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Shoulder Dystocia


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Resources



All-fours maneuver for reducing shoulder dystocia during labor.
Bruner JP, Drummond SB, Meenan AL, Gaskin IM
J Reprod Med 1998 May;43(5):439-443

The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.

Review

I knew this article would be the write-up on the collaboration between Ina May Gaskin MA, CPM and Joe Bruner, MD at Vanderbilt. Joe is trying to promote the all-fours to the medical community and I was a witness at his first attempt.

A year and a half ago during the annual high-risk ob conference at Vanderbilt, Joe Bruner presented the all-fours maneuver to a group of assembled physicians, nurses and midwives (all paths). The response was just short of chaos. The docs went through the roof, to put it mildly. Although it was entertaining in a way after a long day, it was an eye-opener. Nine months later, he presented the data again at a primary care conference I attended. Not as much uproar, but the room was mostly empty.

The paper is basically Ina May's data on the all-fours maneuver from the should dystocia registry she kept (is still keeping?). Out of almost 4500 births, incidence of SD was 1.8% managed by the Gaskin maneuver (h-k). 83% of the SD were resolved without resorting to additional maneuvers. 50% of SD babes weighed >4000 g. The mean diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes with a range of 1-6 minutes. No mortality. Morbidity: one pp hemorrhage (no transfusion required), one neonatal fractured humerus, and three low Apgar scores. All morbidity occurred with neonatal wt > 4500 g.

I should note that SD was defined as "inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers" - so I guess that encompasses snug, medium, tight shoulders plus true SD. But that is another discussion all together.

[I don' t know if the paper discusses the mechanics, but it makes sense as the perfect resolution for a bilateral shoulder dystocia.  If the baby's shoulders have not yet entered the pelvis, they can easily become entrapped above the pelvic inlet if they are in the antero-posterior diameter.  Turning the mom to hands and knees would encourage the baby's back to roll towards the floor, thus moving the shoulders to the transverse diameter and allowing them to enter the pelvis and then rotate back to the antero-posterior diameter for movement through the pelvic outlet.]


A New (Old) Maneuver for the Management of Shoulder Dystocia
Meenan AL, Gaskin IM, Pamela P, and Ball, CA
The Farm Midwives


Shoulder Dystocia from the AAFP - an excellent review of the HELPERR mnemonic and "Enter" elements


Shoulder Dystocia by Dr. Henry Lerner - A thorough review of the literature on shoulder dystocia.


The Johns Hopkins study says that of the 78 cases, 39 babies had permanent brachial plexus injury and 18 had low Apgars. In Bruner et al., which is a series of 82 cases primarily treated with the Gaskin maneuver (putting the mom on all fours), 0 infants had a brachial plexus injury, 1 infant had a broken arm, and 3 infants had low 1-min Apgars. The Hopkins' press release specifies "severe stuck shoulder births," but still, that's a striking difference.


Can Shoulder Dystocia Be Prevented? [from obgyn.net]


Literature Search on Hands-Off Births and Waiting for Shoulders


Delivery Techniques for Shoulder Dystocia - shoulderdystocia.com appears to be sponsored by a physician and his lawyer son.  This has some great diagrams of various techniques for resolving shoulder dystocia, but some of the material is out of date.  In particular, "A bilateral shoulder dystocia. The posterior shoulder is not in the hollow of the pelvis. This presentation often requires a cephalic replacement. (C.Pauerstein [ed.], Clinical Obstetrics, Churchill Livingstone, New York, 1987.)" is no longer true, in light of the research on hands-and-knees position.  There are also some references to fundal pressure, which has become very controversial.


Erbs Palsy Information & Resource Group



Resuscitation During a Shoulder Dystocia



A few months back there was a discussion on this group about the possibility of improving the outcome in a prolonged shoulder dystocia by bagging the baby on the perineum. I didn't save these posts, but I'd like to hear about it again, especially if anyone here has actually tried it or if anyone has seen it published anywhere.


Babies obviously can breathe on the perineum (we've probably all heard babies cry when just the head is born, right? Some of them even wail! Their lungs obviously are capable of worked even when the rest of the baby is still inside).

When shoulders are delayed the baby should be suctioned to stimulate breathing -- I've done that, but not had to do bagging. I know of it being done during an SD of over 30 minutes. that baby had no effects from delay, and good apgars. (Unintended homebirth -- smart EMTs!).

It's referenced in older books -- DeLee mentions it -- and one edition I think has a picture of a baby intubated on the perineum.  Bensons "Handbook of Obstetrics" advises suctioning to open the airway as well -- saying "once the airway is clear, the infant can breathe and is not in immediate jeopardy"


If I'm remembering right, the reason for brain damage in SD has something to do with poor blood flow return from the entrapped head.  placenta should still be doing it's job as the cord should not be compressed at this point, right?


Yeah, that's what is says in oxorn-foote, but I've never seen the theory substantiated. And there are studies showing little  correlation between asphyxia and length of dystocia, so I think the argument is a bit weak.


normally, the placenta and cord should be functioning as usual and the baby shouldn't be more distressed than it was a few inches higher up in the birth canal ---- but --- it's not  necessarily so. A cord can certainly be pinched somewhere; and if its' under an arm or between the legs, it might be getting squeezed pretty tightly. "Normally" and "usually" there isn't a need to hurry the shoulders. And "normally and usually" a stuck baby can handle a pretty long delay while we find the gentlest way to maneuver him out without damage. But sometimes we have to intervene sooner depending on baby's condition -- and certainly  if the cord is pinched!

it seems pure common sense to clear the airway and help baby to breathe! If he needs a bit of O2 or bag&mask, there's no reason we need to wait for his body to be born!


I have been at several really serious SD in my career - ones where the baby needed full resuscitation -I can't imagine there being room to bag with my hands in there, and with as much moving around as we do trying to get the baby out -- hands and knees, on her back, standing, etc. --trying to get that extra nudge that it takes -I have thought that it might be a smart idea to put blow by on the baby.  Wouldn't it be a waste of time to attempt bagging instead of concentrating efforts on getting baby out?


ya know, it only takes SECONDS to do a couple of breaths if the baby needed it. And a couple of lungsful of air can make all the difference if a baby DID need it!


how much time does it take to suction a baby: 2 seconds, 3? and if he didn't breath, how long does it take to give him two rescue breaths? five, eight?

If you really have an SD, then the very problem is that minutes are going by (normally minutes going by is not an issue -- time of delay is not related to asphyxia but if there's a cord pinch it could be).

Frantic, panicked pulling and twisting aren't a good way to get out a stuck baby. Calm assessment and repositioning of mom and baby ARE. During that calm assessment, there are PLENTY of spare seconds in which to clear an airway. If the baby breathes then he isn't in immediate danger, and you have bought more time in which to get him out without damage. If the baby doesn't breathe, and seems to be failing (as shown by fhb and reflex response), then you can take another few seconds to get some air into him.

Pumping the bag a few times doesn't "take" any time out of what the midwife is doing if she has an assistant to do it. And if she's the only one who could do it -- and if it worked -- then she's bought another minute or so of ADDED time with each rescue breath.


The only way I see this working is if you have an extremely competent assistant doing it.  But then, she wouldn't be able to help you get the baby out.


you don't need to keep it up, or do it continually! you just need a couple of breaths!


