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MANAGEMENT OF ANTICIPATED AND ACTUAL SHOULDER DYSTOCIA

Interpreting the Literature

Authors

  • Deborah Morrison Piper cnm, mph,

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    • 1 Deborah Morrison Piper is a staff nurse-midwife at the Hitchcock Clinic in Lebanon, New Hampshire, and Assistant Professor of Obstetrics and Gynecology at Dartmouth Medical School in Hanover, New Hampshire. She recently relocated from California, where she had been Associate Director of Nurse-Midwifery Education at the University of California, San Diego, in the Department of Family and Preventive Medicine. She is a graduate of the University of Vermont's College of Arts and Sciences and School of Allied Health, the Medical University of South Carolina Nurse-Midwifery Education Program, and the San Diego State University Graduate School of Public Health.

  • Patricia McDonald cnm, ms

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    • 2 Patricia McDonald is a staff nurse-midwife at Naval Hospital Camp Pendleton in Oceanside, California, where she is also active in childbirth education and sibling preparation and is currently a lieutenant in the United States Navy. She earned her baccalaureate in nursing at Rutgers University, her master of science from the University of California, San Francisco, and her certificate in nurse-midwifery at the UCSF/UCSD Intercampus Graduate Studies, Nurse-Midwifery Education Program.


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ABSTRACT

Shoulder dystocia is a rare but serious obstetric complication that can result in significant neonatal and maternal morbidity and in costly litigation. Conflict exists in the literature regarding definition, incidence, predictability and preventability, relationship to neonatal injury, and appropriate management models. Anticipatory clinical interventions for potential shoulder dystocia have included ultrasound assessment of macrosomia; elective induction of labor, elective caesarean section; altered place of birth, and generous episiotomy/episioproctotomy. The authors note that these interventions often conflict with client desires and nurse-midwifery philosophy of birth, generate significant risks and costs in themselves, and do not address the poor predictability of shoulder dystocia. In recent literature, the safety and efficacy of maternal position change maneuvers (such as McRoberts maneuver, hands-knees position, and squatting) have been presented as methods to resolve most cases of shoulder dystocia Despite the success of these more benign, external maneuvers, the episiotomy mandate remains in nearly all obstetric and midwifery texts and handbooks (1–8) and journal references (9–19). A literature review of related professional disciplines was undertaken to study these conflicts and to identify support for applying a philosophy of minimal, appropriate intervention to the complex issue of shoulder dystocia.

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