:
Abnormal (category Ⅱ or category Ⅲ) FHR tracing
Loss of fetal station or no fetal descent also can occur
Sudden sharp abdominal pain or a ripping or tearing sensation
Bright red vaginal bleeding
Signs of hypovolemic shock caused by hemorrhage
Fetal parts may be palpable through the abdomen
Care Management
Care Management
Prevention is the best treatment for uterine rupture. Management depends on the severity of the rupture.
The nurse's role involves:
Starting IV fluids
Transfusing blood products
Administering oxygen
Assisting with preparations for immediate surgery
Inverted Uterus
Inverted Uterus
Inversion (turning inside out) of the uterus is potentially a life-threatening complication. An inverted uterus is classified as incomplete, complete, or prolapsed. Primary presenting signs are hemorrhage, shock, pain, and the uterus is not palpable abdominally. Causes include excessive umbilical cord traction with a fundally attached placenta and fundal pressure in the setting of a relaxed uterus.
Inversion of the uterus is an emergency and requires the following immediate interventions:
Maternal fluid resuscitation
Replacement of the uterus within the pelvic cavity
Correction of associated clinical conditions
Tocolytics or halogenated anesthetics
Oxytocic agents after the uterus is repositioned
Broad-spectrum antibiotics
"Clinical Gyncology, Medical Surgical" by Internet Archive Book Images , used under Public Domain/Cropped from original
"The Science and Art of Midwifery" by Internet Archive Book Images, used under Public Domain/Cropped from original
Anaphylactoid Syndrome of Pregnancy (ASP)
Anaphylactoid Syndrome of Pregnancy (ASP)
(aka Amniotic Fluid Embolus)
(aka Amniotic Fluid Embolus)
Analphylactoid Syndrome of Pregnancy (ASP) (aka Amniotic fluid embolus) is an anaphylactoid syndrome of pregnancy and is considered one of the most critical emergencies in obstetrics. ASP is a devastating complication of pregnancy that involves sudden, acute onset of hypotension, hypoxia; and hemorrhage caused by coagulopathy from a widespread anaphylaxis reaction when amniotic fluid enters the maternal blood stream. ASP occurs during labor, during birth, or within 30 minutes after birth. The combination of sudden respiratory and cardiovascular collapse, along with coagulopathy, is similar to that observed in clients with systemic inflammatory response syndrome or anaphylaxis. The exact factor that initiates ASP has not been identified. Predisposing conditions include:
Rapid labor
Meconium-stained amniotic fluid
Tears into uterine and other large pelvic veins
Older maternal age
Postterm pregnancy
Labor induction or augmentation
Eclampsia
Cesarean birth
Forceps- or vacuum-assisted birth
Placental abruption or placenta previa
Hydramnios
Early recognition and prompt, aggressive treatment will improve survival rates.
Analphylactoid Syndrome of Pregnancy (ASP) (aka Amniotic fluid embolus) is an anaphylactoid syndrome of pregnancy and is considered one of the most critical emergencies in obstetrics. ASP is a devastating complication of pregnancy that involves sudden, acute onset of hypotension, hypoxia; and hemorrhage caused by coagulopathy from a widespread anaphylaxis reaction when amniotic fluid enters the maternal blood stream. ASP occurs during labor, during birth, or within 30 minutes after birth. The combination of sudden respiratory and cardiovascular collapse, along with coagulopathy, is similar to that observed in clients with systemic inflammatory response syndrome or anaphylaxis. The exact factor that initiates ASP has not been identified. Predisposing conditions include:
Rapid labor
Meconium-stained amniotic fluid
Tears into uterine and other large pelvic veins
Older maternal age
Postterm pregnancy
Labor induction or augmentation
Eclampsia
Cesarean birth
Forceps- or vacuum-assisted birth
Placental abruption or placenta previa
Hydramnios
Medical Centric (2023, May 7). Amniotic Fluid Embolism: The Silent Threat During Childbirth: https://www.youtube.com/watch?v=Ra-GtEDB2bQ
Care Management
Care Management
Although it is rare, if ASP occurs during labor, cesarean birth should be performed to aid in resuscitation of the woman and improve the chances of fetal survival. Early recognition and prompt, aggressive treatment will improve survival rates. Treatment includes using adrenaline (epinephrine) to maintain blood pressure, initiation of CPR if cardiac arrest occurs, administration of oxygen, and an intravenous fluid bolus. The nurse’s immediate responsibility is to assist with the resuscitation efforts. She will likely go to the Intensive Care Unit and will be in serious condition; mortality rate estimates vary from 30% to 86%.
Other Resources
Other Resources
Boushra, M., Stone, A., & Rathburn, K.M. (2023, May 8). Umbilical Cord Prolapse. NIH StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK542241/#:~:text=Umbilical%20cord%20prolapse%20is%20when,not%20rapidly%20diagnosed%20and%20managed.
Davis, D.D., Roshan, A., Varacallo, M. (2023, December 20). Shoulder Dystocia. NIH StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK470427/#:~:text=Shoulder%20dystocia%20is%20an%20obstetric%20emergency%20where%20the%20anterior%20fetal,chin%20and%20the%20turtle%20sign.
Haftel, A., Carlson, K., & Chowdhury, Y.S. (2024, January 10). Amniotic Fluid Embolism. NIH StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK559107/
Thakur, M. & Thakur, A. (2022, November 28). Uterine Inversion. NIH StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK525971/
Togioka, B.M. & Tonismae, T. (2023, July 29). Uterine Rupture. NIH StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK559209/#:~:text=A%20uterine%20rupture%20can%20allow,nonreassuring%20fetal%20heart%20rate%20tracing.
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