Birth of the Shoulders

Birth of the shoulders

How does the labeling of shoulders work? Are anterior and posterior related to nearest and furthest, or front and back of the woman’s body? And do you think – if woman “traditionally ” gave birth on all fours that the teaching would be to pull upwards when the shoulders are being born?

Fiona


Posterior is the arm nearest the woman’s bottom. And you are right, the “mechanisms” if you are using “manouevers” for normal birth on all fours are upwards traction, then downwards. I find the best way on all fours is to catch rather than do anything at all!

Laura


I find all this talk of ‘which shoulder should be delivered first’ amazing – both of my babies were hands-off waterbirths. Do midwives really stick their hands in and pull one or the other shoulder out routinely? Why on earth is it assumed that *anything* is needed to be done routinely to enable a baby to be born, other than the spontaneous efforts of the mother? I do not intend this as criticism of anyone on the list – rather as wide-mouthed amazement at the ‘system’!

Angela


Midwives do not routinely stick their hands in and pull shoulders but many do encourage downward traction on the foetal head to ‘aid delivery!!’ I agree it is very strange that this is done and represents a learning as others have taught them. You have identified one of the benefits of a water birth in creating your own little nest free from the interfering hands of those professionals around you!

Kate


Due off shift recently, ‘relieved’ by another m/w and a student. Primip waterbirth about to occur. Student aseptic, (Why?) and desperate to control delivery. Other m/w and me exhorting student to get her hands away – mother bought her child to surface to greet him, student amazed – gosh, women can do it alone???

E


As a first year student with only two ‘deliveries’ under my belt, I have been taught (by my mentor) to be hands off the perineum, but very hands on the baby, applying pressure on the head to encourage flexion, then to extend the head as the brow is born, then to do the ‘see-saw’ motion as previously described.

My mentor told me that she had read that when a baby is left to be born completely hands off, the posterior shoulder appears first, though she had never seen it. I should have asked her why she hadn’t tried the hands off approach to see if it was true. She told me she had done one birth completely hands off, but she thought the anterior shoulder came first, though she wasn’t sure.

Tomorrow I’m on labour ward with a new mentor, so it’ll be interesting for me to see what her approach is. I’m beginning to gain a bit more confidence to question what’s going on, but if I continue to be taught anterior shoulder first, that is how I will have to practice, for now at least.

N


As a student with just 4 deliveries, I have been taught the same but just guarding the perineum as well. At uni we were taught the mechanism of labour (with us on the floor being fetuses and midwives) and this also included the see saw movement. My mentor on delivery suite is hands on as well, as was my community midwife at a recent home birth, although that was a compound presentation with hand by shoulder and therefore did need assistance (I think) as it was a tight fit. How are students to learn of other ways unless we are shown a different approach? Being on this list is a start and enables me to go back and challenge the opinions of my mentors (in a nice way of course). If I want to do a hands off birth, can I just do that or do I need to follow what my mentor is telling me to do, at this early stage in my training? At the end of the day she is responsible for my practice and therefore surely I need to follow her lead so to speak.

A


I would suggest that your mentor is responsible for teaching you good evidence-based practice, but YOU are responsible for your OWN practice and while I can remember how tough it is when theory is way different to the practice we see as students, I would suggest that you find ways to practice the way you feel is the correct way and mentors may then also learn from you. Some suggest just going along for the ride and abandoning bad things once you are qualified and while that is the easy way I feel it is not the way to help others change their practice.

I was never able to be diplomatic always getting my head shot at but I think I made a few stop and think when I refused to do things the “right” way (left hand here, right hand here, instruments lined up, correct towels, sterile this, watch the clock phew I thought I was playing twister half the time!!!) There is probably a diplomatic way – hope you find it. Good luck.

Virginia


I think it’s helpful to sometimes look back and see how we arrived at where we are now. When women lay on their backs all the time to give birth, it may have been appropriate to assist the birth in the ways described. Times change – research comes along and changes thinking and practice, but not at once and not for everyone. Some people fnd it very hard to give up their behaviour patterns, and we haven’t always known (in this generation!) of different ways of enabling women.

It’s not the mechanisms so much, as the cherishing support; it’s not the hands off so much as knowing when to be hands on; what we know now we haven’t always known, or have lost sight of.

It’s easy, now, to knock practice which is disempowering and controlling, but it wasn’t always so. Be patient with the laggards, and be kind. You could try saying to your mentors that your tutors were very keen for you to ‘try it this way’ and you’d like to be able to go back and say that is what you have done. Your mentors may sniff, but they will probably stand aside and let you. They may have other valuable things to teach you and you may be able to show them something they didn’t fully appreciate. It’s all about putting the pieces of the puzzle together.

Lesley


I think one of the best ways to learn hands off birth is to watch a waterbirth as this is totally hands off (or should be). Have confidence in the normal process of birth. I know it is hard to be challenging your mentors but if this is the way you wish to practice find one who is hands off and stick with her!

Laura


All through my midwifery training we were taught the “normal” midwifery maneouvers of birth which always included downward traction! As a midwife I am completely hands off unless I need to intervene. By working in this way it enables me to know that when I do intervene it is necessary and helps to differentiate between the true “dystocias”.

Laura


“Downward” traction implies that the woman is lying on her back or is semi-recumbent. I can’t remember when I last helped a woman birth in this position. It is certainly not the “norm” for me and I suspect it is not the “normal” position that most women would choose.

Mary Cronk


All through my midwifery training we were taught the “normal” midwifery maneouvers of birth which always included downward traction!

Crikey! WHY?!! What are the supposed benefits of touching the baby at all? Presumably it must be something pretty important if the powers that be deem it worth meddling with a system of spontaneous birth developed during 220 million years of mammalian evolution…… Can anyone tell me what outcome this is supposed to prevent, or to improve upon? When people routinely ‘deliver’ babies by using traction one way or another – what do they think would happen if they just left the mother alone?

After my own experiences, and the refreshing views of the midwives on this list, I do find it amazing to hear what goes on ‘routinely’. I greatly value midwives and midwifery and am very glad to have the expertise and experience of a midwife there when I’m in labour – IF things don’t go well then I might be very glad indeed that she was there. I value the fact that she or he will have seen many labours and will hopefully be able to reassure me if there is something which I worry is abnormal, but which is in fact OK. I value most of all her emergency resuscitation skills. But I just don’t get this idea about ‘something needing to be done’ to get a baby out, in a normal birth!

Angela


In my limited experience 2.5 years I to have seen the shoulders come out in the tranverse, without a tear! Also I have seen a few babes do what I call a comando crawl, when the head and hand present together and the babe seems to pull its own shoulder out!

But to shake things up a bit I thought I would mention the HOOP trial. To my understanding this study has recommended hands on for the delivery, since women in the hands on group repoted less perineal pain. Such practice therefore could influence which shoulder naturally delivers first since the hands poised’ group exerted lateral flexion to facilitate delivery of the shoulders.

The study states “in the light of this evidence, a policy of hands poised’ care is not recommended”. (MIDIRS 1999 p76)

Any thoughts…….


I guess this is a birth announcment of sorts, but a topical one.. Re: the discussion on shoulders and positions and birth, I am please to announce that my first child, Oliver Bee, born at home, 10-17-99, 15:26 in Toronto (9lbs 6 oz) refused to ‘take sides’ and was born both shoulders at once from a supported squat. Little tears, no sutures! Oh well, maybe he’ll be a diplomat.

Sky, midwifery student and on leave administrator, oh yah, and new mama. —


I am a first year – nearly second, midwifery student in Leicester. The third birth I attended on placement, too was born with both shoulders together, in a standing position, with a small second degree tear and no sutures. There was mention of shoulder dystocia, but being a niave student, I was just amazed to watch this head appear in stages and to catch him when came out.

Helen.


Which shoulder is born first?

I am a student midwife, during the last year I have looked after several women who birthed their babies in the “all fours” position. The first time this happened my mentor midwife instructed me to take the baby in a slight upwards curve so as to release the anterior shoulder first and I have followed this advice on subsequent occasions. This summer I had a placement outside my home area where I was able to observe midwifery care. At two of the births I witnessed the women were on all fours and the midwife used a no touch, hands poised approach, both times I observed that the posterior shoulder came first. The textbooks aren’t very helpful in this area and the only reference I have been able to find is in Enkin et al, A Guide to Effective Care which states that in kneeling or squating positions the posterior shoulder may be released first.

Do any of you experienced midwives have any opinions, tips, comments about this? Do you use hands on or poised in this position, and if they are on which shoulder first?


In any postion the woman takes, either shoulder can come first. You learn that by ignoring the text book and just watching the process. So ignore what your mentor told you, she is a text book case and birth just isn’t.

