Republic of the Philippines

CAVITE STATE UNIVERSITY

Don Severino delas Alas Campus
Indang, Cavite

NURSING CARE PLAN: Risk for Fetal Injury

Related to Shoulder Dystocia
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for fetal injury rt to Short term goals Assess FHR manually or Detects abnormal
 previous pregnancies shoulder dystocia as electronically. Note responses, such as  Patient participated in
have all been evidenced by failed gentle  Patient will participate in variability, periodic exaggerated variability, intervention to improve
uncomplicated traction of the anterior fetal interventions to improve changes, and baseline bradycardia, and labor pattern and/or
 past medical history is shoulder. labor pattern and/or reduce rate. If in the free tachycardia, which may reduced identified risk
significant for uterine identified risk factors standing birth center, be caused by stress, factors
fibroids  Continuous fetal monitoring check Fetal heart tone hypoxia, acidosis, or
will show fetal heart rate between contractions sepsis.  Continuous fetal
maintains variability of 6 to using a Doptone. Count monitoring shows fetal
OBJECTIVE:
10 beats/minute, with for 10 min, break for 5 heart rate maintains
 blood pressure is min, and count again for
reassuring pattern. variability of 6 to 10
160/100 mm Hg 10 min. Continue this beats/minute, with
 pre pregnancy weight Long term goal pattern throughout the reassuring pattern.
was 250 lb, and she contraction to midway
gained 30 lb during  Patient will achieve good between it and the  Patient achieves good
the pregnancy. labor pattern, and neonate following contraction. labor pattern and
 fundal height is 43 cm will be delivered without delivers neonate without
 Gentle traction fails to complications. Note frequency of uterine Contractions occurring complications.
deliver the anterior  Patient and fetus will contractions. Notify every 2 min or less do not
fetal shoulder. maintain optimal well-being. physician if the frequency allow for adequate  Patient and fetus
is 2 min or less. oxygenation of intervillous maintain optimal well-
spaces. being during labor and
delivery.

JOHN LLOYD B. AGASANG

BSN 2-3
 Note uterine pressures Resting pressure greater
during resting and than 30 mm Hg or
contractile phases via contractile pressure
intrauterine pressure greater than 50 mm Hg
catheter, if available. reduces or compromises
oxygenation within
intervillous spaces.

Assess for malpositioning Determining fetal lie,

using Leopold’s position, and presentation
maneuvers and findings may identify factor(s)
on internal examination contributing to
(location of fontanelles dysfunctional labor.
and cranial sutures).
Review results of
ultrasonography.

Arrange transfer to Risk of fetal/neonatal

aacute care setting if injury or demise increases
malposition is detected in with vaginal delivery if
client in a free-standing presentation is other than
birth center without vertex.
adequate surgical/high-
risk neonatal capabilities.

Assist with positioning Because most cases of

during delivery: shoulder dystocia can be
McRoberts maneuver relieved with the
McRoberts maneuver and
suprapubic pressure,
many women can be
spared a surgical incision.

Prepare client for the Such presentations

most expedient method increase the risk of CPD,
JOHN LLOYD B. AGASANG
BSN 2-3
 of delivery if fetus is in owing to a larger diameter
brow, face, or chin of the fetal skull entering
presentation. 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 Failure of the vertex to

transverse arrest of the rotate fully from an OP to
fetal head. an occiput OA position
may result in a transverse
position, arrested labor,
and the need for cesarean
delivery.

Note color and amount of Excess amniotic fluid

amniotic fluid when causing uterine
membranes rupture. overdistention 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.
JOHN LLOYD B. AGASANG
BSN 2-3
 Observe for visible cord Cord prolapse is more
prolapse when likely to occur in breech
membranes rupture, and presentation, because the
occult cord prolapse as presenting part is not
indicated by variable firmly engaged, nor is it
decelerations on monitor totally blocking the os, as
strip, especially if fetus is in vertex presentation.
in breech presentation.

Note odor and change in Ascending infection and

color of amniotic fluid with sepsis with accompanying
prolonged rupture of fetal tachycardia may
membranes. occur with prolonged
rupture of membranes.

Have client assume These positions

hands-and-knees encourage anterior
position, or lateral Sims’ rotation by allowing fetal
position on side opposite spine to fall toward the
that to which fetal occiput client’santerior abdominal
is directed, if fetus is in wall (70% of fetuses in
OP position. OP position rotate
spontaneously).

Administer antibiotic to Prevents/treats ascending

client, as indicated. infection and will protect
fetus as well.

If fetus fails to rotate from Delivering the fetus in a

OP to OA position (faceto posterior position results
pubis), prepare for in a higher incidence of
delivery in posterior maternal lacerations.
position.Alternatively, Vacuum extractor may be
apply vacuum extractor used to rotate and
as indicated. expedite delivery of fetus.

JOHN LLOYD B. AGASANG

BSN 2-3
 Prepare for cesarean Vaginal delivery of an
delivery of breech infant in breech position
presentationif fetus fails isassociated with injury to
to descend, labor the fetal spinal column,
progress ceases, or CPD brachial plexus, clavicle,
is identified. 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

CASE STUDY

A 34 year old woman, G7P6, undergoes induction of labor at 39 weeks (due to the development of new-onset hypertension). The patient became pregnant 5 months after
her most recent delivery, and the pregnancy has been uncomplicated. Her previous pregnancies have all been uncomplicated as well. Her past medical history is
significant for uterine fibroids. Her blood pressure is 160/100 mm Hg. Her pre pregnancy weight was 250 lb, and she gained 30 lb during the pregnancy. Her fundal height
is 43 cm. About 22 hours after the induction of labor, the fetal head delivers and then retracts in the maternal perineum. Gentle traction fails to deliver the anterior fetal
shoulder.

JOHN LLOYD B. AGASANG

BSN 2-3