How could one get chest expansion with the torso all scrunched up in vagina?


babies don't need chest expansion to breathe.  Haven't you ever heard a baby cry when just his head is born -- or noticed how many of them breathe? it's very common for non drugged babies to show signs of respiration before the body is born (carefully watch the little hairs under the nose).

I'll bet we've all heard babies squeak and give out little cries -- and I'll bet some of us have heard full-blown wails -- when just the head is born. Clearly there is enough room for lung expansion!

The major impediment is fluid in the airways - and some in the lungs of course. But if we suction them -- and if they are getting "orders to breathe" because of rising COO -- they often will do so.

One of the arguments against routinely suctioning on the perineum is that it can stimulate the baby to breathe before he's gone through that "fetal heimlich maneuver" and might aspirate gunk -- c contributing to "wet lungs" and TTN.

Under normal circumstances we want babies to take their first big breaths AFTER they are fully born.......but if we have a prolonged shoulder delay, it'd be a relief if they breathed BEFORE!


Bagging or M2M on the perineum would only rarely be needed anyway. It only takes a few seconds to clear the airway -- which is all most kids are going to need anyway -- assuming we do it BEFORE they get deep into asphyxia. If we clear the airway and made it possible for the baby to breathe, then he probably will do it. (I am ASTONISHED that the essential step of "CLEAR THE AIRWAY" is often over-looked in SD classes. I think Suctioning on the perineum for Delayed Shoulders is the best use for a delee trap or bulb syringe -- and the only reason i still carry the silly things. I don't use them at all under normal circumstances))


Has anyone actually bagged the baby, or is this theoretical?


I was the assistant at a 5 min. dystocia of a 12 pound baby. I gave him O2 through the bag while he was on the perineum  (which a well-known NRP instructor says not to do but it WORKS with my bag...) and I remember that he needed a couple puffs after the birth then started yelling.  So no, I have not tried bagging on the perineum, but I think the O2 might have helped.  Seemed like forever!

I have definitely seen babies breathe/cry on the perineum. I have seen stuck babies gasp before their heads started getting dark.


my midwife partner did this during an 11 minute SD (huge baby - almost 12 pounds, had to break humerus, but good apgars). She's certain the O2 helped because baby had gone dusky and turned pink when they put the mask on. It wasn't hard to do -- they put the mask on with the elastic strap. They didn't need to hold anything.


The time of know of when it was done -- was in an ambulance with mom on stretcher. The EMTs had a mask on, but thought kid looked poorly, so suctioned and bagged a couple of breaths and then just kept the mask on until arrival at hospital (this was the documented over half hour dystocia i know of).



Diagnosis



Once the head is out I reach in with a finger to check for cord, then follow the neck up until I hit the shoulder. If you can feel the shoulder, it's not behind the bone so no shoulder dystocia. In true SD, the neck feels about a mile long.


For me there is no set "time" per se'. I watch what is going on. Does the head rotate on its own? is there progress with the mothers pushing effort? How is the color of the baby's head and the capillary refill? Does the baby respond to a finger in the mouth etc. As long as things are all OK I see no reason to interfere. Of course if there is no progress with the mothers pushing efforts then I would apply some traction or try a positional change. I think "true" shoulder dystocias make themselves evident and most of what we call shoulder dystocia is just a tight fit. A tight fit will resolve in a contraction or two with or without my help.


If a mom has a hard time bringing the baby down, the head clears the perineum one hair at a time and immediately starts to darken without rotation....don't panic.....but definitely help without delay..



Difference Between Shoulder Dystocia and Sticky Shoulder



I wonder what the difference is between a sd and "sticky shoulders"? you know, the kind that hands and knees resolves fairly rapidly. Also, do you wait long after the head delivers and resolves (or not)? One push with no progress and no shoulders? Two pushes? One minute? Two? Is it just a matter of degree?


I think that this is really individual, depending on practitioner. I'd say that almost everything I've seen in my years of practice in the SD ballpark has been the "sticky shoulders," which perhaps might have been more moderate SD if the woman had been in lithotomy position (which I almost never use). So I really am a believer that upright or H/K positions probably prevent a lot of SDs, leaving instead that "tight shoulder" feeling where the shoulders don't just slide out, but perhaps require some bit of maneuvering and an extra contraction (babies usually reasonably vigorous at birth).

It seems that when we're looking at a potential SD (primarily the long descent, slow birth of the face and chin, lack of restitution, head just sticks tightly to the perineum), I usually end up with a chin out at the end of a contraction and don't see the sense in having women trying to push out tight shoulders without one. So we spend a minute getting her legs hyperflexed and telling her that she's going to have to work really hard for the shoulders and will have to listen closely to what I tell her. If the next contraction comes and goes without shoulders, then my adrenaline starts pumping, and we're off to another position (usually H/K if we're not already there). Until "THE" nightmare SD a couple of weeks ago, I've never had a baby stick for more than 2nd contraction after the head delivered.

So I'd probably say "tight shoulders" if they come by one contraction after head (but with great effort and perhaps some position changes), mild shoulder dystocia if the shoulder stick until the 2nd contraction, moderate by the 3rd, and severe for anything after that. Or is that too conservative?


If you use pubic pressure and flex the legs, as a guarantee the birth will go smoothly, would you call it a Shoulder Dystocia? I usually only use this term when there has been a bit of a problem with the shoulders. Okay, lets hear your definitions, and how you chart them after the birth.


This is a tricky question, especially for those of us who practice in hospital.

I absolutely never use the word "shoulder dystocia" in the chart. I think this is a red flag which hungry plaintiff's attorneys jump up and cheer for. I feel that the nurses use this much, much, much too often! Anytime I do absolutely anything to deliver the shoulders, the nurses chart it was a "shoulder dystocia". We are handing them our heads on a platter when we write this, because, as we all know, the attorneys are convinced that shoulder dystocia = malpractice. (At least in my neighborhood).

My delivery notes are generally of the format that it was an nsvd, no anesthesia, viable infant at such and such a time. If I have trouble with the shoulders, my note follows these lines:

nsvd viable female at 1 am, no anesthesia, first degree laceration sustained. Delivery completed with McRoberts, suprapubic pressure and manual rotation of shoulders to oblique. (or whatever else I have done.) Time from delivery of head to completion of delivery was ________ minutes. Apgars / . Pediatricians present (if they were). Attending present (if s/he was).


[from ob-gyn-l]


I think that the true shoulder dystocia is made in retrospect only. If the baby is delivered with only a McRoberts maneuver and some supra-pubic direction to the anterior shoulder, then I think that was "tight shoulders". If a baby, or Mother suffers injury, i.e. Erb's palsy, etc. as a result of the manipulation required to deliver the baby, be it Wood's, posterior arm, clavicular fracture, Zavinelli maneuver, or in some countries a symphysiotomy, then in retrospect THAT was a true shoulder dystocia. God be willing this never happens to you or anyone else. I fear shoulder dystocia more than anything in obstetrics and it really deserves your respect.


Whilst I have seen shoulder dystocias which have led to both Erb's palsy and even fetal death I don't think it's correct to classify only those difficult deliveries which result in major fetal pathology as shoulder dystocia, and regard others as "tight shoulders". Equally I don't accept the view that minimal delay in the interval between delivery of head and shoulders ( the sort of thing many of us would regard as the normal interval between contractions ! ) as being true shoulder dystocia either.

