Hand Presentation / Prolapsed Shoulder

UK Midwifery Archives


These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.


Hand Presentation / Prolapsed Hand

A rare and potentially disastrous complication, managed successfully at a home birth.

This was a planned home birth. In the local model of care, the woman’s named midwife provided all the antenatal care. There was the local policy of a routine consultation at the hospital with an obstetrician. There was very little documented discussion around home birth – I say this just to highlight the fact that there were no identified contraindications from a medical perspective and no conflictual issues arose. Post home birth the midwifery supervisor did find some issues of concern and at this point I cannot discuss these in detail. The situation has already been discussed and to greater degree settled with the woman and her family.

The night the birth happened I was on-call for the usual 300-400 pregnant women who are booked with the NHS Community Trust in a geographical patch I work in. It was a busy night with a post-natal suicide threat and emergency blue light transfer of a 23 week prem labouring woman.

The woman had 2 previous births in hospital which went okay. This pregnancy was an unplanned accidental “miracle”. She had used fertility treatment for a previous pregnancy.

I met her for the first time with her in labour. Great jovial atmosphere, labour progressed, the only feature which in retrospect gave me an inkling of what was to come was a pp at -3 above the spines when she was 4cms dilated. For a multiparous woman I wasn’t particularly worried with this finding with a 3/5ths engagement abdominally. I didn’t look for skull sutures as this would be too uncomforatble for her.

Second stage came on quickly as the woman predicted and woman said she felt a strange pop. I thought the waters may have gone but NO…with the next contraction the bag of waters was bulging on the perineum. The second midwife was present as were family members – husband and mother. With the next contraction I thought I would be catching a baby, but a hand shot out waving at me behind the membrane, as was some meconium. I called for the paramedics to be rung as I realised this was not normal and in case we needed resuscitation backup!

The waters broke and the arm dangled out. I didn’t pull on the arm but tried to locate a cephalic pp (presenting part) without success. What to do? I went through the options and and decided to treat at a cord prolapse and got the woman to turn on all fours. This wasn’t straightforward as she has a disability. Yet she did get there and then it flashed into my mind after a short prayer to locate the lower limb if possible and do an internal podalic version. This was done between contractions and then with legs and body dangling with the next push a gentle breech extraction was performed of a 2.3kgs baby boy.

I’d asked the second midwife to be ready for possible resuscitation but as it was very little was needed. In the meantime mum delivered her placenta physiologically with very little blood loss. She sustained a small tear which has now healed well. The baby and mum were transfered to the hospital. Mum chose to come home later that day but baby was kept for a few days. Mum and Dad told me that the time the baby spent on NNU upset them as they felt he was fine and didn’t need to be there and mostly because of the BM tests heel pricks done.

As you can imagine, there was shock on all our parts and we have done a lot of reflection….. Including the thoughts that if this had happened if a labouring woman would have walked through the labour suite doors and waters broken with a dangling arm, the baby may not have made it, as the response would likely have been an emergency c/s and I don’t think we would have had the 15 minutes it would have taken to organise that. That is why I am still very happy with attending home births.

And by way of having a sense of proportion about these things I learned a lesson from the mother…. The Mum said to me a week later ” Are you experienced in this sort of thing?” My answer was “No, but I’ve written about in relation to the delivery of the second twin“. Her reply “Well, there you go duck, I gave you a bit of hands-on experience!” My reply was “Thank you” but to be honest I hope this is a one-off! Then she said “Well, a neighbour told me this happened across the street 20 years ago and the baby died“. Then she gave me her precious miracle baby to cuddle and I shed some tears.

And for the technically curious…. During the labour the baby had palpated twice longtitudinally abdominally, engaged, cephalic with a foetal heart at the final check at the symphysis pubis by Sonicaid. There are lots of possible theories of what happened but at the momemt I believe the smallish baby went oblique at second stage – at the strange “pop”. There is an account of this type of delivery in a 1923 obstetric textbook.

I am open to other interpretations but I rather this unusual presentation not be dissected into too many suppositions as I haven’t been able to share all the relevant details in such a public forum. Of course my notes are being checked with a fine toothcomb and I have had to make a statement from a risk management point of view. As any midwife who has been through this process knows, it feels very disturbing for a number of weeks, but as I have already said the mum helped me regain my sense of proportion. The second midwife has been a wonderful partner in all of this. If needs be, I am happy to discuss finer details face to face at an ARM meeting.