Melody


I am sure you will be flooded with the same message, but here is my two cents worth: The all fours position allows the baby’s body to follow the curve of the birth canal without being a contortionist, and the physiologic (observed) mechanism of birth seems to be that the UPPER shoulder comes first. Gravity and all that, right? The upper shoulder comes first when the woman is semi-sitting or lying supine, and then it is the anterior shoulder. On all fours, it is the posterior shoulder. (Don’t ask me which it is in a lateral position!) If you think about the build of a woman’s body, the posterior shoulder first seems much more natural, and the anterior shoulder first stuff probably came along when women started being placed in supine positions to birth.

Rachel


I have found that either shoulder can come first no matter what position the woman is in. And if you aren’t planning to put traction on the baby’s head to “deliver” him or her but instead plan to “catch” then it is mostly an academic question, unless you have shoulder dystocia.

Melody


It’s been so long since I saw a baby come out with the woman on her back that I wouldn’t dare argue with Melody… but last week I remembered to watch during the birth of a baby whose mother chose to lie on her left side for the last ten minutes of second stage, and it was the posterior shoulder which came first on that one. I am prepared to believe either one can come first, and I have also seen a 3.5 kg baby come out with both shoulders simultaneously in the transverse diameter, without a tear and propelled only by the mother’s expulsive efforts. Guess she forgot to read the textbook too!

Rachel
Who prefers not to catch, or pull or do anything but “receive” babies (I am VERY lazy).


In my experience the posterior shoulder almost always delivers first. Occasionally both will appear almost together. I have never seen the anterior shoulder spontanously deliver first.

I generally practice a ‘hands off’ approach, only intervening if I perceive an actual clinical need. I think this is particuarly important in ‘all fours ‘/kneeling position…..this is not based on trials by the way ….but on anecdotal evidence from midwives past and present ……..It somehow seems the woman’s body and the baby work in harmony …..they seem they know exactly what to do …so I leave them to it. ….Watching and waiting only intervening if I feel concerned about something. Then I have to trust myself that my intuition and learned experience is right …mostly it is, sometimes it isn’t ….but there you go !

I would not choose to try to deliberately deliver a baby’s anterior shoulder when in all fours – with the exception of difficulty or dystocia, when I’ll do whatever works.

Sue, Community based Midwife


I agree with Sue and Rachel – in the normal run of things, the posterior shoulder seems to appear first. Why pull the anterior shoulder first, when to do so puts extra strain on the perineum? It seems to me that if the posterior shoulder slips out first, the bisacromial diameter is considerably reduced. Sometimes, both shoulders may appear together, but generally well curved round and I have noticed this most often when the woman is in a kneeling position rather than all fours.

Lesley


The posterior normally comes first (not anterior as the books say).

Ooooh so I am not the only one to have noticed this! I only noticed that the anterior shoulder does come first when I started attending births here in the UK and was asked to do the see-saw maneuver as I call it (y’know where you do the ritgen maneuver by tucking the babies head then ‘pull’ down with the head then up again with the curve of cares to release the anterior shoulder.)

If you leave the baby alone the posterior shoulder mainly comes out first even if the woman is on the bed.

I have mused over the obstetric book version for a few years now wondering what it meant by anterior shoulder coming first. Two of my texts which are American allude to posterior shoulders coming first but the majority of texts do say the anterior comes first.I wonder why this was not noticed at the Hoop trial ?

Tania


Actually – I think that it may’ve been noticed – but wasn’t one of the ‘recordable’ facts. I trained during the HOOP trial, and regularly noticed the posterior shoulder first, and consequently never thought it unusual.

Lynn


Midwives’ Experiences of Shoulder Dystocia

I have had a couple of difficult shoulder births—one was in left lateral (I tried to encourage her to stand as I felt sure that the baby was large, but this was the best we could achieve), and one was in the birth pool, and she was in a semi-squat. In both cases moving them to all-fours, as in Ina May Gaskin’s study, was immediatly effective, and both babies were born quite rapidly, and though a little shocked, quickly recovered and needed no resusitation.

Pam, midwife


I have been involved with 2 of what were called shoulder dystocia (SD) cases by the other staff present. Thankfully both resolved without physical damage to mum or baby, and because they were in hospital and I was on bank shifts I can’t comment on the amount of psychological damage to them or their relationships.

One thing that I think is probably not well doccumentd is what the maternal position was in the late second stage. I would try McRoberts only after squatting or turning onto all fours and anything else I could try because ir seems to me that it would squash the pelvis in exactly the wrong direction to help free the impacted anterior shoulder.

The 2 SDs I was at were resolved by 1) turning the woman from all fours to her side, legs not pulled up to chest particularly. 2) going from semi-recumbent to kneeling up and gripping the bed head for stability – I took the latter woman over in second stage at the start of an early shift she was having her second baby. There was about a 4 to 5 minute delay with that one but baby bounced out and was as right as rain, as was the other baby. Both these babies were average in size and both were 2nd babies of low risk women in hospital.

I remember a study that said the diffusion of O2 across the placenta was not enough after a time, but what about that baby that had surgery on its mothers abdomen a few months ago, relying only on the cord? According to the surgeon’s reports, that went on for some time and confirmed to me that it was a good supply.

The other thing I think is that it strange to do episiotomies when the head is delayed – it is the pelvis the shoulder is stuck on, not soft tissue. I also agree with the others that many times the birth is rushed and it starts with the directed pushing in 2nd stage. It is alarming to see the baby’s face go purple when there is a bit of a wai,t but anecdotaly I think some babies just do that.

I think I read that most SD’s are with low risk mothers and the baby is often an average size. The biggest baby I have ever caught was 11 lbs 3 oz and was born at home, leaving behind an intact perineum.

I wonder what the incidence is of SD in women in primitive societies or who are traditionally active for birth, anyone know?

The other thing which springs to mind is that Jean Sutton says that in nature the posterior shoulder delivers first – now there’s a thought! I guess lots of times women are laying on the sacrum so the anterior shoulder has to come first even if it doesn’t want to.

Elaine


Well said – many a “shoulder dystocia” should be renamed “birth attendant distress”. Why oh why do we rush this part of 2nd stage?? Poor babes are just getting turned to the AP diameter when – woosh -someone tries to haul them out!! And then the documents read “a degree of shoulder dystocia” which then puts the woman in a higher risk category for future pregnancies.

I totally agree with you about the pelvis being squashed with the McRoberts maneouvre. I attended the Midwifery Today conference at Ealing Town Hall in September 98 and listened with fascination to the teachings of Ina May Gaskin. She advocates turning women on to all fours as the first step of rectifying dystocia – (even if on all fours already, by doing a full 180 degree turn back on to all fours) when she clarified the physiology, it was like a light bulb going on! Secondly, she told the conference that on a few occassions, she had actually pushed the anterior shoulder back up into the pelvis and delivered the posterior one first – now there’s a clear-headed woman for you. I also agree with you about the episiotomy. I feel strongly that many an episiotomy is done unneccessarily – it is not a soft tissue issue but a bony one.

Brenda, Midwife


We brought this issue up of episiotomies when our new guidelines came out. It’s recognised that it’s not done to help get babe out, but so the the person delivering can get their hands in!!! We’ve also been told that not to do an episiotomy would be seen as gross negligence.

Cate


I’ve been looking after a 17yo prim, 999 call last night as her sister got a shock when her waters went. I was on the ambulance when the call came in as I’d just transferred another woman down to the consultant unit. Started contracting about 10 mins after waters went – clear/pink liquor. CTG fine on admission. Went home after a couple of hours to establish (may have gone sooner but we hoped she’d get into good going labour instead of going home and calling out another ambulance.

I was on call last night and expected to be called out for her, but she was pushing when I got up and I took over her care then. You could hear decelerations with pushing but it picked up to 120-130 when the contraction went and the liquor still clear/pink. on VE at 0725 – oedamatous rim of cervix anteriorly. On to left lateral for a while still occasional involuntary pushing. Decels still heard but picked up well. 0810 – still no vertex visible, decels still picked up but spontaneous recovery to baseline after contraction away. Advised change of position to hands/knees – declined.

Sister in room to review, phoned consultant unit. VE at 0825 – fully ROA – advised position change – up to hands/knees. 0845 Next push vertex becoming visible fh better 120 – 130. CTG commenced – fairly normal looking, one ?late decel seen on trace – good variability seen otherwise. Consultant unit happy with CTG when it was faxed to them – normal 2nd stage trace Pushed well spontaneously 5 pushes to a contraction, vx advanced slowly – but she was a prim.Head born about 0934 in hands knees position – head did not restitute and appeared tight on the perineum, hard to feel for cord. Alarm bells ringing – shoulder dystocia.