My definition of shoulder dystocia is that the shoulders won't deliver by a combination of maternal effort and SAFE obstetrician or midwife downward traction.


At midwife deliveries ( which amount for about 80% of births in my unit ) the shoulders are delivered by maternal effort and force of contractions in most cases. Typically there is a lull in maternal effort and uterine contractions after delivery of the head. The next contraction typically doesn't come for 90 -120 seconds. By the 60 sec definition almost all of these normal deliveries would be defined as shoulder dystocia, this must mean the definition is inappropriate.

At the RCOG meeting, a very senior and experienced Dublin obstetrician suggested that many cases of shoulder dystocia ( in which maneuvers to overcome "stuck shoulders" were needed ) arise from OBSTETRICIAN haste to deliver the shoulders as soon as the head is out, without allowing any time for internal rotation of the shoulders.

The audience agreed that both definitions of shoulder dystocia AND hurry to deliver the shoulders is likely to account for the widely differing rates of SD quoted.



Routine Prevention of Dystocia



I have just heard of a rather curious, but intriguing practice, that i will be pleased to share. From another midwife-story of home birth midwife who rotates ALL of her babes manually and if shoulders feel big, starts pulling/guiding babe out in oblique with shoulders at 1-2/7-8o'clock and states she has not had a single dystocia since beginning this practice some 200+ home births ago (learned from friendly MD, by the way).....as i say, it is intriguing, seems invasive, but, if it could prevent those scary dystocias, maybe.........


Suctioning May Cause Sticky Shoulders

A midwife friend and I were talking, and we both observed that we see slow shoulders a lot less since abandoning routine suctioning. We think that the suctioning changes the pattern a bit; you get into a pattern of sort of "hold-everything-while-l-suction-the-baby-now-push.

By allowing natural drainage/clearing, the mom can pay more attention to the clues to push the shoulders.

Just speculation at this stage, but she's liking what she thinks she's seeing!


I would like to hear what midwives think of eliminating external rotation from the usual sequence of cardinal movements in vaginal birth, to supposedly prevent shoulder dystocia? Somewhere in the mid to late 80s, obstetrical based teaching encouraged delivering the body of the baby immediately after the head, usually with the same contraction, what was left of it or by just pulling the baby out irrespective of whether or not the uterus was still contracting. This seems very traumatic to both baby and the mother's pelvic floor to me. After birth of the head, I have always wiped the baby's face, cleared the mouth or DeLeed if mec, assessed for color, etc., checked for nuchal cord, hand, whatever, encouraged the mother to relax, rest, touch the baby if desired, then focus on the next contraction to gently ease out the shoulders UNLESS there is a very compelling reason to speed up the process. It seems unreasonable to eliminate this important step just for the sake of a few. I realize SD can be a major problem, but can often either be anticipated in some cases or dealt with prn. This must lead to a lot of unnecessary tears. What do you all say?


You're kidding, right? Eliminate external rotation? Huh?


Sounds like description of births in a film I have - 1973 Lippincott - Seven Human Births (?) where the kids are literally pried out. Once the head is out, a quick suction is performed, then active pulling on the infant until you are sure they are going to decapitate the kid. I show this to nursing students - always lose one or two who need to leave or faint - but then follow it with "Home Birth in Holland". All you see in the Lippincott film in the draped, shaved perineum being "delivered" by the skilled hands of the auto mechanic...I mean doctor. I think I need to rest.


ah, this is one of my soapbox topics.

This "delivery without restitution" has become accepted routine here among most (all?) medical folks, cnms, the naturopaths and many (most?) midwives. It is taught as fact in some medical schools and midwifery programs and I know of a least one senior and well-known midwife who strongly preaches it!

I am one hundred percent opposed to it --- I think it is an intervention with NO (repeat, NO) data to support it. I can find a tremendous amount of data to support allowing natural restitution.

In my study of shoulder dystocia, interference with natural restitution and rotation is THE NUMBER ONE CAUSE OF SHOULDER DYSTOCIA AND DELAYED SHOULDERS!

If a person is encountering shoulder dystocia more than a maximum of one percent -- then they are most likely attempting to deliver before rotation (I base this on the historical incidence of SD of 3 per thousand).

Sometimes we need to hurry the birth... but USUALLY (almost always) we should wait for natural rotation in order to allow the shoulders to move into the proper position for delivery. JUST AS THE head must rotate into the anteroposterior diameter of the outlet, so must the shoulders! NObody would advocate attempting to deliver the head in the transverse diameter!! It is illogical to think shoulders should be delivered in the transverse diameter!

This new advice is a misunderstanding of the pelvic architecture. SD is caused by the shoulder getting hung up on the symphysis at the INLET. This malrotation happens during descent of the head, NOT during restitution/rotation after the birth of the head!  After the head is born the shoulders are in the TRANSVERSE or Oblique of the OUTLET -- not the INLET -- preventing rotation at that point can't possibly prevent a hangup at the INLET! (Itís at least *centimeters away).  The technique does nothing to prevent true shoulder dystocia...but it sure can impact the shoulders in the transverse or oblique of the outlet and make them much more difficult to deliver -- resulting in broken arms etc.

BABIES Rotate after birth because they are SUPPOSED to rotate -- the  shoulders fit best that way> wHO ARE WE to intervene in this process -- especially without supporting data?

THE FOLKS I know who deliver before rotation say they are preventing shoulder dystocia. I wonder why they see so much SD then? I know a midwife who has to manually deliver at least 25 percent of her births because of SD -- she faithfully tries to deliver before rotation in order to "prevent" SD. IT AINT WORKING!


Ditto from me.  If it ain't broke - don't fix it!!! Keep your hands off until it becomes necessary to intervene.  Gail's description of how SD happens is one that should be engraved in every student midwife's brain. Learn the difference between relative shoulder dystocia and true shoulder dystocia. The body is not stupid, the rotation is there for a purpose... 


It's not called a CARDINAL movement for nothing! After birthing hundreds of babes following this natural process, I never imagined that such a crazy philosophy would come into standard practice. I was horrified when I started attending hospital births (again after a long hiatus) in the 90s and saw all this meddlesome maneuvering going on for the sake of supposedly preventing an infrequent complication. Here we go with the man dominating nature thing......I believe this is also yet another function of the anesthetized (epidural) patient--women who are having natural births would find this type of intervention on a regular basis very painful I'm sure! But once women have epidurals, all bets are off as to what will happen next--poor rotation, no rotation, no pushing reflex, ad nauseum not to mention how easy it becomes to get in there and start doing stuff when patients can't feel anything! As you can tell, my soap box as well. Medical people generally look at me like I'm nuts when I get on this topic. An entire generation of health care providers has already been trained on this crazy principle. I bet they don't even know what the CMs are! Keep on spontaneously restituting and rotating gals, its NORMAL & NATURAL!


Human Labor and Birth by Oxorn and Foote is the best for showing the various cardinal movements, you name the baby's position, the cardinal movement for it will be in there.  The pictures are so clear that they are used in other texts.  I have an older edition, hopefully, the newer editions contain the same information.


One of my concerns about routinely birthing the baby other than by the natural expulsive power of uterine contractions is that you often get around to talking about pushing in between contractions or after a contraction has ended.  There's some evidence that this increases the damage to the pelvic floor and increases the risk of rectal incontinence.