… The following is perhaps not an elegant textbook explanation of IPV but this is what happened in more detail. On ve, realising that the baby wasn’t in a cephalic presentation/longtitudinal axis but what felt like something firm but not bottom on oblique axis I asked the mother to go on to all fours. Then I inserted my hand with the mother’s co-operation ( I actually said to her -“if you listen to me we’ll get this baby born together”- I said this because at this point the situation was becoming very scary for her and me and the others and I had to get some focus and some calm for all of us – I don’t think I’ve ever said something like this ever before at the time of birthing) I then followed the bodyline up from the reinserted baby’s arm and felt a thigh/leg- there felt like there was enough room to do this – and then I gently turned/eased scooped/ the little bottom into a breech presentation on the longtitudinal axis to be the presenting part on the pereneum- almost direct sacrum anterior, on removing my hand one leg extended out and with next contraction breech birth followed fairly nicely with aiding the delivery of the head. Also, I need say to thank you to all the encouraging responses but I feel that I should also acknowledge that at this birth there felt like “spiritual midwifery” voices over my shoulder of all the ARM midwives from all the workshops I have ever been to and especially Mary Cronk’s words steadying me (whether you knew it or not Mary!). And I wasn’t hallucinating from the 24 hour awake time it just felt like I was drawing on real support so to speak of and unashamedly too! Kerrianne <P>Kerrianne

 


Dear Kerrianne,

This is SURELY a case to be celebrated and not subject to negative scrutiny. Here is a story of a midwife turning potential disaster into absolute triumph with skills, patience, and knowledge. This is midwifery expertise at its very best – at its most fundamental.

I have heard of a similar situation when the prompt and expert action of midwives attending a home birth some way distant from a hospital setting resulted in the successful birth and resuscitation of a baby which had suffered shoulder dystocia, with the result that the baby entered hospital in good condition and all was well. Meanwhile, in the consultant unit to which that baby was admitted, another baby died following a long period of being monitored by CTG which did not appear to have been able to save it. I am pretty sure I know which of those two babies was the luckiest. Of course these cases are probably not as simple as they seem – but, for heaven’s sake, lets celebrate our successes, and praise and support those midwives who are truly keeping birth normal!

MANY congratulations

Soo


Well done Kerrianne – absolutely textbook emergency procedure for a shoulder presentation with an arm prolapsing in the second stage. An internal (and external if you have another competant practitioner present ) podalic version is not usually difficult to do, It is much more difficult and usually a waste of time to try and do a a cephalic version. I last had to do this for a second twin years ago. There is a real problem if an arm comes down in the first stage and the cervix is not dilated enough to do a version. Usually the womaan’s body knows what to do and the labour stops and one has time to transfer for a CS. I had one of them a couple of years back, 6cms or so dilated if I remember correctly. Membranes ruptured and on VE there was an arm and a cord presenting but not prolapsed – ambulance stat- inform super hospital-rapid transfer – knee chest theatre all ready- difficult CS but mum and baby fine. Mary Cronk Kerrianne, What a great birth story! So glad that everything worked out well for both mom and baby! I was assisting at a home birth and when we got there she was about 6cm dilated but there was NOTHING in her pelvis. NOTHING! The midwife I work with doesn’t do breeches (yet) and her instinct said to transport. Got to the hospital and the CNM checked her, she was complete, but felt nothing as well. Had to do a sonogram to see the baby’s head. Since being a DEM is not legal and they were asking too many questions, the parents felt it would be better for us if we left. We were willing to stay, but they were going to let her labor and sleep some. She slept all night and after she woke and went to the bathroom her waters broke. As they did the baby’s arms swept forward(b/c he was still so high) and a hand came out. She WAS rushed for an emergency section and they actually had to cut her in both directions and use forceps to get this baby out (stuck behind a hip), and his little hand was cut during the surgery. Mom later developed a very severe infection and was in the hospital for several days and is now into a deep depression. Really sad. Your story is the only other story I have heard where this sort of thing had happened (other than with a twin). Dawn

AH updated 10 July 2000


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Posted on

April 12, 2013

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