I thought hands knees position would be best for this. She pushed with next contraction but there was no give – with some difficulty we got her round on to her bottom, head still not restituted and looking a bit bluish, pushed the alarm for the other midwife to give a hand. Legs in to McRoberts and traction applied with next contraction/push – still nothing. I asked sister to take over from me and she birthed the babe with the next push/contraction, babe born 0940 – shoulders appeared to birth in the transverse diameter.

Babe pale and floppy on arrival heart rate 60ish – to resus. Apgars 1 at 1, 5 at 5, 8 at 7 and 10 at 10. GP on call helped sr with resus and paed flying squad allerted to come. They were fairly happy with babes condition but transferred him to SCBU as there was sternal recession, there was talk of CPAP but they transferred him without it as he seemed stable. He looked to be around 3000g.

All well with the mother, placenta and membranes born with no problems and on examination her perineum was intact. 50 ml blood loss.

I feel absolutely awful about this – and I knew what I was doing with shoulder dystocia. the fact the babe was so flat has really got to me – now I’m wondering about the earlier decels and if I had been more concerned with them and got her transferred maybe things would have been different, although by the time the ambulance got down the road we may have had the baby in the ambulance with the same scenario and only one midwife and a paramedic.

I’m beginning to wonder if I can handle this job, maybe i should have stayed put in the consultant unit I was at previously, or maybe i should be on the check out in tesco.

Advice/criticism welcome on my management

C


What you described sounds like a text book piece on how to manage shoulder dystocia. It sounded to me like you handled the situation very well, and did all the right things at the right time. I guess you may be feeling so bad because of the baby being flat…and coming at the end of a series of really grotty shifts. From what you say…it sounds like a normal CTG for that stage of labour. Babies can and *do* come out unexpectedly flat…I’m sure that you can think of other occasions where this has happened (an elective C/S springs to mind). By acting as you did, and not flapping and tugging, you have probably given this babe a *better* outcome.

Take the time to debrief with your colleagues who were present, as well as us. Life is a challenge and we are always learning…use this as a “critical incident” and write it up while it is still fresh.

Janet


It seems to me you handled the Shoulder Dystocia very well. A substantial percentage of SD’s are totally unexpected and there is no evidence that when they happen in a consultant unit the outcomes are any better, it depends so much on the response experience and skill of the practitioners who are actually there when it happens. I am presuming that once you put the woman into McRoberts the second midwife did Supra pubic pressure…

Shoulder dystocia is a rare but potentially serious complication nearly half of cases occur in babies of “normal” weights. Most are unpredictable. ALL professionals midwives and medical practitioners should have thought about what they would do and have “fire drill” regularly.

I had a case recently ..The woman Gravida 4 had had a longer than expected with a grav 4 second stage, and birthed the head on her hands and knees. Nothing much happened – the turtle neck sign was present. We quickly asked the woman to move to Left lateral and I tried gentle lateral flexion there was NO movement so into McRoberts position and Supra Pubic pressure from the second midwife whom I had asked to be there for reasons that I still do not understand, (I almost always work alone). The impacted shoulder freed and the baby was born in pretty good condition. It freed so easily with SP pressure that I wondered if it had been a true Shoulder dystocia. However the baby had a fractured clavicle so it really had been an impacted shoulder.

A fracture of the clavicle is an acceptable and sometimes unavoidable sequala of resolving a shoulder dystocia. If you bring your own shoulders together by folding your arms across your chest you will see that by doing so you markedly reduce the size of your shoulders. .. it heals without treatment and there are no sequalae, as there can be with excess traction which can cause a brachial plexus injury which can have lifelong effects.

Mary Cronk


From the mother mentioned in the above post:

About the McRoberts position, I was in a deep squatting position prior to going left lateral then the McRoberts..the deep squatting did help…I do believe at some point I spent a lot of time on my knees leaning over a birth ball when the baby was OP and the anterior lip was present….honestly, after having seen extreme versions of McRoberts during my training as a student midwife, the McRoberts position I was in seemed a ‘kinder’ variation of it. I don’t think I spent more than 3 minutes in the McRoberts position as opposed to what seemed like half an hour or so in my 2nd labour. I believe Mary actually chose the position at its optimum moment (does that make sense?).

This birth has been such a wonderful experience, much to Mary’s amusement as she thought I experienced a horrid and long labour. What was different this time was that never during the labour did I feel negative or defeated (even when the gas and air ran out and Mary refused my request for another dose of 50mg Pethidine – I didn’t really want it actually). I was not physically or emotionally drained, infact I was very focused. I came away from this experience thinking that I have achieved something.

Aida


One particular birth sticks in my mind.

A primigravid woman I was looking after had been mobilising throughout her 1st stage of labour, using an extended pipe for the entenox. I monitored the FH and maternal observations while she was mobilising (I never ask women to lie on the bed to be monitored unless they want to!). As she was approaching 2nd stage, she decided that she wanted to go on all fours on the floormat. She took off her nightie as she felt it was cumbersome. External signs and the woman’s demeanour indicated 2nd stage. The woman then kept rotating herself every few minutes – from all fours position – over onto her back -stranded beetle position – and then back on all fours again. She continued this for about an hour in 2nd stage and then decided to stay on her back with a bean bag behind her to support her in an upright position. Very slowly the head started to descend and crown. I’ve never seen it take so long for a head to actually deliver! The baby had really fat cheeks. Then -y es – I think you’ve all probably guessed by now – the shoulders seemed to be stuck – but as soon as we adopted the McRoberts manoeuvre, the baby delivered easily.

The baby weighed ten and a half pounds! There was no trauma to the genital tract – not even a graze!

Do you think all the rotating this woman did was a natural instinct to ensure that her ‘big’ baby and its shoulders would rotate for delivery? The woman was actually of a very small build!

If this woman had been “stuck” on a bed, then she would not have had the freedom of rotating her body so easily at will – and the outcome of this labour could have been very different.

I am grateful to the midwife I was working with, who disregarded the one hour time limit for 2nd stage as progress was being made – albeit slowly. I think 2nd stage lasted about one and a half hours.

This is where I get on my high horse. These time limits, dictated by the hospital protocols are so unrealistic. If we are treating women as individuals – surely they don’t all have uniform time limits for their 2nd stage of labours!

I had very sore knees for the next week!!!!

Lorraine


I would like to know how many of us still use/advise the McRoberts for shoulder dystocia – we’re speaking normal labouring women here (not epidurals etc). I am under the impression that by putting women into this position, flat on their back with knees drawn up to chest, that we were actually causing the pelvis to narrow, i.e., the coccyx would not be able to move out of the way, therefore narrowing the available space. Sometimes, I think, this is called “closing the back”.

The reason I ask is that I heard Ina May Gaskin speaking at the Midwifery conference in Ealing and she advocates the turn onto hands and knees – even though the woman may be in the hands/knees position in the first place. She reckons that this is enough to free an impacted anterior shoulder from the supra-pubic bone.

Brenda, Midwife


I have recently undertaken the advanced life support in obstetrics course(ALSO). Part of this course is the management of shoulder dystocia. They recommend the McRoberts manoeuvre, citing that it corrects sacral lordosis and removes the sacral prominence as an obstruction, thus increasing the available space. They also cite that upto 75% will deliver with this manoeuvre alone. There is research to back this up but unfortunately I have left all this information at work.

Anne


I have (thankfully) only attended one true shoulder dystocia and I elected to try hands and knees as this woman had chosen to birth sitting up. Successful outcome, Apgars 4/1 6/1 8/10, resuscitation needed but fine.

I have had a couple of ‘difficult shoulder births’ and have used McRoberts as this women were already in active mobile positions ie hands and knees.

Lynn


If there are risk factors for a shoulder dystocia, would you never immediately treat the birth as a dystocia problem if it looked like one after the head delivered? [ie would you treat as shoulder dystocia even before any problems actually occurred with the delivery of the shoulders?]

I missed a difficult birth recently in which the doctor declared shoulder dystocia in the middle of a difficult ventouse delivery. He noted that the birth of head to birth of baby interval was only 1 min. 45 seconds. Primigravida mother. So I assume that she hadn’t even had another contraction in which the fetus could rotate. Yet the baby was expected to be big, progress of labour had been poor, syntocinon augmentation and still slow progress, moulding ++, difficult delivery of the head then I presume “turtle” sign and a presumption of “impacted shoulders”.

McRoberts position and suprapubic pressure worked and babe was okay, considering. The baby’s head was phenomenally moulded though – and a post-dates baby who looked like an infant of a poorly controlled diabetic mother, very chubby face neck and middle.

