A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.



Which of the following actions should the nurse take?

Choice A rationale:

Encouraging the mother to push during the next contraction is not the appropriate action in this situation. Retraction of the

fetal head against the maternal perineum is a sign of shoulder dystocia, a serious obstetric emergency that requires immediate

intervention. Pushing could potentially worsen the situation by further impacting the anterior shoulder against the maternal

pubic symphysis.

Choice B rationale:

While preparing for immediate delivery of the baby may be necessary in some cases of shoulder dystocia, it is not the first

priority. The initial focus should be on relieving the impaction of the anterior shoulder and facilitating the safe delivery of the

baby. This often requires additional maneuvers and medical support.

Choice C rationale:

Calling for additional medical support is the most appropriate action in this situation. Shoulder dystocia can be a complex and

challenging emergency, and it's crucial to have experienced healthcare providers available to assist with the delivery.

Additional personnel can provide support with various maneuvers, fetal monitoring, and management of potential

complications.

Choice D rationale:

Administering pain relief medication is not a priority in this situation. While pain management is important during labor, it

should not take precedence over addressing the immediate obstetric emergency. The focus should be on resolving the

shoulder dystocia and ensuring a safe delivery.

Additional notes:

It's important to note that shoulder dystocia is a relatively uncommon complication, occurring in approximately 0.5-1% of all

vaginal births. However, it's a potentially serious emergency that can lead to significant complications for both the mother and

baby, such as brachial plexus injury, hypoxic-ischemic encephalopathy, and postpartum hemorrhage.

Early recognition and prompt intervention are crucial for optimizing outcomes in cases of shoulder dystocia.

Choice A rationale:

Uterine atony is the most common cause of postpartum hemorrhage, and it is characterized by a lack of uterine muscle tone,

which leads to excessive bleeding after delivery.

A macrosomic newborn (weighing over 4000 g) is a significant risk factor for uterine atony because the overdistention of the

uterus during pregnancy can impair its ability to contract effectively after delivery.

Other risk factors for uterine atony include prolonged labor, multiple gestations, rapid labor, use of oxytocin or magnesium

sulfate during labor, and a history of uterine atony in previous deliveries.

It's crucial for a nurse to closely monitor clients with these risk factors for signs of uterine atony, such as excessive vaginal

bleeding, a soft and boggy uterus, and a rising fundus.

Prompt recognition and management of uterine atony are essential to prevent life-threatening hemorrhage.

Choice B rationale:

Retained placental fragments can also contribute to postpartum hemorrhage; however, they are not as strongly associated

with macrosomia as uterine atony.

Risk factors for retained placental fragments include premature separation of the placenta, placenta accreta, and manual

removal of the placenta.

Choice C rationale:

Thrombophlebitis, a blood clot formation in a vein, is a postpartum complication, but it's not directly related to macrosomia.

Risk factors for thrombophlebitis include venous stasis, hypercoagulability, and trauma to the veins, such as from prolonged

bed rest or cesarean delivery.

Choice D rationale:

Perineal infection is also a potential postpartum complication, but it's not specifically linked to macrosomia.

Risk factors for perineal infection include perineal lacerations, episiotomy, and poor hygiene.