Early Reaction to Dystocia



I've had quite a few of these over the years. Recently a CNM told me that an old doc told her not to let the baby fully restitute, when you see that tell-tale blue head, and no chin, go for the shoulders as it is turning that 90degrees...the oblique angle is easier to pull out. I tried it at my next birth, and it worked perfectly



Shoulder Dystocia Protocols



There's an excellent review article on Shoulder Dystocia in the Journal of Nurse-Midwifery, March-April 1994 Supplement

I wait until the shoulders have completely rotated and entered into the pelvis -- this is the next contraction after the head has been born, and might be 30 seconds to 2 or 3 minutes! I don't stimulate the baby to breathe --which suctioning might do -- I DO keep a good, close eye on him/her and will encourage pushing if it looks like it's needed. THIS IS THE NORMAL NATURAL WAY for babies to be born -- women PUSH with the NEXT contraction after birth, not when we see the head is out! IF we push before that contraction and full restitution of the baby, I think (and some research supports) we are more likely to get poorly rotated and/or impacted shoulders, and thus, shoulder dystocia!


yes, we get most babies after a few pushes immediately after the head is out, but some just wont come for several minutes... If you envision the last times you had 'slow shoulders", what "usually" happens is we get the mom pushing as soon as the head is out, nothing happens, we change her position and get her ankles up by her ears or (whatever is the latest fad[Grin]) and she pushes and -- the baby comes as she pushes WITH THE NEXT contraction! Pushing before the contraction might not bring the baby, might impact the shoulders, and if it's going to take till the next contraction anyway -- then maybe we can relax a moment, mom can catch her breath, we can get a clean chux down, the camera fellow can get in position and voila! Next contraction a baby is born!


Now, I gotta give the usual disclaimers about baby's condition, signs of distress etc -- and if it looks like the baby is trying to breathe then I'd probably have mom push anyway. YOU CAN STILL GET THE FHT (usually) with a handheld Doppler --low, just about the pubic bone -- or just by observing or feeling the pulse over the baby's soft spot; and the baby's color tells you a lot. Monitoring a baby on the perineum is no different from monitoring while he's in the uterus --there's actually more to observe!


Waiting until the next contraction used to be the rule -- just look in any older medical texts - they all assure you "Wait for the next contraction... There is no hurry" -- unless the baby shows signs of distress --same as at any other point in labor. Over the last several years the trend is to get the mom pushing as soon as the head slips out. (Can anyone claim this is physiologic[Grin]?)


Heartsongs Official Protocol:

TRY EACH THING QUICKLY, MOVING ON TO THE NEXT. Do NOT waste time in fear, panic, lighting smudge sticks, consulting crystals, pyramids, tarot cards, or asking your new apprentice what the __ to do. FOCUS and WORK.
  1. Spiritually, and with positive, thankful vibes to Ina May, the grand, grooviest, earth-mother midwife of all, ask woman to immediately flip to hands-and-knees if not already so positioned.
  2. Have woman Wiggle and Push, while You jiggle and Mush: Work fingers around baby to see how much leeway you have, room-wise. If No Baby Go To Step 3. (INBGTS3)
  3. Do the Back-sweep: exerting firm and steady(no jerks) downward and backward traction on the side of the baby's head- No pulling or twisting EVER EVER! The point of this is to pop the anterior shoulder out from under the pub bone. (INBGTS4)
  4. Try the Screw-Woods maneuver, and/or see if you can hook a finger under an armpit while you're in there. In the Screw, try to rotate the baby to oblique diameter. (INBGTS5)
  5. Go for the posterior arm. Sweep it across baby's chest & out, thereby reducing the shoulder diameter, allowing baby to slip out. YES! This has always worked for me. (But INBGTS6)
  6. Quickly flip to McRoberts at edge of bed so room to work. Have assistant do SupraPubic Pressure to dislodge shoulder. (INBGTS7)
  7. "Dance the Dystocia Away" maneuver; Have mother dance up and down stairs with exaggerated bounce, baby should bounce right out. Haven't actually tried this but "tricks of the trade" says it's great.
  8. Last ditch effort: cut epis. for more room to work, have assistant do FUNDAL pressure and S.P.P. Go back to Step 1. & Keep trying. FAST. GET that baby - YOU CAN DO IT!!!

Loved your list of maneuvers for shoulder dystocia, very similar to my own. Only difference is that I have never used McRoberts, have gotten the worst out bringing the posterior arm out (actually once I had to bring the posterior arm out, rotate the baby 180 degrees and then bring the other arm out..now posterior, and then still had to pull for all it was worth....baby was fine, midwife grew 100 new gray hairs and went home to sleep for a week!!)

The one problem I had with your list was # 7. I would not have a mom moving so much with a head hanging out. Serious damage could be done to the very fragile neck.....I believe this technique is used for labor dystocia and not shoulder dystocia.


I have had to use McRoberts several times and found it worked most of the time and hands and knees worked when it didn't. The secret to a good McR is Mom is absolutely FLAT (no pillow, no lifting head) and her legs are brought up as if she were doing a backwards somersault -- to her ears if possible! Quite a trick but effective. Varney says McR works 50% of the time so if Mom is in almost any position but H&K I start there and then move along the list of maneuvers.


Great rules, AND fun to read, easy to understand.. I would only suggest, reversing these though... It's usually much easier and far safer to go for the arm than it is to do Woods, I think....


re step 3 -- could you be more specific about this? awhile back someone described a similar (?) lever action with the shoulders, but i don't see how traction on the head comes into it --?

re step 8 -- fundal pressure??? seems to me this will only further impact the shoulders

I saw a resident do suprapubic pressure in a very effective way -- like a plunger, directed obliquely, so as to pop the shoulder out from above.


I agree that fundal pressure will further impact the shoulders. Was taught never to do it, and intuitively I agree. What we want to do is find out where the shoulder is, and request that suprapubic pressure be directed to help the shoulders go where we want. We don't always need to rotate the back anteriorly, as in Woods Screw maneuver. It seems to me that the most efficient maneuver is turning the shoulders through the shortest arc to an oblique diameter.

Suprapubic pressure directly perpendicular to the mom's abdomen may actually prevent rotation to the oblique. I always get a couple fingers under the pubic symphysis and see exactly where the shoulders are. There is no point trying to rotate clockwise (for instance) if the shoulder is at 11 o'clock. In this instance, the suprapubic pressure prevents rotation to the oblique. I always direct the assistant to angle the suprapubic pressure in the direction I want the baby to turn, and turning the back posteriorly may make the most sense. I always have one hand on the shoulder pushing in the direction which takes the shortest distance to an oblique, and the other hand is telling the assistant exactly how I want suprapubic pressure directed. This is my decision, not theirs. I guess the analogy is to external version....which is easier, a forward roll or a back flip? Gotta know how the fetus is positioned to decide.

I always do McRoberts (cheap trick, takes no time), check location of shoulders, direct suprapubic pressure to push them to an oblique diameter. If that doesn't work, I go for the posterior arm. Interestingly, I wonder if a nuchal hand doesn't sometimes cause sticky shoulders?

I had 2 births on Friday (3, actually, but only 2 with tight shoulders). They were identical! Nuchal cord (1 I could slip over, one I couldn't, so just delivered baby through the cord without problem), shoulders that were sticky...didn't come under the symphysis with the usual maternal and midwife efforts. Tried to rotate to the oblique with only partial success. Delivery still not imminent. Went for the posterior arm and found a nuchal hand in both instances. Delivered the hand and then the posterior arm and the rest of the delivery was uneventful.