I have to wonder if the outcome would have been worse if they awaited another contraction….or if one suspects a problem is it best to adopt a new position and await spontaneous delivery still?? This mother had an epidural so needed assistance to move out of lithotomy…

(When I have been away from work awhile I often dream of a shoulder dystocia or unexpected breech delivery the night before my first shift back….a personal refresher device?)

Carol


Good question. In a nutshell, if I thought there was a problem AFTER delivery of the head then I would turn the woman onto all fours. I would also do this if she were already on all-fours – ie 180-degree turn.

My practice – if there are “risk factors” then I observe very carefully. However, I do not treat the birth as a problem when no actual problem exists; otherwise I reckon that we would treat everything as a potential problem! I take the whole view of the whole labour into consideration and especially the descent and position of the baby.

If the head (largest diameter) has been born, I am confident that the rest of the baby will follow, provided that we do not rush in and try to pull a baby out when his/her shoulders are still in the transverse.

I also feel that women pick up on any negativity in their labour and, if only for this reason alone, the wrong thing to do is to treat someone as a potential risk. It would be like going back to the days of the “unproven pelvis” – YEUCH, what a horrible expression.

I do try to encourage women to adopt their own positions as their bodies usually know best.

I hope I can say that I am alert to the normal and the not so normal. Midwife = with woman – and woman is individual.

It’s so long since I worked with any woman who has had an epidural, so is the McRoberts and supra-pubic pressure still used in this case?

Brenda
Midwife, Scotland


I have had only a few experiences of shoulder dystocia over the last seven years in part I am sure is due to actively discouraging recumbent positions and maybe not interferring with the delivery of the shoulders as the posterior normally comes first (not anterior as the books say). When it does occur it is important to stop pulling as injury can easily occur. In my experience shoulder dystocia results in a ‘flat’ baby often requiring resuscitation and shoulder dystocia does occur you should anticipate problems. If the dystocia is short lived so that the baby is in primary apnoea then it will gasp to establish respirations but the longer the dystocia is the more likely it will be in secondary apnoea and will die if it is not resusciated. So although I believe shoulder dystocia is more prevalent than it should be due to recumbent positions it does still occur and it is important to have manoeuvres you can implement immediately to provide an optimum outcome.

Kate


I was discussing shoulder dystocia the other day, and the woman I was talking with asked why we worried about lack of oxygen to the baby when the umbilical cord/placenta was attached. Any thoughts?

Possible cord compression and, if it is prolonged, the placenta will begin to come away leaving the uterus useless. I recently heard of a case where it was placenta accreta that was believed to have saved a fetus as the dystocia was fairly prolonged…

C


Are you saying the strong contractions of second stage would eventually sheer the placenta off and this is what causes the O2 deprivation? Interesting, but is it proven?

In the recent case of the Guatemalan co-joined twins the mother laboured hard for 8 days before she had a c/section. I’ve also heard of contractions stopping in second stage to allow the big or stuck baby time to ease out.

I personally know a womyn birthing at home whose breech baby became stuck at second stage (no decent) and she stayed like that for hours and hours before calling the ambulance. She knew the baby wasn’t coming out, she also had a c/section for a posterior frank breech, sitting inside her like a little fat buddha.

I have often cringed at hearing these rush ‘life and death’ shoulder dystocia actions forced on the mother and baby, although don’t know enough to say if they were warranted or not.

I’ve read some birth stories where it seemed the attendants panicked at the thought of a stuck baby and acted too quickly in my opinion, causing horrid trauma to the mother and baby, when maybe they could have just watched and waited on the process for a while longer.

Andrea


Are you saying the strong contractions of second stage would eventually sheer the placenta off and this is what causes the O2 deprivation?

I am stating that in my understanding, there is the possibility that the third stage will begin if the dystocia is prolonged. We know that the placenta doesn’t always wait for the fetus to be born all of the way before making its escape and so, that would certainly be a risk. I am also not saying that it would happen in all cases. There is also the possibility of uterine and maternal fatigue should the dystocia continue +++.

C


The 5th Annual CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy, published by UK government) report included the findings of a focus group on shoulder dystocia. This has all the usual problems of CESDI reports, as mentioned in Jane Evans’ piece in the latest Midwifery Matters – ie that they look at babies whose cause of death was given as shoulder dystocia, then work backwards. I’ll summarise the main points that seem relevant here.

Recommendations: Anticipate the possibility of SD if there is evidence of a big baby, especially in connection with maternal obesity or glucose intolerance.

If, following delivery of the head, there is immediate head retraction (the ‘turtle sign’) or restitution does not occur with the next expulsive contraction then immediate action is necessary. Call for asistance….

McRoberts’ manoeuvre should be carried out by flexing the woman’s legs right back so that her thighs are on her anterior abdominal wall. Suprapubic pressure should be applied to disimpact the anterior shoulder.

(This probably assumes that the mother is on her back or semi-reclining, so McRoberts is the quickest manoeuvre to try ? )

If obstetric assistance is not available and these manoeuvres fail, then it is reasonable to try delivery in a squatting position, or on all fours, using downward traction to release the posterior shoulder.

If a generous episiotomy, McRoberts’ manoeuvre and surapubic pressure have not achieved delivery of the body, and obstetrician or midwive should attempt to get access to the posterior shoulder.

FUNDAL PRESSURE OR INCREASINGLY FORCEFUL TRACTION ON THE HEAD SHOULD BE AVOIDED.

…Symphysiotomy, deliberate clavicular fracture, or the Zavanelli procedure (that’s where baby’s head is shoved back up and a c/s performed) have not been included in this sequence because they are not widely used in the UK. However, shoulder dystocia is a desperate situation for the fetus, so obstatricians and midwives should be aware of all the possible techniques for effecting the delivery.”


HELPER mnemonic for shoulder dystocia

The HELPER mnemonic for shoulder dystocia is:

Help
Evalute for an episiotomy (not necessarilyy done at this point)
Legs (McRobert’s- flexing the thighs up onto the maternal abdomen)
Pressure (suprapubic)
Enter (internal manoeurves- Wood Screw)
Remove posterior arm
Roll onto hands and knees

This is the recommended emergency drill from Advance Life Support Obstetrics (ALSO).

Louise


I have been looking through the obstetric emergencies handbook issued by my university during my revision and was reminded of the HELPERR nmemonic…. I have a question about this.

H

stands for call for help
E is for EVALUATE FOR EPISIOTOMY, and this was said to be done to aid some of then more invasive manouvres.
Funnily enough, the all fours position doesnt take place til the last R, after you’ve tried the Rubin’s, woodscrew and removing the posterior arm bit. This is my query, why not try the all fours first before trying the McRobert’s and the supra pubic pressure and the other manouvres that might require an episiotomy for easier access?

I remember reading that most cases of shoulder dystocia are resolved by the use of all fours or the Mc Roberts, and suprapubic pressure. Why inflict the woman with an episiotomy that might not be necessary? Any thoughts on these? I will go to university tomorrow and challenge this with my tutors, I am sure I will be shot down in flames, but at least I am used to it.

A


I had this same discussion at a skills drill day at my local hospital and the consensus was that as long as you tried all things then you have done your best, that the HELPERR was there to remember the manoeuvres and does not mean you have to do them in any order. Your point is very valid so would back this up.

Virginia


Why not try the all fours first before trying the McRobert’s and the supra pubic pressure and the other manouvres that might require an episiotomy for easier access?

This is in fact what I do, often as a woman has just got out of a pool, so that all fours is the easiest and most obvious thing to try first. I’m also talking about ‘tight shoulders’ not just shoulder dystocia. I have actually had 2 true shoulder dystocias – one all fours worked, and one it didn’t.

Lynn


The ALSO mnemonic is just a guide. Would anyone on this list fancy doing an epis AFTER the head is born!!? I know that there are fluffy “risk factors” for predicting a dystocia but I would never do anything “just-in-case”

L


I agree that the Also course teaches mnemonics for guidance. But I would have no problem doing an episiotomy after delivery of the head if required. What i wouldn’t do is automatically do one before trying other external manoeuvres to dislodge the shoulder.

Linda


When we had the obstetric emergency lecture at uni we did the whole HELPERR mnemonic, but we were also told that this mnemonic was really taught so that if you are faced with such a situation, you are able to act automatically and not panic. As I understand it these are the steps that you should try, but not necessarily in the order that that they should be carried out – for instance evaluating for an episiotomy has propbably been done subconciously before you have summoned help.

I have heard experienced midwives say that in such a situation the first thing that they would do is to change the woman’s postion from whichever postion she is in – onto all fours or helping her to turn over from all fours back to the all fours position – and then try the McRoberts manouver, as moving the pelvis is what dislodges the shoulders – However,I myself have not had to act in this situation and I may not be correct in my understanding of things!!!

