Shoulder dystocia is the inability to deliver spontaneously because of the failure of the shoulders to pass the symphysis pubis in the anteroposterior diameter. In such a case, the rest of the body cannot deliver by usual delivery methods. Shoulder dystocia commonly occurs due to the failure of the front shoulder to pass the sacral promontory.

The signs and symptoms of shoulder dystocia occur during birth, it is noticeable after delivery of the baby’s head. The delivery does not go on because the rest of the body has not yet deliver because the baby’s shoulders are in the birth canal stuck behind the mother’s pubic bone.

Shoulder dystocia is one of most dangerous emergencies faced by the labor and maternity nurse in the delivery room. The problem in most cases occurs without any warning although there are some of the contributing factors that led to this problem (Petrou & Khan, 2013). The term shoulder dystocia can also use to refer to the state at which additional maneuvers are required in order for the fetus to get out when the normal delivery has failed. Shoulder dystocia is the failure of the shoulders to get out of the sacral promontory of a woman. Shoulder dystocia is dependent on the weight of the fetus, the heavier the fetus, the more he chances for shoulder dystocia.

Risk factors associated with shoulder dystocia are many such as high birth weight. When the birth weight increase to over 4000g the morbidity and mortality of shoulder dystocia increases significantly. It occurs more especially when the weight is equal or less than 4500g. This risk associated with maternal diabetes is fetal microsomia and maternal obesity (Frank, Parker Frisbie & Pullum, 2000).

Another possible cause of shoulder dystocia is the larger chest circumference of the fetus as well as the increased bisacromial diameter. The cause of the problem is the mother more especially when she is diabetic. Infants of diabetic mothers are usually characterized by larger shoulder and extreme circumference, the high percentage of fats, decreased head to shoulder ratio among others. These factors do not allow rotation of the infant from the anteroposterior to oblique position.

Another contributing factor is the frequency of male gender. Frequency of make gender in most case have a high chances of contracting shoulder dystocia by more than a sixty percent. It is due to the relationship between the microsomia and gender, such that the microsomia are high in males than in females. However, the anthropomorphic can account for some other factors.

Other antepartum risk factors, of course, include advanced maternal age, short maternal stature, and excess weight during pregnancy, platypelloid pelvis, and previous experience of microsomia infants. Intrapartum factors included the epidural anesthesia and protracted first stage of labor.

Fetal problems can also be a contributing factor towards shoulder dystocia. A fetus may develop a problem and the result to be a shoulder dystocia problem (Fuentes, 2012). An infant child develops a problem while in the uterus of the mother, the problem first starts with the mother. In most cases mother who are diabetic usually result to shoulder dystocia problems when it comes to delivering. There are so many factors that lead to the incidence, but this paper is going to discuss the major problems incurred in most delivery rooms. The most common risk factors according to labor and delivery nurses diary is the use of a vacuum extractor or forceps during delivery.

It is obvious that complications that result from shoulder dystocia will affect both the mother and the child after birth. The most common complications are fourth-degree lacerations and postpartum hemorrhage, and they remain unchanged after several maneuvers. Fetal complications also follow in that it suffers from the brachial plexus palsies that occur between 4 to 15 percent of infants. The rate at which this problem occurs remains constant, and it is mostly dependent on the operator experience.

Many complications result from shoulder dystocia such as uterine rupture. Some of the complications include the uterine rupture. Uterine rupture is when a scar from the previous birth tears off. It is uncommon but in a shoulder dystocia, the scar must open up due to forcing of the infant out of the mother birth canal. The patient can also suffer from rectovaginal fistula, which is characterized by an abnormal connection between the large intestine, the rectum and vagina. Contents of the bowel can leak through one’s vagina, the vagina can pass gases or stool. It means, therefore, that during a birth where shoulder dystocia is involved to take great care to prevent such a hazardous orientation (Rosenberg et al., 2005). Symptoms of rectovaginal fistula are low self-esteem due to physical distress. Postpartum hemorrhage can be a potential complication that can result from shoulder dystocia. This is the loss of blood from the body more significantly. It is psychologically significant to cause a person to contract anemia. Third or fourth degree episiotomy steals and symphyseal separation can also be possible after shoulder dystocia complications to the mother.

The infant on the other side is so affected by factors such as the fetal death due to shoulder dystocia, fracture of the humerus, clavicle fracture, brachial plexus palsy, and fetal hypoxia.

HELPERR mnemonic is also another way of the structured framework to deal with shoulder dystocia. The process entails of three things. First, is the reduction of the binomial diameter (reduction of the fetal shoulder diameter). Secondly, it is through the change of the relationship between the bisacromial diameter and the pelvic bone through the internal rotation maneuvers. Finally, is to increase the functional size of the bony pelvis that can be achieved by ensuring that the lordosis and the cephalad are flat make it easier for rotation of the symphysis. Of the three procedures, there is no indication that one is superior to another, but the fact is they relieve the problem of the shoulder dystocia. Order of steps is not efficient as one can suggest, what matters is how efficient that procedure is likely to be applied. Persistence of any ineffective maneuver should stop; clinical judgment ways should be in use in such a situation (Heazell & Bhatti, 2004).

