Research to Remember
The most common risk factor for shoulder dystocia is the use of a vacuum extractor or forceps during delivery. Dystocia occurs to varying degrees in infants with a birth weight of 2500 grams (0.6 to 1.4% increased risk) and in infants weighing 4000 to 4500 grams born to diabetic mothers (5 to 9% increased risk). However, most dystocia occurs with infants of normal birth weight, making prenatal identification of risk factors difficult. Maternal complications of dystocia include postpartum hemorrhage (11%) and fourth-degree maternal lacerations (3.8%), and fetal complications include brachial plexus palsies (4 to 15%), which nearly always resolve within 6 to 12 months after birth. The degree of practitioner experience has no bearing on the incidence of fetal complications.
— American Family Physician, 1 April 2004
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Obstetrical solutions for stuck shoulders evolved without the advantage of listening to midwives. Thankfully, midwives have traditional strategies of their own for shoulder dystocia.
Squatting and Standing: Moving into a squat may shift the pubic bone and roll the shoulder out from under the pubic bone. The widening of the ischial spines will increase room in the transverse. In this vertical position, uterine contractions may be stronger and more efficient. Moving the mother to a standing position can work as well. The pelvis may be more mobile when a mother stands with knees slightly bent. A strong helper can hold her under the arms to stabilize and support her. Standing allows a hand in, if needed, more than does squatting.
Gaskin Maneuver: Simply flip the mother over onto her hands and knees. The motion can cause an inner rotation of the shoulders. Remember, to move the baby, move the mother. Notice if the head now restitutes and look for a lengthening neck. If yes, pushing will now bring the baby.
"Running Start": What if the baby still doesn't come out? With mother on her hands and knees, she quickly lifts a knee and sets the foot down flat. At the same time, since verbal instructions are difficult for the mother to process at this time, the midwife or assistant grasps whichever leg is handy and moves it up to the new position with the foot flat on the bed. The mother now has one knee down and one knee up, a bit like a runner waiting for the signal to begin. This move rotates the symphysis pubis joint and rolls the shoulder off and into the open pelvis. The symphysis shrugs off the shoulder, like the lumberjack rolling off the log. The pelvis widens on the side that the knee is raised, so the midwife may want to raise the knee on the side where she suspects the baby's back is. Often the mother's right leg is the one to lift. But in a flurry, just grab a leg and lift it. Immediately, the posterior shoulder should slide out and with it, the entire child.
Praying Hands Rotation: If the baby is still stuck, the next step can be done quickly also. The midwife slips the fingers of both hands inside. With flat palms, one hand braces the baby's back and the other hand braces the chest, like a prayer around the baby. Thumbs are not required and can stay out of the mother. The baby is rotated so that the posterior shoulder moves toward the chest. The baby is essentially spiraled out.
Lift the Sacrum: If the posterior arm can't move, it may be that the baby is too large to rotate easily in the praying hands rotation. The midwife uses her dominant hand to attend the posterior shoulder. She uses the back of that hand like a wedge between baby and sacrum and lifts the sacrum up with her knuckles while her fingers sweep the posterior arm to baby's chest (and into the oblique diameter). Opening the sacrum enlarges the pelvic outlet diameter.
Bring the Posterior Arm Out from the Hands and Knees Position: Whenever success at bringing the baby's shoulder into the oblique fails to bring the baby, the midwife should go after the posterior arm and bring it out. For the mother already on her hands and knees for the birth, it is easy for the midwife to slip the four fingers of her hand inside along the mother's thigh. She will want her hand along the baby's back, not the chest. She should then sweep the fingers upward toward the tailbone. This act alone may move the posterior arm into the oblique.
— Gail Tully, excerpted from "Shoulder Dystocia: The Basics," Midwifery Today Issue 66
For more information about bringing the posterior arm out and much more information about rectifying shoulder dystocia—read this article in Midwifery Today ISSUE 66, which can be ordered.
Protocols [commonly] require mothers who are anticipating large babies to leave the bath [in a waterbirth]. Now there is a growing body of experience that suggests shoulder dystocia can be managed more easily in the pool. Canadian midwife Gloria Lemay has written a protocol for management of shoulder dystocia in the water. It appears that tight shoulders happen more often because of a practitioner or a mom trying to push before the baby fully rotates. There is no harm in waiting for a few contractions to allow baby to rotate, especially since the baby is not going to be taking a breath. Position changes in the water are so much easier to effect and the mother doesn't panic but remains calm. A quick switch to hands and knees or even to standing up with one foot on the edge of the pool if shoulders are really tight can help maneuver baby out.
