November 11, 2009
Volume 11, Issue 23
Midwifery Today E-News
“Shoulder Dystocia”
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Learn shoulder dystocia management, techniques and experiences.

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The Shoulder Dystocia Handbook will help prepare you for this complication. Authors include Marion Toepke McLean, Gloria Lemay, Gail Hart, Mayri Sagady, Sara Wickham and Jill Cohen.
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Quote of the Week

"Attending births is like growing roses. You have to marvel at the ones that just open up and bloom at the first kiss of the sun but you wouldn't dream of pulling open the petals of the tightly closed buds and forcing them to blossom on your time line."

Gloria Lemay

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The Art of Midwifery

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
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According to a study published in the New England Journal of Medicine, infants who have been starved of oxygen at birth may benefit from gentle cooling of their body temperature for their first 72 hours. Researchers conducted a randomized trial involving 325 babies who were less than 6 hours postpartum, had a gestational age of at least 36 weeks, and had suffered perinatal asphyxial encephalopathy. Roughly half of the infants received body cooling in addition to standard intensive care procedures; the remaining infants received intensive care alone.

While body cooling did not reduce the rate of death or disability associated with the asphyxia, it did appear to reduce the risk of cerebral palsy and improve neurological function in those infants to whom it was applied.

The full text of the study is available by subscription to the New England Journal of Medicine Online. The abstract can be read here:

New England Journal of Medicine 361(14): 1349–1358, 2009

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Managing Shoulder Dystocia

Following are some suggestions for dealing with shoulder dystocia:

First, don't overdiagnose. The rate of shoulder dystocia is 1.7% in babies over 8-1/2 lb. Shoulder dystocia occurs when the anterior shoulder of the baby lodges above the pelvic brim and won't enter the pelvis. Very slow delivery of the head, face and chin suggests shoulder dystocia but may not always lead to it. Note the time of delivery of the head. While it is true that complications tend to cluster, if you have experienced shoulder dystocia four times in your last 50 births you are probably overdiagnosing.

When you suspect shoulder dystocia, encourage the mother to push and be sure her legs are widely separated, drawn up and back, positioned as if she were in a squat. An assistant can apply suprapubic pressure, which may dislodge the shoulders. Watch for the neck! If the neck appears, the shoulder is not impacted.

Communicate. Tell the mother the baby's shoulders are stuck and that she must push hard to get the baby out. Tell her you are going to help her and be very clear about what you want her to do.

Changing the mother's position to hands and knees will deliver many babies at this point. If advance of the neck is not seen, slide one hand inside, along the mother's sacrum, and locate the posterior shoulder of the baby. The hand is up inside to the wrist at this point. Traction is made on the arm and shoulder [while] being careful to avoid the axilla, where pressure on the superficial brachial nerve plexus can cause partial or complete paralysis of the arm. If this is not successful, flex the arm with pressure on the antecubital fossa, inside the elbow, and pull it across the chest and out. The most severe shoulder dystocia babies who do not deliver progressively at this point can be worked loose by rotating the now delivered posterior shoulder and arm up under the pubic bone. The other shoulder comes out through the roomy curve of the sacrum.

Marion Toepke McLean
Excerpted from "Managing Shoulder Dystocia," Midwifery Today, Issue 12

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    “There is a truly authentic, mammalian sense of love among midwives in the region, and beyond that, an ardent sense of human rights that is often difficult to come across. I think more than anything it is these two virtues that characterize midwives working throughout Central America. In this short commentary, my hope is to share with you the lives and work of two midwives in the region who exemplify these virtues. Around these parts, they are well-known, loved and respected, and their stories deserve to be told.”

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Question of the Week Responses

Q: What is your best tip for shoulder dystocia?

Midwifery Today E-News staff

A: One of the things I would like to contribute to the discussion of shoulder dystocia (SD) is the idea that SD is sometimes, often, an arrest of rotation. Help the baby finish the rotation that nature intended.

An arm may have been swept behind the back in labor after the baby had rotated from occiput posterior (OP) to occiput anterior (OA).

Please feel inside for the location of the shoulder girdle. If the shoulders are front to back, the likely [solution is] one of these: standing, Gaskin's followed by Running Start (if needed), McRoberts with suprapubic pressure or rotation by strongly guiding the posterior shoulder from the back towards the chest and into the oblique diameter.