Any thoughts that maybe a nuchal hand is a cause of tight shoulders by increasing the bisacromial diameter?

I don't think there is any one set of maneuvers for shoulder dystocia which have been shown to be preferred. What I think is crucial is that we are able to systematically, and calmly, run through the maneuvers which work for us. My personal favorites are McRoberts, pushing the shoulders into the oblique in conjunction with suprapubic pressure, and going for the posterior arm. I have never done an epis for shoulder dystocia, and must honestly say that the above guidelines have kept me from ever having what I consider a true shoulder dystocia (my definition of shoulder dystocia is a stressed baby or midwife)


When working with my Sr. midwife, if the mother was in Semi-Fowlers or some kind of sitting or lying position, before moving her to hands and knees, she would have the mom put both feet on the bed and lift her hips up off of the bed, as if we were going to change a blue pad underneath her. This worked so many times to give just a little extra room so the shoulder could dislodge. My partner and I continued this trick and I use it more than flipping to hands and knees. So far haven't had to do too many corkscrew maneuvers or any other further techniques. My former partner (whom I dearly love) had a true phobia of shoulder dystocia and almost every baby she caught, it was "Push, Push!!" as soon as head was out and she considered many of her catches to be a shoulder dystocia of some degree or another, which I debated with her often. I got to the point that when the head was born I would say, "Look, here comes the neck and I see the top of the shoulder" just to kind of keep her calm about the whole thing (even when I couldn't really see it yet...). Sort of the placebo affect on midwives I guess. She would quietly talk me through my fears too.... She was justified in her fear because her first primaries consisted of a couple of really stuck shoulders.

There is a midwife here in Texas who has delivered over 3000 babies who has her own little technique that she spoke about in a workshop I attended once. I don't know if I can accurately describe it because I have never seen it nor tried it. When Mom is on H and K's someone with a fresh sterile glove on (this midwife is used to having several apprentices at a time and lots of pairs of hands around - she has a birth center) goes in through the rectum and somehow "pops" that posterior shoulder up and dislodges it. She says it works really well.


In 1100 births I have never encountered shoulders I could not deliver within 2-3 minutes. That might mean I have never encountered SD OR that my management of shoulders prevents SD. I don't know the answer to this. I know that I have had shoulders where the sweat ran down my back, and I had to do all my tricks. I have yet to have them fail.

I never wait for the next contraction...whether I suspect SD or not. After restitution/external rotation of the head, I proceed to delivery.


Serious SD is reported at 3- 8/1000 -- and these should deliver with a little work. SEVERE shoulder dystocia should be almost unheard of in the absence of forceps or vacuum extraction (though there is always room for the "fluke" occurrence). Texts and practitioners greatly disagree on the incidence of milder degrees[Grin]

I tend to be a bit more relaxed re shoulders -- believing that many (most?) slow shoulders are not SD, and I have a few points of disagreement with the El Halta article in MT....... However.. Our results are the same I think... Like you, I few times I've had to use some tricks for shoulders, but never anything really nasty -- and have always had a baby out pretty quickly once we began trying -- though may have started later if the baby looked terrific when the head was born.

I mean -- if the baby looks great and we wait for the next contraction; the mother pushes; and we need to use a little jiggle to help the kid out - then the baby may be born 2 minutes after the head, but after only thirty seconds of maneuvering to help the shoulders.. Is this a 2 minute and a half minute shoulder dystocia? Of course not. It's been two and a half minutes since the head was born - but only a "thirty second" dystocia -- If you count from when we begin to maneuver.

If the head looks lousy or FHTs are not reassuring then we don't wait for the next contraction, of course..

Although you might not wait for the next contraction, you do wait until AFTER RESTITUTION/EXTERNAL ROTATION OF THE HEAD (which means internal rotation of shoulders).. Yep! I wait for this too! And this is the point of disagreement with some. They do NOT wait for restitution/rotation, but ROUTINELY begin traction and maneuvering BEFORE restitution/rotation occurs -- a technique which I believe is possibly related to their high reported incidence of shoulder dystocia! When a midwife/OB says she/he sees SD nearly 40% of the time (and some do) -- - then I figure we are either using different definitions, or we are using some very different techniques.....

What you are doing works. If the vast majority of babies come without any manipulation or work with the shoulders, then the technique works. You've proved it..

But if we are finding (as some are) that babies "frequently" need a good deal of help with the shoulders, , then I think we need to re- examine what we're doing (or our assessment of what we are seeing!)


Shoulder Dystocia: Traditional Midwifery Solutions

The basic premise: To move the baby, move the mother.

When squatting, standing, and the Gaskin Maneuver don't work:

A Running Start
With mother on her hands and knees, she quickly lifts a knee and sets the foot down flat. [Her assistant may choose to do this for her because it is difficult for a birthing mom to process verbal instructions.] The mother now has one knee down and one knee up, 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 of 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 on. But in a flurry, just grab a leg and lift it. The posterior shoulder should immediately slide out and with it, the baby.

Praying Hands Rotation
If the baby is still stuck, the next step is for the midwife to slip 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 in 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, 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.

Any difficulty getting the posterior arm out now is likely due to the arm's position. The midwife can reach in to find the posterior shoulder and follow down the arm with her fingers. It may be that one or both arms are behind the baby's back! An arm behind the back has to be worked to the chest of the baby before the shoulder can be rotated into the oblique.

-Excerpted from "Shoulder Dystocia: The Basics," by Gail Tully, CPM, Midwifery Today Issue 66

GlM - Editor's note: This article continues to discuss in detail how to extract the posterior arm, lifting the sacrum if needed, working with the baby's joints. It's an excellent read!



About Hands And Knees



But I use a very different way of handling them. After turning to hands and knees to free the posterior shoulder, I then turn back over to lithotomy to free the anterior shoulder. If that is not enough we do exaggerated lithotomy and suprapubic pressure. If that is still not enough we get her up to a squat.


Once that was still not enough and we went back to the lithotomy and back up to the squat again. That was an 11-5 baby that was patting itself on the back, literally. I could not get that baby's hand to move. It really was an elbow dystocia more than a shoulder dystocia. That baby was fine when it came out. But it was one of those where you seek supernatural help to get it out.


[from ob-gyn-l]


What I don't quite get the grasp of is your "on hands and knees" position for the patient with shoulder dystocia. As much as I try, and I have tried (and even discussed it with my partners), I can't envision that position giving more room for a shoulder dystocia since every response to the list has stated that it is a bony dystocia, not a soft tissue problem. I'm having trouble understanding the mechanics behind a change in the mother's position and a change in the orientation/size of the bony pelvis which is restricting the delivery of the infant's shoulders.

Thanks for any light you can shed on my biomechanical dilemma.


When I first heard of using the hands and knees position for resolving shoulder dystocia, I was skeptical also. It was several years ago and I was at a Midwife Alliance of North America conference and a well known midwife by the name of Ina May Gaskin talked about the position and it's use in shoulder dystocia. She explained that when a woman is in the hands and knees position the three anteroposterior diameters of the inlet actually increase by as much as 1-2 cms., and it slightly tips the inclination of the symphysis pubis forward. She showed a video of this position and of some shoulder dystocias resolved in this position....all the babies were huge and the perineums intact. The video can be purchased from The Farm Midwifery Service.