Julia


As it turned out during Skills Lab today, I didn’t even get the opportunity to query this HELPERR nmemonic because she clarified herself by saying that the nmemonic was from ALSO, and apparently there wasn’t any adequate research to say that the management of a shoulder dystocia should be done in that particular order. Unfortunately half the class had spent a lot of time going through what they thought was the ‘correct’ way of managing it, only to come out of the session feeling more confused and less able. I am just amazed why the mnemonic was used in our Obstetric Emergency Handbook without anyone bothering to add a footnote that the management does not really follow in that particular order.

A


Shoulder Dystocia in a birth pool

What happens in the event of a Shoulder Dystocia occurring if women are submerged in water?

I experienced a ‘true’ shoulder dystocia in just these circumstances recently.

I have seen quiet a few ‘tight shoulders’ and initially with the ‘signs’ of possible shoulder dystocia was not immediately concerned as always in the past, simple manoeuvres have sufficed. However, the chain of events was: slow advance of head AFTER crowning – turtling – x2 contractions no restitution – therefore initially pulled plug and asked woman to stand and put one leg on side of pool (the leg corresponding to the lie of the baby) – still no restitution with contraction so helped out of pool – onto all fours as it’s the simplest thing for a woman to do on exiting the pool – still no advance even with assisted restitution and traction – into McRoberts plus traction – very stretchy perineum, no need for episiotomy – even McRoberts didn’t do it – 2nd midwife offered supra pubic pressure, however, by this time I could see that it was the posterior shoulder which was the problem – hand in (yes, HAND) dislodged shoulder – baby finally out. All this happened in 6 minutes! (manoeuvres, not whole process). Baby apgars I think were 4, 7, 9. Baby did not suffer any damage, and woman had a 1st degree tear not sutured.

I already had a 2nd midwife present – and this was not in a hospital, and our only reflection afterwards was whether we should have called for a paramedic as soon as problem was identified? But I have to say that we were both so intent on sorting the problem, calmly and efficiently, that neither of us felt that it was worth the few minutes it may have made, as it would have held up what we were actually doing to help.

The biggest surprise for me was how quickly it all happened, and yet it wasn’t ever ‘panicky’. In fact the ironic/hilarious thing afterwards, was the mother’s reaction – within 15 minutes of birth, she was on the phone to relatives and described it as ‘a bit ‘hairy’ at the end’ but a lovely birth’!

Lynn


I’ve been involved with a couple of cases like this. One was sorted when we got the woman standing with one foot in the water and one on the edge of the pool and the other, we helped the woman into a ‘floating McRobert’s’ and both babies were a tight fit, but ok.

For me (and I admit this may just be my own anxiety) the important issue is to avoid the risk of the baby’s head re-submerging, so getting her lower half free of the water is crucial. Pulling the plug out isn’t much help as it still takes too long for the pool to empty; moving one leg then the other into a different position is what seems to free the shoulder.

Lesley


Sub aqua – we had an animated discussion about how long a baby should sit on the perineum in the second stage. In the particular case we were discussing, contractions had become spaced out – almost 5 minutes apart and the head just sat there – the second midwife thought the woman should have been asked to get out of the pool, the midwife who conducting (interesting word?) the birth thought not. (BTW, they didn’t have this discussion at the time). Penny Simkin says something about there not being perfusion of O2 across the maternal/placental barrier after a certain point in the birth – certainly not after the baby is born, even if cord attached and pulsing – would be interesting to know just when that point was (when perfusion becomes inadequate)- because that’s surely what would give us the answer to this question…

Terri, Midwife, Devon, UK


How long between delivery of the head and shoulders? When does it become shoulder dystocia?

All being well, how long may one have to wait between the birth of the baby’s head and birth of his/her shoulders? Is there a “safe” limit, beyond which one may ask the mother to “try a push”? I’ve noticed recently how some midwives get very anxious at this point and keen to hurry things up. I feel I need some soothing facts at my disposal to encourage patience. Any thoughts?


–I find this a fascinating question.

When I returned to midwifery in the early 80s, after 8 years out having babies, one of the things I most noticed was that everybody seemed to be rushing deliveries. Gone was the relaxed atmosphere I had been trained to expect.

This included giving syntometrine – we used to give this after the birth of the baby, no rush, now it was given with the anterior shoulder. When I asked why, no good explanation was given. In fact on one occasion the sister told me I couldn’t give it, cos it had to be given with the anterior shoulder(and I hadn’t) or it was too late!!

So to answer your question, whilst the babe is still in utero and syntometrine has not been given, whats the rush? The placenta is still working, the cord is attached, the baby is getting all the oxygen it needs.

Also it is important to allow restitution and rotation to take place so that the widest diameters of the shoulders are delivered thro the widest diamter of the pelvic outlet.

So yes be patient, provided there are no signs of fetal distress.


The 5th Annual CESDI report, section on Shoulder Dystocia, says:

In 47% of deaths due to shoulder dystocia, the interval between birth of the head and body was 5 minutes or less, and that “one would expect a previously healthy fetus to survive a period of cerebral hypoxia of that duration” – and that other factors were often involved: perhaps “a preceding hypoxic stress renders a fetus less able to withstand the additional asphyxial impact of shoulder impaction”.

Here are the stats on intervals, of the 45 cases where they were available (out of 56 deaths in the year attributed to shoulder dystocia):

Less than 5 minutes: 21 babies (47%)
5-9 mins: 15 babies (33%)
10-14 mins: 4 babies (9%)
15 or more: 5 babies (11%)

The report does not define shoulder dystocia. It says that all cases where a putative diagnosis of shoulder dystocia had been made at some stage were included, although “many showed a degree of difficulty in delivery of the shoulders, but would not necessarily have fulfilled the strict criteria used by some authors to define true shoulder dystocia…”.

Only 45% of cases were autopsied. On autopsy, 96% of the babies had evidence of acute hypoxic organ damage and birth trauma in 24%. In 6 cases there were unepected findings: 2 of acute chorio-amnionitis in stilbirths and 4 neonatal deaths where the baby had pneumonia.

**QUOTE:**

Conclusions:

Fatal shoulder dystocia is uncommon… most cases are unexpected. Midwives are usually attending the mother when the problem becomes apparent, but medical staff are frequently needed to expedite delivery of the body. Fetal or neonatal death may occur even with relatively short (< 5 minute) delays in delivery of the body….

**END QUOTE**

All discussions are confounded by the fact that just about every researcher uses a different definition of shoulder dystocia. Some define it as ‘any birth where the attendant has difficulty delivering the shoulders’, but that of course depends on the birth attendant’s views and practice and experience. There is a good discussion of definitions etc.. on the USA Midwife Archives athttp://www.gentlebirth.org/archives/shoulderDystocia.html

Some definitions include *any* situation where the shoulders are not born in the next contraction after the head, while others employ arbitrary time limits such as 1 or 2 minutes between birth of the head and shoulders. Others define it as any situation where the attendant needs to ‘do’ something to help the shoulders arrive, whether that is changing the mother’s position, pushing her legs up to her chest (McRoberts Manouvre) etc.. Many studies appear to consider only whether the notes describe a case as shoulder dystocia or not, but one which looked deeper (ref below) found that of 91 cases initially described as shoulder dystocia, only 24 were found to be ‘true’ shoulder dystocia on review.

Ref: Shoulder dystocia: predictors and outcome. A five-year review. AUTHORS: Gross SJ; Shime J; Farine D SOURCE: Am J Obstet Gynecol 1987 Feb;156(2):334-6

Angela


Shoulder dystocia and birth injuries, including brachial plexus injuries

The research I’ve read suggests that brachial plexus (B.P.) injury is the most common after-effect of shoulder dystocia, but that normally the injury is just transient. Most studies find that few injuries persist after a couple of months [4, 7, 17, 23]. The highest figures quoted are in the range of 15% of shoulder dystocia babies suffering some injury, of which 5% of the injuries are permanent (I think this means 5% of the 15%, but it’s not clear) [10].

More examples: Discussion of [17] says: “Shoulder dystocia occurs in < 1% of vaginal births and 12% to 15% of cases are associated with some evidence of injury to the brachial plexus. Injury to the C5-6 nerve roots leads to Erb’s-Duchenne palsy, whereas injury to the nerve root C8-T1 leads to Klumpke’s palsy Fortunately, 80% to 90% of Erb’s palsies and up to 50% of Klumpke’s resolve without leaving any persistent neurologic deficits.”