But if the shoulders are in the oblique or transverse, suprapubic will not work. McRoberts may not work. Rotation of the shoulders will help bring them down. Work from behind the shoulders to be protective of the brachial plexus. Never stick a finger tip in the arm pit from the front; never draw the baby out without rotation, to avoid panic-driven pulling. Be calm. You can do this. You must do this.

FlipFLOP is an easy-to-remember series of actions: 1) Flip to hands and knees (Gaskin); 2) lift the leg in a running start position (almost as if for running a race); 3) rotate the posterior shoulder into the oblique diameter; and 4) bring out the posterior arm.

If the mom is on her hands and knees, start with Running Start and go get the arm. This works for most SD.

Occasionally, SD is a matter of size. Bringing out the posterior arm helps here. Rotating and pulling from the posterior axillary crease (PAC Pull) brings out the larger babies. We had a happy outcome with the PAC Pull for our Christmas baby in 2008. She was 11-1/2 lb through a 5 ft 1 in mother. We really underestimated her baby's size!

Occasionally, arms are locked in a rectangle across their chest. Unlock the arms; bring one out if you need to. Keep rotating the baby. Keep the spiral turning. Rotation is protective.

See a detailed description of FlipFLOP, at:

— Gail Tully, CPM

A: In answer to your [question on] shoulder dystocia, the best tip is anticipation—practicing in your mind what you will do and what position you will need to move the laboring mother into. Have a spiritual connection with her; this will enhance her response when you need her to work quickly.

I have used the hands and knees position many times to unlock a shoulder. Even having the mom do a side-step will sometimes allow the baby to slide through. You must remember, though, to always check for a nuchal cord, because of compression.

Bottom line is: anticipate, and don't hesitate.

— Debbi Leonard, CNM

Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Think about It

The accountability sometimes feels overwhelming when shoulder dystocia happens out of the hospital. There is no one to call—no doctor on the floor, no neonatal intensive care team to come help with resuscitation, no extra nursing staff to lend assistance. It's just me and a frantic woman trying to push out a stuck baby. We have to get the baby out. We have to keep that baby from dying. Just us. If I don't know what to do and how to do it, that baby will die. I will be accountable.

It scares me that midwives are delivering babies at home who are inexperienced enough to be confident that "birth works" all the time, that all we need is faith and to let nature take its course. What I know for a fact is that I would have three dead babies in my career if I didn't know what to do with shoulder dystocia. I would have dead babies if I confidently assumed that all I'd have to do is get the woman on her hands and knees and the baby would come. These last two kids definitely did not come when mom was moved to hands/knees. McRoberts doesn't always work. Standing doesn't always work. Screw maneuver doesn't always work. Suprapubic pressure doesn't always work. Trying to deliver the posterior arm doesn't always work. Breaking the baby's clavicle isn't always possible. Even cutting a big episiotomy, a favorite technique of the medical profession, probably won't do a thing to help release most babies.

As far as I'm concerned, the key to delivering a baby with shoulder dystocia is to keep one's mind clear enough from panic and fear that you can direct the woman into various positions, try multiple techniques and never quit until that baby comes out. If you don't know the techniques, you have to learn them and review them often. A severe shoulder dystocia may not happen until a practitioner has delivered hundreds of babies. You can never get cocky and think you have the right technique or position to prevent shoulders from sticking. Sticky shoulders aren't all that uncommon—they'll come with just a trick or two. Real shoulder dystocia is different and deadly. Every midwife who delivers enough babies will get caught someday. I know of midwives who stopped doing midwifery after experiencing true shoulder dystocia. The fear and sense of helplessness became unshakable and polluted their ability to see birth as a normal process. The accountability became too much to cope with.

I cope with the aftermath of shoulder dystocia by trying hard to keep my boundaries clear. I didn't cause it to happen. I just happened to be the one there who had to deal with it. I do the best I can at any moment in time, which is all any of us can do. I know the various techniques and I use them all until the baby comes, and then I make sure I know how to resuscitate that baby. It's the birth that woman got; it's the birth that I got. Bad things happen sometimes and we have to live with them and move on, knowing that we do not have supernatural powers, that we're only human with limited ability to control life and death.

Gretchen Brauer-Rieke
Excerpted from "Shoulder Dystocia: The Event that Wraps a Midwife's Heart in Cold Terror," The Shoulder Dystocia Handbook

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