In addition, since the woman isn't sitting or lying on her bottom, there is more room to work and to get your hand (or hands) inside to maneuver the baby, and the women seem to be more relaxed, less tension in their legs and bottoms.

Generally speaking, if I have any idea the baby is going to be a tight fit (the turtle sign, larger baby than I expected, baby estimated to be more than 2 lbs. bigger than previous babies, rapidly darkening head, etc.) I get them over onto their hands and knees right away. It's amazing how quickly and easily a woman can move when she thinks it's important for the baby! I think that on occasion just moving the mother around dislodges that stubborn shoulder. On the next contraction, with the mother pushing, I try to deliver the anterior shoulder by lifting the head upwards (remember everything is turned around!!) If this doesn't unlodge the anterior shoulder, I then try to deliver the posterior shoulder. If the baby isn't looking too dark yet, I might give it another contraction to try for the anterior shoulder. If I can tell the anterior shoulder is just not going to come, I go right for the posterior arm.....in every case but one, getting the posterior arm out led to a quick delivery of the rest of the baby. In the one time it didn't work, I had to rotate the baby 180 degrees and delivered the other arm and then the baby finally came....this baby was nearly 3 lbs. bigger than the mother's previous largest baby.

I lost a baby to shoulder dystocia several years ago and after using most of the methods listed in the textbooks to deliver this baby, I was able to finally get it out with the mother in the hands and knees position, a position I had never tried for shoulder dystocia before then. While I was dealing with the shoulder dystocia of the baby who died (parents were advised to turn off the respirator a few days after the birth) I was too busy trying to get the baby out to think about cutting an episiotomy. I had no problem getting my hands into her vagina for doing the usual maneuvers. Had her vagina felt too tight to maneuver properly, I would have cut an episiotomy. A couple of weeks after the birth the woman went to her ob-gyn for a PP checkup and he was surprised I had not cut an episiotomy, but conceded that it was unlikely to have helped and that he himself had lost babies from shoulder dystocia even with an episiotomy. Afterward the mother thanked me for not cutting her, as she felt she had to deal with so much in the weeks after the birth that she was glad that she didn't have to deal with the pain of an episiotomy too.

The most amazing thing I have seen with women birthing on their hands and knees (I suggest this position to women often) is on several occasions a baby actually starts to cry with only the head out!! I'm not talking a small whimper, I'm talking taking breaths and crying out.


The anterio-posterior diameter is reduced in recumbent and lithotomy positions where the weight is taken on the sacrum. The sacrum is capable of rotational movement through an axis at the upper part of the sacro-iliac joint, about 5 cm below the sacral promontory (Weisl H: Acta Anat 1955;23:80-91). This movement results in an increase in the AP diameter of between 10 and 20 mm (Borrell V and Fernstrom I, Acta Obstet Gynec Scand 1957;36:42-57 and Acta Radiol 1957;47:365-70). As the sacrum is wedge-shaped in cross section, backwards movement will splay the iliac bones so that the transverse diameter also increases, as shown by JGB Russel's XRay studies (J Obstet Gynaecol Br Cmwlth 1969;76:817-20; Br J Obstet Gynecol 1982;89:712-5). In a vaginal ultrasound study published as part of my thesis, I have also found that upright positions increase the bispinous diameter (average 4mm).

I think the first and best maneuver in any suspected SD is to get the mother squatting or kneeling. Many good midwives already do this, before (and usually instead of) hitting the panic button.


Biomechanically, there are a couple of things that may well help with the move to hands and knees. The first is the simple act of turning over - asymmetrical loading of the pelvis while turning may actually dislodge the impaction. The second and probably more important is that gravity and "arching" the back may help dislodge the posterior shoulder by decreasing the sacral promontory. Folks who have tried this maneuver pass on that it tends to be easier to go in and get the posterior arm in this position as well. Midwives I've spoken with on the subject have been confident enough in the maneuver that they tend to move to hands and knees immediately if McRoberts doesn't work rapidly.



Other Maneuvers



For true (what is a true one?) SD we use Jacquemier's maneuver. Supra pubic pressure is just able to break the clavicle and not being of real use.


McRoberts' Maneuver is the forced flexion of the mother's hips (by pulling her knees up to her chest) to increase the AP diameter of the pelvis. It was taught to them by an older attending named McRoberts, as I recall.


McRoberts' maneuver is hyperflexion of the hips, sort of "knees behind the ears" :-)-O. Supposed to move the symphysis up.

I'd like to know what the Jacquemier maneuver is. I have read about it in a paper that a french contributor to ob-gyn sent me once (a workup of court decisions on fetal disasters), but never quite managed to figure out what it is.


It's the old position of Devraigne & Descombs dating from long ago. They were two heads of dept in the hospitals of Paris in the 1900's. It has been described for delay of engagement. I don't know, as it has been told in an other post, the effectiveness of that position for bony shoulder dystocia.


Repositioning Baby's Head

We just had a study group on Shoulder Dystocia management, and the woman who presented it had an advance copy of the SD chapter of Anne Frye's new book which she passed around for us to peruse.  It had a maneuver in it that I have not seen discussed.

The maneuver was to return the baby's head to it's original position (looking down) and exert pressure on the head, flexing it, causing the shoulders to spin a little and release from the pubic bone.  My explanation is inadequate, but it looked like it would work.



Flagpole Position
Recently had a shoulder dystocia during delivery. I work with Fijian midwives trained through a WHO program. They are not familiar with the standard maneuvers I am used to - McRoberts, oblique shoulders, Woods screw, etc. and the Gaskin maneuver. The midwife assisting (we assist each other during deliveries as we have only one RN and no techs) during this delivery was trying to place the woman on her side with leg held straight and up in the air. Needless to say, communication was not at its best in this instance.

My question is:  Have you heard of this position, I cannot find it in anything I have or any of the research I've read. If you have heard of it, can you explain the rationale for it. If you just have an idea of why it is supposed to work, please share.

Many of the "cross-cultural midwifery" experiences here have been very interesting, but this has been perplexing to me.

Did it work? Well, I'm not sure. You know how those things go. She had the woman on her left side with leg up in the air, then she tried fundal pressure which I immediately asked her to stop (I'm not a fan of that particular intervention), all the while shoulders were being moved into an oblique and then my OB consult walked in and shoved the woman back onto her back and put her legs into the most extreme McRoberts I've encountered and the shoulders delivered.

So - it was a myriad of actions and I can't pinpoint one that worked. I've yet to see a shoulder dystocia that produced calm, cool heads all around the room.  I was completely soaked after this birth. 


I am guessing here, but it would make sense to get mom off her back to free the tailbone, and perhaps raising the leg is in hopes of rearranging things in the same way that McRoberts does. 


A thought just came to me about this position.  I had a lady that had a 12 1/2 lb baby a few years back.  When she started to push, sitting, reclined, we got no movement.  Tried H&K, baby fell down and out of pelvis.  Then I put her on her side-and baby moved right out, easily.  Thought I would have shoulder Dys , lifted a leg and out she came.  My feeling was that sitting was wrong cause she needed room for expansion toward the rear and side-lying allowed that to occur. 