Although approx. half of all shoulder dystocia cases involve babies of normal weight, large babies with shoulder dystocia are more likely to suffer Erb’s palsy (a specific B.p. injury) than small babies with shoulder dystocia. They appear not to be any more likely to suffer other serious consequences though, eg oxygen deprivation. [12]

The causes of B.P. injury are controversial, but all the evidence is that they are caused mainly, not by shoulder dystocia itself, but by some delivery methods attempted to resolve shoulder dystocia. The big no-no is pulling on the head, which stretches the neck and nerves in it. However, this can’t account for all cases as some babies born by elective c/s have B.P. injuries. See [10] for a discussion.

Elective c/s to avoid birth injuries in large babies?

Elective c/s to avoid the possibility of shoulder dystocia is NOT recommended for large babies on the basis of several recent studies, eg:

For non-diabetic women, for each permanent brachial plexus injury prevented by the policy of elective c/s for babies estimated to weigh over 4,000g (8lb 13 oz), 3695 cesarean deliveries were performed at an additional cost of $8.7 million…For the policy of elective c/s for babies estimated at over 4500g (9lbs 15 oz), it takes 2345 cesarean deliveries and $4.9 million to prevent one permanent brachial plexus injury. [5]

For non-diabetic women, another study found that : “Under the most plausible assumptions, a prophylactic cesarean policy with either a 4000- or 4500-g macrosomia threshold would require more than 1000 cesarean deliveries and millions of dollars to avert a single permanent brachial plexus injury.” [15]

Doctors with higher c/s rates for babies over 4000g do not achieve better outcomes than those with lower rates [20] – but various outcomes for mothers were worse with ‘liberal’ use of c/s for large babies.

A retrospective study [23] of 227 babies weighing over 4,500g (9lb 15oz), average 4,706g (10lb 6oz) found that : “Shoulder dystocia occurred 29 times, for an incidence of 18.5% in vaginal deliveries for macrosomia. There were seven cases each of Erb palsy and clavicular fracture, and one humeral fracture. By 2 months of age, all affected infants were without permanent sequelae. There was no birth asphyxia or perinatal mortality related to delivery for macrosomia. ..There was no statistically significant difference with respect to hemorrhage or hospital stay for women who had a vaginal delivery (with or without shoulder dystocia) compared with women who had a cesarean delivery.”

A dissenting study is [11], which suggests (on the basis of 77 cases of shoulder dystocia) that “A policy for elective caesarean section for birthweights in excess of 4000 g (97 percentile) would prevent 44% of shoulder dystocias, increase the caesarean section rate by 2% and half the perinatal mortality among births with shoulder dystocia.”.

However, note that this study is from Singapore where, as the authors say,

“The local birthweight distribution is very different from the West…” It says that 4000g (8lb 13 oz) is the 97th percentile there, but in the UK I think the 97th percentile is about 4,500g. A brief look at a growth chart suggests that 4000g is only 75th percentile here.

Interesting … but perhaps even more interesting is the fact that two obstetricians in the USA [10] are taking these figures and applying them to shoulder dystocia generally, saying without qualification that elective c/s for estimated weights over 4000g would “would prevent 44% of shoulder dystocias……” –

This is a classic case of abuse of data. There is no reason to suppose that a plicy of elective c/s for babies above the 4000g would achieve the same results in other populations, and that could mean elective c/s for 25% of babies in some countries! For these conclusions to be applicable to the USA or UK, you would need to have comparable c/s rates generally, comparable obstetric practice, and the average sizes of mothers and babies would have to be similar… none of these applies as far as I know.

I found a couple of other papers suggesting (few actually recommend) elective c/s for babies over a certain weight. I noticed a trend in the research; those studies which involve retrospective case controls reach different conclusions than those which look at births for large groups. The retrospective case control studies usually take, say, 100 cases of shoulder dystocia, or of births of large babies, and look at complications which occurred, and consider whether they would have been prevented by elective c/s. They do not generally look at any other outcomes (eg maternal morbidity or mortality) – just what cut-off policy for c/s would have prevented the shoulder dystocia. If *all* you cared about was shoulder dystocia then all babies would be born by c/s…

The problem with this is that they reach a conclusion for a known birthweight – so they might recommend that all babies weighing 4,500g or over should be born by c/s to prevent 20% of shoulder dystocia cases, *but* that doesn’t help much with decisions before the baby is born, because of the inaccuracy of weigh estimation. So retrospectively you might be able to say that having had such a weight as the cut-off point for c/s would have achieved these results, eg say that 10 c/s would have been necessary to prevent one case of s.d…. but if you then start to do elective c/s for an *estimated* weight of that level, you might find that 20 c/s were necessary to achieve the same results… or 5. The point is that the ‘tool’ of ultrasound weight estimation is so flawed, it is hard to extrapolate guidelines from retrospective analysis.

Anyway, I digress. The studies which start out looking at large numbers of births of all weights, and then consider what would happen if you imposed a cut-off point for elective c/s for predicted large babies, tend to find that elective c/s is *not* recommended, eg [5] and others cited above.

I suppose there is an element of human psychology reflected in this too. If you start out looking at the cases which went wrong, and think about what you might have done differently with the benefit of hindsight, you may reach very different conclusions than if you start out thinking about what the best decision would be overall. Which seems to me to be the basic difference between retrospective case-control studies and the others.

Induction of labour at term for suspected large babies?

Again, the evidence suggests that induction at term is NOT recommended to avoid birth trauma for suspected large babies. It increases the c/s rate and associated problems for mother and baby, but does notreduce the shoulder dystocia rate, nor does it improve outcomes. See [13, 14, 24, 25, 26].

I’m afraid reading all this is just confirming all my prejudices…

Inaccuracy of fetal weight estimation

The problems of intervention such as induction or c/s based on estimated fetal weights are of course compounded by the notorious inaccuracy of ultrasound weight estimation. For example, [22] found that “”Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged”. Predictions of macrosomia > 4,200g increased induction rates and c/s rates, but “There was no significant difference in the incidence of shoulder dystocia or the occurrence of birth trauma.”

Ultrasound may overestimate fetal weight in general, and is pretty hit-and-miss at the best of times – eg [26] found that “In 66 of 86 women (77%) delivering within 3 days of ultrasound examination, estimated fetal weight (EFW)exceeded birth weight. In only 41 of these 86 women (48%) were the EFWs within the corresponding 500-g category of birth weight” Bear in mind that 500g is over 1lb!! That’s a big margin for error…

The 6th Annual CESDI report looked at deaths of large babies (4000g and over), and it concluded that ultrasound estimation of fetal weight was *NOT* recommended where a large baby was suspected, because “the inaccuracy of ultrasound estimates have been well documented. Indeed, it is possible that estimating fetal weight by late ultrasound may do more harm than good by increasing intervention rates” (p47). They also quote research concluding that elective induction and elective c/s are not recommended, although suggest that large randomised controlled trials are needed. Their main recommendation is that, where a large baby is suspected, the attendants should be on the alert for a delay in late labour, which could be a warning sign for shoulder dystocia.

What about death or brain damage from shoulder dystocia?

Note that the above study is talking about permanent brachial plexus injuries, not the things that worry us more, like death… but death or brain damage from shoulder dystocia is rarer than nerve damage. An article online [8] is a review of birth injuries arising from shoulder dystocia, and the author says that “Recent investigations have noted no clear link between shoulder dystocia and hypoxic brain damage”. If you read this article, by the way, note that some of the stats quoted are confusing as the study actually looked at 107 ‘potential or actual’ malpractice litigations where shoulder dystocia was involved. This means that presumably only the more serious injuries were considered, and of course the more serious the injury, the more likely it is to be the subject of a malpractice suit. So when the researchers say that “Permanent hypoxic or traumatic cerebral damage was documented in almost one-third of the cases. “, they mean that one third of their malpractice cases involved brain damage, not that one third of shoulder dystocia cases involve brain damage. This study also says that “Five cases of cerebral palsy followed intentional cutting or incidental breaking of the umbilical cord, wrapped around the neck once, prior to delivery of the shoulders. ” – interesting as elsewhere I found warnings against cutting or clamping nuchal cords where there is any possibility of shoulder dystocia.

The 5th Annual CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy, published by UK government) report on shoulder dystocia looked at 56 deaths in the two years (1994/5) where some degree of shoulder dystocia had been documented. They note that there is a real problem with definitions, and it appears that in many of these cases, shoulder dystocia may not have been the main problem. It says that in 47% of deaths due to shoulder dystocia, the interval between birth of the head and body was 5 minutes or less, and that “one would expect a previously healthy fetus to survive a period of cerebral hypoxia of that duration” – and that other factors were often involved: perhaps “a preceding hypoxic stress renders a fetus less able to withstand the additional asphyxial impact of shoulder impaction”. It seems at least possible that some of these babies would have died even if there had not been any difficulty delivering the shoulders, and as noted before, we do not know what degree of shoulder dystocia any of them exhibited. So the figure of 56 deaths over two years does not mean that shoulder dystocia was responsible for all of these deaths.

