A nurse is assisting a client during the second stage of labor. After the fetal head is delivered, it immediately retracts firmly against the maternal perineum. Arrange the following nursing actions in the correct order of priority from first to last.
- 1Call for immediate assistance from additional obstetric and neonatal personnel.
- 2Instruct the client to immediately stop pushing.
- 3Assist the client in sharply flexing her thighs against her abdomen.
- 4Apply downward pressure directly over the client's symphysis pubis.
- 5Document the exact time the fetal head emerged and the maneuvers performed.
Answer
The correct sequence for managing shoulder dystocia is to first call for help, then instruct the client to stop pushing, followed by assisting with the McRoberts maneuver, applying suprapubic pressure, and finally documenting the event.
When shoulder dystocia occurs (indicated by the 'turtle sign' where the head retracts), the immediate priority is to summon help, often remembered by the 'H' in the HELPERR mnemonic. Next, the nurse must prevent further impaction by instructing the client not to push. The first-line physical intervention is the McRoberts maneuver, which resolves a large percentage of dystocias by altering pelvic angles. If this fails, suprapubic pressure is applied to manually push the shoulder under the pubic bone. Finally, after the newborn is delivered and the acute emergency is managed, meticulous documentation of the timing of the head delivery and all maneuvers is required.
Step-by-Step Solution
Key Concept
Nursing priorities during an obstetric emergency (Shoulder Dystocia)