I have not heard of this in any literature, however I understand the name of this to be "the flag pole" position, according to my boyfriend who affectionately tagged it after I naturally assumed it during 2nd stage in our births and I would not budge to come out of it for anything.  A good way for you to develop your own rationale for this practice is to lie down and do it while at the same time touching your own pelvis in various places, particularly the sitz bones and pelvic outlet.  Try side lying with knee flexed and leg pulled back to chest, then extend your leg up to the flag pole position.  When I do this, I can feel a difference in my sit bones that appears more roomy. 



Rubin Method



I have made a little adjustment with how I have suprapubic pressure done, and I wanted to share it with those who may be unfamiliar with this method. I am not posting this to imply that you should've done it, or that it would have worked. It's just something that works for me.

When I have stuck shoulders I take two fingers (or my whole hand if necessary) and identify where the shoulders are, and which is the shortest arc to turn them out of the AP and into an oblique diameter. Usually this is on the baby's back, rotating forward, but sometimes, esp. if baby was OP, it may be easier to put fingers on baby's chest and rotate posteriorly. Once I have identified the direction I want to rotate, I specifically tell the assistant to apply suprapubic pressure in that direction...directing the force of the suprapubic pressure down but towards the woman's leg. I feel that pushing straight down, with the vector perpendicular to the mother's body may actually inhibit rotation.

I've been doing it this way for quite some years now, and am quite satisfied with it. Imagine my surprise when, having just taught the method to a medical student and a resident using our units poor old battered teaching doll, that I found it described in an ob text as the Rubin method.


I feel that suprapubic pressure directed straight down is also more likely to break clavicles. Unnecessarily.



Hooking the Armpit



Years ago, I read an OLD book that was on her coffee table - by an MD. He was an old country doctor that did house calls and births. Said he never had a problem getting a baby out when it appeared to be stuck by - go in with one hand up the back and the other in the front at the baby's chest (for counter pressure to manipulate). Slip a finger from the hand that is along the back in the armpit and pull the baby out. (Seems that I recall he did this in one move.)


I have used this "technique" in this past year more than once. The last time was a dystocia (not shoulder - whole baby dystocia :-) ) with a babe at 11#6 oz, my biggest. He was not coming. Worked the perineum over the face - knowing that isn't a good sign in itself. Baby didn't budge. Pushing didn't do a thing - nor did change of position. Had the mom in H&K and went in and pulled the baby out at 5 minutes. He needed resuscitation - but after about 5 rounds of CPR he started up and pinked up -looked great.

While pulling on him I heard a rather loud POP. Kinda got a sick feeling as the thought, "I broke the baby!", went through my mind. No time to stop at this point, though. Continued to pull and got him out - with a broken arm. Parents took him to dr. later that day and they (dr.s) were positive about the home birth and said his arm would heal without intervention - just immobilize it! While at that clinic my clients spoke to a woman who had a similar experience in the hospital - at least baby with a broken arm due to delivery technique - and they kept her baby for 6 days for observation! My client was thrilled that they stayed home and could have their new one with them.


I think that we are not "supposed" to hook the armpit because it can damage the baby's nerves. However, I have also done what you describe, and it works. I would not do it were I not desperate to get the baby out, and at that point, I think you do what you have to do. I have also broken an arm, on purpose. Also did it because we had run out of tricks. Arms heal really well, and I think are easier to break than clavicles, and with less risk to the baby. Please, may i say, that it is the most sickening sound, and leaves the most terrible feeling inside of you, that you hurt this baby to this extent, and is NOT my idea of good midwifery.....however SD is not my idea of a nice birth, either.

I also want to add that, like everything else, hooking the armpit doesn't always work. i have had SDs where you couldn't reach the armpit, and babies who were stuck so badly, that you couldn't get your hand in that far. Other SDs i have gotten both hands all the way in. I have often wondered if taking g your gloves off would give you more traction, to get those slippery shoulders, or arms. I've never done it, and I always were gloves, even at my daughter's birth, but i have wondered about it. Better than a damaged baby.


It says in Williams that we are not supposed to hook the armpit. However I have worked with a respected OB who taught me that it was OK to hook the posterior axilla. The brachial nerve plexus is under the anterior axilla. He is very adamant about not applying traction to the neck, however, with respect to causing nerve damage. I also have hooked from behind, with no ill effect.



Head Traction



I was taught that traction on the head is okay as long as it is prolonged and steady, not intermittent and jerky. It should also be in a downward (or upward) direction, not trying to pull the baby out. This was according to the late great Dr. Jim Green, one of the most remarkable men I've known. He recommended 30 seconds of steady downward traction (trying to free the anterior shoulder), then 30 seconds of steady upwards traction (trying to free the posterior shoulder) before moving on to other maneuvers.



Hospital Beds Cause Problems with Shoulder Dystocia



As somewhat of a 'birth assistant' for many years, I have also found this to be the best way to give suprapubic pressure. I will usually try the AP version first, then identify and go from the side if the first is not a quick fix. The worst problem that we have as nurses, is the fact that the bed is usually up to the ceiling! Imagine trying to give adequate pressure while clinging to the bed. I always get a stool and lower the bed rail with any SD as it is first identified. What a goofy waste of time, just so the doc can have the position of choice!



Is it Necessary to Do an Episiotomy for Shoulder Dystocia?



Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes.
Gurewitsch ED, Donithan M, Stallings SP, Moore PL, Agarwal S, Allen LM, Allen RH.
Am J Obstet Gynecol. 2004 Sep;191(3):911-6.

"CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy."


MANUAL TECHNIQUES MAY EASE TOUGH DELIVERIES WITHOUT NEED FOR EPISIOTOMY

In the rare but serious case of shoulder dystocia, in which an infant's shoulders get stuck in the birth canal after its head emerges, mother and baby might fare better if doctors use their hands to manipulate the baby's position to ease delivery than if they cut perineal tissue to widen the opening, a Johns Hopkins study suggests.

Gurewitsch, Edith et al, "Episiotomy Vs. Fetal Manipulation Maneuvers in the Management of Severe Shoulder Dystocia: A Comparison of Outcomes."


[from ob-gyn-l]


How many of you feel that episiotomy is actually of any benefit in the management of shoulder dystocia ? How many feel that it is not of any benefit? I know all the text books say that a LARGE episiotomy is a must, but I still am not sure how that helps. Come on everybody out there answer this one. Let's make it a real poll.


Not per se. However, I would do it if McRoberts and maternal repositioning had failed, and I were attempting intravaginal maneuver, and found insufficient room for my hands to get to the fetal head.


I do not believe episiotomy is of benefit in the resolution of shoulder dystocia, and do not do them for this indication. SD is not generally a soft tissue problem, and I do not see any reason why an episiotomy would be of benefit (except to CYA and buff the chart so the attorneys are kept at bay). I can always get my whole hand into the vagina for various manipulations, and feel that there has always been plenty of room. I would cut an epis, however, if I couldn't get my hand in...

Now, if we could also define what we mean by shoulder dystocia! I see lots of tight shoulders that need McRoberts, compression and rotation of the bisacromial diameter, and sometimes delivery of the posterior arm, but have not yet had a compromised infant by calmly and deliberately performing the above maneuvers.


Ditto.


The only published definition of shoulder dystocia that I have seen, came out about 1-2 years ago and defined S.D. as a delivery where maneuvers to deliver the shoulders were required or the interval from delivery of the head to delivery of the baby exceeded 60 seconds. I like this definition and think it should be universally adopted. I know. There are those who will disagree.