Article [16] is a detailed summary of issues in shoulder dystocia cases, although perhaps outdated and conservative. The authors say: “A normal term fetus can endure up to 10 minutes of asphyxia before permanent neurologic injury occurs. During the first 5 minutes, the major harm to the neonate is most likely to be iatrogenic….Although the fetal pH declines at a rate of 0.04 units/min between delivery of the head and trunk, shoulder dystocia rarely results in death or asphyxial injury… ”

Intervention causing shoulder dystocia?

I understand from a previous post that the rate of brachial plexus injuries was significantly higher in the USA than in the UK. I would not find this surprising, given the high level of intervention which seems normal in births there – the studies I’ve looked at found that shoulder dystocia was more likely where labours were induced, accelerated with oxytocin, and particularly where forceps or, especially, ventouse deliveries are attempted [6, 19].

Perhaps this is because

a) These interventions were employed because progress was slow, but progress was slow for a reason? Baby needed more time to turn, mother needed more time to move?

b) If you’re having oxytocin you’re probably being continuously monitored, and thus are probably lying down/semi-recumbent…great position for trapping a baby. Discussions on web articles [2,3] listed below give more info about specific increases in pelvic diameters when mother moves to all-fours.

c) Other factors about assisted deliveries – eg the speed with which the head is brought down, or the angle – which makes shoulder dystocia more likely. Any thoughts, anyone? eg Article [1] says one of the situations where s.d. is more likely is “when truncal rotation does not occur (as with precipitous labor).” – could this also apply to assisted deliveries? There is also mention on the USA Midwife Archives [2] about the need for the shoulders to rotate properly to fit through the pelvis, and that with assisted deliveries the head may be pulled down before this has happened. Apparently shoulder dystocia linked to assisted delivery is more common in smaller babies; in larger babies, it’s more likely to happen even with spontaneous birth of the head.

Midwife management of shoulder dystocia

Someone asked about midwife management to avoid brachial plexus injuries. There are a couple of studies showing very good outcomes for midwife management of shoulder dystocia. See for example [3]

The Farm article on Shoulder Dystocia and use of the all-fours position http://www.thefarm.org/lifestyle/dystocia.html

“From 1971 to the present, the midwives have attended 1750 births. Thirty-five of these were complicated by shoulder dystocia, and all of them were managed by midwives .. Three early births were managed with traditional maneuvers, resulting in some birth injuries. The remaining 32 were managed by having the mother assume the all-fours position, with no mortality, no birth injuries, and with excellent Apgar scores. All the babies for whom follow-up was possible (29 of 35) were developmentally normal (ages 9 months to 15 years). These statistics compare favorably with the reported mortality rates of 21% to 29% and morbidity rates of 16% to 48%. In addition, despite frequent recommendations that any maneuvers to deliver the shoulders be preceded by a generous episiotomy or proctoepisiotomy, 23 of the babies were delivered over an intact perineum, and there were no 3rd or 4th-degree lacerations. Finally, though some authors recommend the time-consuming step of administering general anesthesia to the mother before attempting alternative maneuvers, 23 these babies were all delivered without anesthesia.”

This is a study on The Farm’s results for shoulder dystocia, co-authored by Ina Mae Gaskin and a doctor who is trying to ‘educate the masses’ amongst obstetricians:

All-fours maneuver for reducing shoulder dystocia during labor. Bruner JP, Drummond SB, Meenan AL, Gaskin IM http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9610468&form=6&db=m& Dopt=b

Study [18] found comparable outcomes for nurse-midwife practices compared to general medical practice in the USA, but a trend towards fewer incidences of s.d. was noticed when mothers were side-lying (as opposed to the ‘obvious’ recumbent/lithotomy position I suppose)

Shoulder Dystocia and home birth

Something I have learned from all this is that shoulder dystocia is far less likely to happen at a home birth than a hospital birth – or at least, if it does happen at home, it’s likely to be in a known high-risk situation.

Shoulder dystocia figures for large babies are complicated by the inclusion of children of diabetic mothers, and obese mothers. The body shape of babies born to diabetic mothers appears different, making shoulder dystocia more likely for any given circumstance. For non-diabetic mothers, rates of s.d. for large babies are much lower, and for non-diabetic women of normal weight, lower still. [20, 16]

So, the reasons why I believe shoulder dystocia to be a lesser risk at home births are:

  • Most cases of serious s.d. involve women with gestational diabetes, and to a lesser extent women of great size. If a mother doesn’t fall into either of these categories then you can cut your worrying by about 90%.
  • Home births will not involve oxytocin augmentation – a known risk factor for s.d…. if the mother needs oxytocin then she will be transferring to hospital anyway.
  • Ditto assisted deliveries.
  • A mother at home is less likely to be lying on her back in the first place, so baby has more room to get out.

Angela Horn
www.homebirth.org.uk

REFERENCES [1] Shoulder Dystocia LCDR Robert B. Gherman, MC USNR; T. Murphy Goodwin, MD http://www.shoulderdystocia.com/reviews4.html

[2] USA Midwife ARchives page on Shoulder Dystocia – lots of information and discussion. http://www.gentlebirth.org/archives/shoulderDystocia.html

[3] The Farm article on Shoulder Dystocia and use of the all-fours position http://www.thefarm.org/lifestyle/dystocia.html

[4] Fetal macrosomia: risk factors and outcome. A study of the outcome concerning 100 cases >4500 g. (9lbs 15 oz) AUTHORS: Berard J; Dufour P; Vinatier D; Subtil D; Vanderstichele S; Monnier JC; Puech F SOURCE: Eur J Obstet Gynecol Reprod Biol 1998 Mar;77(1):51-9..Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) …There were five cases of Erb’s palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia..

[5] The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. AUTHORS: Rouse DJ; Owen J; Goldenberg RL; Cliver SP SOURCE: JAMA 1996 Nov 13;276(18):1480-6 )

[6] This study looked at 100 cases of babies predicted over 4,500g, whose average birth weight turned out to be 4,730g – about 10lb 7 oz…

TITLE: Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. AUTHORS: Benedetti TJ; Gabbe SG SOURCE: Obstet Gynecol 1978 Nov;52(5):526-9 In the absence of prolonged second stage (PSS) and midpelvic delivery, the incidence of shoulder dystocia was 0.16%. However, with PSS and midpelvic delivery (ie assisted delivery), the incidence of shoulder dystocia was 4.57% ..When PSS occurred and midpelvic delivery was attempted, the incidence of shoulder dystocia was 21% in infants weighing in excess of 4 kg.. All shoulder dystocias and failed vaginal deliveries occurred after use of the vacuum extractor. Immediate neonatal injury was apparent in 47% of infants with shoulder dystocia after PSS with midpelvic delivery. There were no maternal or fetal deaths related to shoulder dystocia during the study period.

[7] TITLE: Shoulder dystocia: its incidence and associated risk factors. AUTHORS: Sandmire HF; O’Halloin TJ SOURCE: Int J Gynaecol Obstet 1988 Feb;26(1):65-73 ABSTRACT: ..Among the 73 shoulder dystocia cases there were no perinatal deaths and all birth-related injuries associated with shoulder dystocia were temporary except for two cases of mild muscular weakness among 12 brachial palsy cases.