— Barbara Harper, excerpted from "Waterbirth Basics: From Newborn Breathing to Hospital Protocols," Midwifery Today Issue 54 [Theme: Waterbirth]
Midwifery Today ISSUE 54 can be ordered.
Researchers who conducted a retrospective study of 592 births involving shoulder dystocia identified 127 of the most severe cases. These cases involved 57 births with fetal manipulation (moving the infant in the birth canal) without episiotomy, 22 births involving episiotomy without fetal manipulation, and 48 births that combined episiotomy with fetal manipulation. Among these 127 births, the researchers compared rates of brachial plexus palsy outcome and chest depression in the newborns and the incidence of anal sphincter trauma in the mothers. The researchers concluded that in severe shoulder dystocia, fetal manipulation can be successfully and safely performed without episiotomy, ultimately reducing the risk of BPP and anal sphincter and perineal trauma. When manipulation was performed without episiotomy, the incidence of BPP, fetal chest depression, and maternal anal sphincter trauma was significantly decreased. In addition, episiotomy, with or without fetal manipulation, is associated with a nearly seven-fold increase in severe perineal trauma.
Nevertheless, in 2002, nearly 780,000 episiotomies were performed in the United States.
Gurewitsch, E.D., et al. 2004. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: A comparison of outcomes. Am J Obstet Gynecol Sep;191(3): 911–6.
Order this educational booklet from Midwifery Today and read about shoulder dystocia management, techniques and experiences: Shoulder Dystocia Handbook
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I know some midwives use cord blood to perform the Eldon tests for newborns. Does anyone know the best way to collect the blood to keep it from getting contaminated with the mom's blood?
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Question of the Week
Q: What are midwives' thoughts on myomas and vaginal birth? A client was recently sectioned as a way to "prevent hemorrhage." It occurs to me that a waterbirth may have been an option with an infiltrated vein to react to hemorrhage.
— Luna Maya Birth Center
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Question of the Week Responses
Q: My baby was born with a tight triple cord, with red marks and bruising around neck, once born. We actually managed to get the cord over the head and free before birth. I was glad since I felt strongly that the cord shouldn't be cut early. After baby was born, the woman who managed the cord said she really believed she would not have been able make the cord slip over the baby's head if not for the watery birth environment reducing friction and sticky residue. Have other midwives found this to be true?
A: I think it's reasonable to assume that water reduces friction. I don't check for cord around the neck in waterbirths (or air births) unless there is an obvious delay in the birth after the head has been born. When there is enough cord to slip over the baby's head, it's also enough to be born with and then carefully untangled. The distance from the baby's navel to the neck doesn't change in birth, and the distance from the baby's neck to the place of insertion on the placenta becomes slightly reduced as the baby passes down the birth canal and the baby and amniotic fluid are released from the uterus. This tells me that if there was enough cord for the baby's head to be born, there will be enough in almost all cases for the rest of the baby to be born without interference. The cord won't usually become any tighter than it already is.
I have attended a birth in which the baby had a very tight cord and was born in water. The baby's neck muscles were tight, and she had some initial difficulties breastfeeding, which we attributed to the tight cord.
I studied midwifery in 1972 in a hospital program, and of course I was taught to check for cord and clamp and cut if it couldn't be looped over the head. I now think this is usually an unnecessary intervention. If the baby is big and the shoulders are the cause of delay, the cord's integrity could make a lot of difference in subsequent resuscitation.
— Joy Johnston
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My sister-in-law has myasthenia gravis, an autoimmune disease that causes muscle weakness. She now has a one-week-old baby (delivered by c-section) and is trying, trying, trying to breastfeed and having much difficulty. I've talked with her about the common things (positioning, eating nutritious foods, drinking lots of water, etc.), but baby is having a rough go of it. She tries to nurse the baby for nearly an hour (during this time baby is fussy, crying, screaming), then gives up and gives baby a bottle of formula. She trusts her doctor, doesn't seem interested in seeking a lactation consultant, and I don't know what else to say. Any advice?
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Regarding finding a birth practitioner in Spain [Issue 7:21]:
Wherever you give birth in the world, it is best to be well-informed and to have your own philosophy about childbirth. It is your experience and your body. Are you already in Spain? Do you speak Spanish?
If you wish to correspond with a New Zealand midwife I am more than happy to be available for any questions. You can check out our Web site, www.maternitymatters.co.nz, which has my profile.
— Heather Donald
Nurse midwives attend most normal births in Spain, but do follow an obstetric model. In Catalunya there is a homebirth movement with a group of homebirth midwives who are doing wonderful work. I know midwives in Valencia, Madrid, and the Canary Islands. Please let me know [through E-News] exactly where you will be and what kind of birth experience you are seeking so I can help you better.
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Luna Maya Birth Center, Chiapas, Mexico
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