Maneuver is the only way that can relieve the patient from that state of shoulder dystocia such as McRoberts maneuver or positioning. McRoberts is one of the procedures that are recommended in shoulder dystocia problems. This process leads to a cephalad rotation of the symphysis pubis and flattening of the sacral promontory. McRoberts maneuver entails of the central rotation of the maternal hips. In addition, hyper-flexion and abduction of the hips should be done resulting to the positioning of the pelvic and outlet into a vertical alignment. It is through the pushing of the posterior side of the shoulder over the sacral promontory thus allowing it to fall into the sacrum, and the rotation of the symphysis is over the impacted shoulder. McRoberts maneuver is appropriate when all the procedures are in place since it relieves over forty percent of the problems of shoulder dystocia. Combination of McRoberts and suprapubic results to fifty percent of the resolved shoulder dystocia

Wood’s maneuver is also in use as a management system to relieve the problem of shoulder dystocia. Performance of this procedure is through the posterior shoulder rotation and application of pressure on the backward surface of the front shoulder; this will achieve rotation towards the fetal back. The motion creates a more efficient rotation of the fetal thus allowing movement. Wood’s maneuver and the Rubin II is used to increase pushing from behind the forces by using two fingers behind the fetal shoulder and another two finger in front of the fetal posterior shoulder. This step is often difficult because the space of the physician is usually very small.

Another way is through the Rubin II maneuvers, this way the episiotomy is supposed to gain vaginal space for the physician’s hand. It Entails of inserting the physician fingers to the posteriorly to the anterior aspect of the fetal shoulder and start rotating it to fetal chest. The process will reduce the diameter of the fetal shoulder thus enabling him infant to pass through.

Another way we can apply suprapubic pressure through applying pressure downwardly by use of two fingers the anterior fetal shoulder in a more oblique way. Hands should be placed on the mother’s abdomen over the fetal anterior shoulder and applying pressure on the in a relaxation cycle towards the cardiopulmonary resuscitation so that the shoulder can pass through the symphysis (Langel, 2010). The assistant should apply pressure on the side of the mother, and a hand should be moving downward towards the lateral motion of the posterior side of the fetal impacted shoulder. Pressure can be persistent, but delivery cannot materialize; it is better for locking action to dislodge the fetal shoulder from the pubic symphysis. Fund is not recommended since it worsens the situation by potentially injuring the baby and the mother too.

Another possible way is the removal of the posterior arm. It involves the insertion of the physician’s arm to the vagina of the patient and locating the arm, displaces it behind the fetal arm, and must be nudged anteriorly. Squeeze the fetal elbow and place in a sleeping motion over the anterior chest of the fetus. The arm should not be pulled or snatched directly because it may result to a fracture of the humerus the posterior arm followed by the arm and the shoulder will ease the delivery of the inborn. The fetus spontaneously rotates in the corkscrew manner as the arm is removed.

Gaskin maneuver is also another way of solving shoulder dystocia problem through the patient into hands and knees. It is said to be better and protective way of dealing with shoulder dystocia. Radiographic studies indicate that the diameter of the pelvis increases due to change of the recumbent position. Once the patient is in a different position, delivery is through the help of the gravity. This position is in line with the intraviginal manipulation for shoulder dystocia. Performing a normal delivery through tis positioning helps the physicians to deal with emergent cases such as shoulder dystocia.

A training based on shoulder dystocia on trial of a simulation is by use of low fidelity and high fidelity mannequins. The focus of the training will be to evaluate the effectiveness of simulation dystocia management and there should be a comparison of training using mannequin with that of using traditional methods and tools.

The method will require the training to take place in more than six hospitals and probably in a simulation center. All participants in the delivery room must be included are chosen randomly using high fidelity mannequin and low fidelity mannequins. Assessment of performance will be in pre and post training by use of PowerPoint and videoed standardized shoulder dystocia simulation. The expected measures include delivery; force applied communication and the use of appropriate and inappropriate actions. It should of concern that the training should take a maximum of 60 minutes afterward, a test over question and answers will be available to check on understanding.

A study done by Jakobovits & Iffy (1996) showed critical value of clinical estimation of fetal weight is higher than that of trasonography. Later the second part of this study will focus on prenatal diagnosis of microsomia caused by the occurrence of the shoulder dystocia and the birth trauma resulting to preventing it from occurring again.

Resnick (1998) said it is never easier to understand and predicted the essence of shoulder dystocia; he noted that is impossible for one to know unless he or she has delivered the head. Studies have been done to determine the possibilities of shoulder dystocia before the due date and time but have gone in vain. Shoulder dystocia remains to a great challenge in the nursing industry.

Geary(1995) noted that it was ethical for all internal risk factors of shoulder dystocia to be taken into account to know the positive value of the patient.

Levine (1992) showed that if the microsomia were present then ninth percent of the fatal in birth would increase given gestational age. Therefore, he concluded that the sonographic prediction was wrong citing it was 50% of the both underestimation and overestimated that fetal weight.

McFarland (1998) argued that microsomic infants of diabetic mothers have larger shoulder that makes it impossible for a kid not to get out of the mother’s vagina. Anthropomorphic characteristics explain the propensity for shoulder dystocia amongst this population. This characteristic makes the fetus grow abnormally in their shoulders thus making it difficult for a child to pass through vagina.

Li (2008) discovered that women with parity of more than two had a great chance of giving birth to a microsomic baby who is underweight hence having difficulty in giving birth due to shoulder dystocia. Baskett (2014) gave evidence on microsomia associated continued growth of the fetal growth in pre-birth pregnancies thus presenting a high risk of shoulder dystocia.

Camune (2007) pointed that the relative frequency of shoulder dystocia varied directly with the increasing weight of the baby there it a fact that the babies who were in the average body size recorded an ordinary delivery. In a research conducted in Beth Israel Hospital that forth seven percent of the babies who were shoulder dystocia and weighed more than 4000gms weight category thus encompassing ninth one percent of the total deliveries.

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