[8] http://www.shoulderdystocia.com/common.html

Common Intrapartum Denominators of Shoulder Dystocia Related Birth Injuries Leslie Iffy, Valeria Varadi, A. Jakobovits Department of Obstetrics and Gynecology and Pediatrics UMDNJ -New Jersey Medical School, Newark, New Jersey, USA and Universitats-Frauenklinik Aachen, Germany

[9] Macrosomia–maternal, fetal, and neonatal implications. AUTHORS: Modanlou HD; Dorchester WL; Thorosian A; Freeman RK SOURCE: Obstet Gynecol 1980 Apr;55(4):420-4

[10] http://www.shoulderdystocia.com/causes.html Brachial Plexus Causation: An Old Problem Revisited by James A. O’Leary & James L. O’Leary, II

[11] An analysis of risk factors for the prediction of shoulder dystocia in 16,471 consecutive births. AUTHORS: Yeo GS; Lim YW; Yeong CT; Tan TC AUTHOR AFFILIATION: Department of Maternal Fetal Medicine, Kandang Kerbau Hospital, Singapore. SOURCE: Ann Acad Med Singapore 1995 Nov;24(6):836-40

[12] Maternal and infant complications in high and normal weight infants by method of delivery. AUTHORS: Gregory KD; Henry OA; Ramicone E; Chan LS; Platt LD AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, University of California at Los Angeles, School of Medicine, 90048, USA. SOURCE: Obstet Gynecol 1998 Oct;92(4 Pt 1):507-13

[13] TITLE: Induction of labor versus expectant management in macrosomia: a randomized study. AUTHORS: Gonen O; Rosen DJ; Dolfin Z; Tepper R; Markov S; Fejgin MD AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Meir General Hospital, Kfar-Saba, Israel. SOURCE: Obstet Gynecol 1997 Jun;89(6):913-7

[14] Labor induction with a prenatal diagnosis of fetal macrosomia. AUTHORS: Leaphart WL; Meyer MC; Capeless EL AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Vermont, Burlington, USA. SOURCE: J Matern Fetal Med 1997 Mar-Apr;6(2):99-102

[15] Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography–A Faustian bargain? AUTHORS: Rouse DJ; Owen J AUTHOR AFFILIATION: Division of Maternal-Fatal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama, USA. SOURCE: Am J Obstet Gynecol 1999 Aug;181(2):332-8

[16] Shoulder Dystocia LCDR Robert B. Gherman, MC USNR; T. Murphy Goodwin, MD http://www.shoulderdystocia.com/reviews4.html A thorough overview of the subject although quite conservative (no mention of all fours, assumes women on back) and possibly outdated.

[17] http://www.shoulderdystocia.com/new1-2.html

Dr. Dwight P. Cruikshank, Milwaukee, Wisconsin. Shoulder dystocia occurs in < 1% of vaginal births and 12% to 15% of cases are associated with some evidence of injury to the brachial plexus. Injury to the C5-6 nerve roots leads to Erb’s-Duchenne palsy, whereas injury to the nerve root C8-T1 leads to Klumpke’s palsy Fortunately, 80% to 90% of Erb’s palsies and up to 50% of Klumpke’s resolve without leaving any persistent neurologic deficits.

[18] Outcomes of macrosomic infants in a nurse-midwifery service. AUTHORS: Nixon SA; Avery MD; Savik K AUTHOR AFFILIATION: University of Minnesota School of Nursing, Minneapolis 55455, USA. SOURCE: J Nurse Midwifery 1998 Jul-Aug;43(4):280-6 ABSTRACT: …Large infants had birth outcomes comparable to those reported by others in the medical literature, suggesting that nurse-midwifery management, including consultation with physician colleagues, can be appropriate and safe.

[19] Shoulder dystocia and associated risk factors with macrosomic infants born in California AUTHORS: Nesbitt TS; Gilbert WM; Herrchen B AUTHOR AFFILIATION: Center for Health Services Research in Primary Care, Department of Obstetrics and Gynecology, University of California, Davis, USA. SOURCE: Am J Obstet Gynecol 1998 Aug;179(2):476-80 CITATION IDS: PMID: 9731856 UI: 98400582

[20] Anthropometric differences in macrosomic infants of diabetic and nondiabetic mothers. AUTHORS: McFarland MB; Trylovich CG; Langer O AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio 78284-7836, USA. SOURCE: J Matern Fetal Med 1998 Nov-Dec;7(6):292-5

[21] The Green Bay cesarean section study. IV. The physician factor as a determinant of cesarean birth rates for the large fetus. AUTHORS: Sandmire HF; DeMott RK

[22] Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? AUTHORS: Weeks JW; Pitman T; Spinnato JA 2nd AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Louisville, School of Medicine, KY 40292, USA. SOURCE: Am J Obstet Gynecol 1995 Oct;173(4):1215-9

[23] The outcome of macrosomic infants weighing at least 4500 grams: Los Angeles County + University of Southern California experience. AUTHORS: Lipscomb KR; Gregory K; Shaw K AUTHOR AFFILIATION: Division of Maternal Fetal Medicine, Los Angeles County + University of Southern California. SOURCE: Obstet Gynecol 1995 Apr;85(4):558-64

[24] Influence of spontaneous or induced labor on delivering the macrosomic fetus. AUTHORS: Friesen CD; Miller AM; Rayburn WF AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Nebraska, College of Medicine, Omaha, USA. SOURCE: Am J Perinatol 1995 Jan;12(1):63-6

[25] TITLE: Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. AUTHORS: Combs CA; Singh NB; Khoury JC AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Ohio. SOURCE: Obstet Gynecol 1993 Apr;81(4):492-6

[26] Pregnancy outcome following ultrasound diagnosis of macrosomia. AUTHORS: Delpapa EH; Mueller-Heubach E AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Women’s Hospital, Pennsylvania. SOURCE: Obstet Gynecol 1991 Sep;78(3 Pt 1):340-3

[27] Shoulder dystocia: predictors and outcome. A five-year review. AUTHORS: Gross SJ; Shime J; Farine D SOURCE: Am J Obstet Gynecol 1987 Feb;156(2):334-6

[28] J Reprod Med 1998 May;43(5):439-43 All-fours maneuver for reducing shoulder dystocia during labor. Bruner JP, Drummond SB, Meenan AL, Gaskin IM http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=9610468&form=6&db=m&Dopt=b


From Medscape:

Appropriate Use of C-Section Cannot Prevent All Cases of Shoulder Dystocia

WESTPORT, CT (Reuters Health) Jul 23 – Performing a cesarean section based on ultrasonic fetal weight estimates can prevent some but not all cases of shoulder dystocia, according to the findings of a study conducted by Israeli researchers.

Dr. Salem Kees, from Sheba Medical Center, in Tel Hashomer, and colleagues, performed a retrospective analysis of shoulder dystocia cases that occurred at their institution from 1996 to 1999.

Shoulder dystocia was present in 56 of approximately 24,000 deliveries with more than half occurring after spontaneous deliveries, the researchers state in the June issue of the Journal of Reproductive Medicine. While the McRoberts maneuver was used in 48 cases, it was only adequate as the sole procedure in 9 cases.

In addition to the McRoberts maneuver, 27 cases required suprapubic pressure, 2 of which also required a double episiotomy. Twelve cases required the McRoberts maneuver, suprapubic pressure, and the corkscrew procedure, with 3 also needing a double episiotomy. Eight cases required no maneuvers, the investigators state. Midwives were involved in 35 cases, 27 of which required assistance from physicians.

Only 20 of the infants delivered weighed more than 4000 g. Thus, even if cesarean section had been performed in all these cases, 36 cases of shoulder dystocia still would have occurred. Only seven cases of shoulder dystocia would have been diagnosed based on ultrasonic measurements, the authors note. While six women had gestational diabetes, not one of them had an infant with ultrasonically estimated weight of 4000 g or greater.

One infant with shoulder dystocia died prior to delivery, the researchers state. Twelve infants developed Erb’s palsy, one experienced a fractured clavicle, and one developed Erb’s palsy and a fractured clavicle, the investigators point out.

“Shoulder dystocia creates a complex clinical scenario,” the authors state. “Certain cases can be prevented by the careful selection of patients for cesarean section,” they add. “However, there will always be unexpected cases of shoulder dystocia.”

Dr. Kees’ team points out that “as shoulder dystocia is relatively rare, there is little possibility that any obstetrician will become thoroughly experienced with the maneuvers for freeing the shoulders.” However, the investigators emphasize that “all labor ward staff are strongly urged to become as familiar as possible with these techniques.”

J Reprod Med 2001;46:583-588.


Links to other sources of information:

On this website:

Shoulder Dystocia – Mary Cronk discusses management at a home birth.

A Personal Reflection on Shoulder Dystocia – Louise Walker considers the impact of maternal position.

On other websites:

USA Midwife Archives page on Shoulder Dystocia
www.gentlebirth.org/archives/shoulderDystocia.html

The Farm article on Shoulder Dystocia and use of the all-fours position 
www.thefarm.org/lifestyle/dystocia.html

Midwifery Today E-News edition on Shoulder Dystocia 
http://midwiferytoday.com/E-News/enews1n3.html

Medline abstract of All-fours maneuver for reducing shoulder dystocia during labor
Bruner JP, Drummond SB, Meenan AL, Gaskin IM
J Reprod Med 1998 May;43(5):439-43

Shoulder Dystocia.com – website about s.d. and birth injuries. Conservative medical/legal approach.
www.shoulderdystocia.com

Thread on shoulder dystocia and all-fours, on obgyn-net forum, starting with this first message.

West Midlands Perinatal Institute – practice recommendations for shoulder dystocia
www.wmpi.net/reviews/oe/oe_shoulder_dystocia.htm


AH updated 27 November 2002

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