What you describe above is the general plan for the management of shoulder dystocia. If we all are lucky, we will see it work in every case, HOWEVER, there is always that one case out there which will not respond to these maneuvers and that is where you end up with long term sequelae for the child. I hope you never run into that case. I am afraid that I have.


I think this is a reasonable definition of SD, although I suspect that the incidence of SD would greatly increase if a > 1 minute interval is the criterion for definition. I have had many births where the interval from delivery of the head to delivery of the shoulder exceeded 1 minute, but few where the interval exceeded 2-3 minutes.

I kind of like the non-scientific definition of SD - if sweat rolls down the middle of my back, it's a SD. No RCTs on this one, just MHO.


I agree, the point of impaction is not at the perineum. the only benefit of a large episiotomy is to allow you to reach in in order to sweep the arm and deliver the posterior shoulder. I've always felt that if I had SO much room in the pelvis that I could do this then why is there a dystocia at all.


I agree with those who said episiotomies should be reserved for times when you need the room for manipulations.


I have only had a few very serious shoulder dystocias and I have never cut an episiotomy to help get the baby out. In all cases I got the mother into the hands and knees position and was easily able to get both my hands into the woman and assist in the birth without cutting an episiotomy. The worst shoulder dystocia I ever had was an 11 lb. baby where I had to deliver the posterior arm, rotate the baby 180 degrees and deliver the other arm and still had to pull that baby out with a lot of power! At one point both my assistant and I had our hands in there!!! The baby needed about 30 seconds of CPR and about 2 minutes of rubbing up and stimulating to get her going well. She was nursing at about 30 minutes old and today is a fine, intelligent 6 year old. Mom's bottom was intact!

I suspect that cutting an episiotomy with a shoulder dystocia in the mother in the lithotomy position might give you the same amount of room for your hands to maneuver that having the mother in the hands and knees position gives without cutting!


Don't forget that I had that woman on her hands and knees which gives you a lot more room for getting your hands in there. I have tried to resolve shoulder dystocias with the woman on her back and have been unable to get my hands in properly and once they are in, the baby is very difficult to move.

When the mother is on her hands and knees the posterior fornix of the sacrum expands appreciably, not only allowing your hands more movement, but when you do sweep the fetal posterior arm out, there is less danger of it impacting in the mother's vagina, thereby causing lacerations to the vagina. This is especially true of the very large babies.

Though cutting an episiotomy with the woman in the lithotomy or supine position might give you the extra room needed to make the necessary maneuvers, I would rather spend the time turning the mother over. Until you have tried dealing with shoulder dystocia both ways you can not know how much easier it is with the mom off her back! It's quite remarkable!


If both you and your assistant had a total of four hands in this woman's vagina and her bottom was intact, you can be damn sure she didn't need an episiotomy.


I have had one bad shoulder dystocia in 13 years and 1500 babies. I have lots of tight shoulders. I have watched CNMs and OBs get impatient and try to deliver the body before the baby restitutes, and call it a dystocia, so I believe that my definition is different than theirs.

I have only cut one epis in the last few years, due to an impatient OB who was called in for bad variables and had poor sphincter control as he watched the delivery.

I also don't believe they solve a dystocia, dystocia is a bone problem. For my one bad shoulder, I cut the epis while the resident was running in response to my call. I didn't want him to waste time discussing or doing an epis. I pulled the baby out as he came in the door.

So my limited experience tells me that intact perineums do not hold babies in and my reasoning tells me that shoulders are not freed from behind pubic bones by cutting the perineum. But I think that if I had tried everything else, including changing positions, McRoberts, screw maneuvers etc., I would probable cut an epis.


I'm sure many of us (like myself) were trained to do an episiotomy when SD is encountered. Of course this doesn't make any sense anatomically for SD but there is no good literature to provide any help either way. Of interest I know of a case where there was a lawsuit and the case rested on the OB decision NOT to do an epis. You couldn't believe how many of our low life colleagues were willing to testify under oath (and for a hefty fee) that it is malpractice not to do an epis. That OB lost the case. The main points that came up were 1. ACOG tech bull #196 states "Some have advocated performing a generous episiotomy to increase space for manipulations" 2. the same is said in Williams and is repeated in the new 20th ed (on page 452). The lawyer twisted this statement to indicate if your procedures don't go well to release the SD an epis is needed. I don't know if you can argue with that. Just to really get you going I was just served on a case where a midwife delivered the baby and I was the backup. The baby did well -- no SD but she cut an epis. Patient is suing because she states she didn't want an epis and it (the epis) caused her a rectocele and now sex is painful. Sounds ridiculous right. Well they have an expert opinion by a FACOG that this is the case. Remember for any case to begin there has to be an expert opinion that malpractice exists. Until we get rid of our colleagues who will say anything for buck -- garbage like this will continue. On a happy note the new Gabbe is out and the chapter on malpresentation discusses SD and says nothing about episiotomy (sounds like Steve Gabbe is on the right track).


Not me if it's true SD (i.e. bone on bone problem). Might help with tight shoulders (soft tissue problems), but I haven't had to do one yet. Never had a third, and usually get them out intact even with classic turtle sign, etc.


I have had "true" shoulder dystocias and I have also never had a third or fourth degree episiotomy or laceration from the dystocia or from the maneuvers involved in resolving the dystocia, and usually it has been with an intact perineum. It can happen!


I've seen SDs with fetal injuries with no episiotomy, no fourth degree tear either. One was seven minutes from birth of the head to birth of the whole body; the midwife used several maneuvers; baby was born with a dark purple head, white limp body and needed resus; baby had a broken arm, client had a first degree tear. It is possible to resolve SD with the client having an intact sphincter, even an intact perineum.


So far (cross my fingers) I have always managed to relieve the dystocia by other means before having to decide whether to cut.

FWIW, here's the summary of the meager evidence on this question from my review:

3. Fetal distress

There remains the question of whether fetal distress is an appropriate indication for episiotomy. Such use is conceded even by many authors who take an otherwise dim view of the procedure [21, 50, 81, 121, 127]. This defense obviously depends on the assumption that episiotomy will abbreviate the delivery. As discussed in the previous section, there is little scientific rationale for this assertion.

That said, it must quickly be granted that the question "Does episiotomy shorten the second stage of labor?" is not equivalent to asking "Does episiotomy shorten the interval from its performance to delivery when late second stage fetal distress is diagnosed?" There is simply no published research on the latter query. Nor is there likely to be. Such a study would have to deal with the high incidence and low specificity of fetal heart rate "abnormalities" in the second stage [52-57] and the wide range of opinion as to which cardiotocogram features indicate distress needing intervention [128-129]. It is also unlikely that institutional review committees would allow or many clinicians participate in a randomized trial of episiotomy in the face of diagnosed fetal distress, given the prevalence of the assumption of its benefit. Nevertheless, we need not simply abandon the issue. An RCT could be designed so that distressed fetuses are excluded and the accoucheur learns the patientÕs allocation (episiotomy or none) only after deciding that it was time to perform one. If episiotomy truly hastens delivery by a clinically significant amount, a fairly small trial of this design should have power to demonstrate it, since, say, a two-minute decrease in the crowning-to-delivery time will be more readily apparent than a two-minute decrease in the overall second stage duration. The results in healthy fetuses should be generalizable to those in distress.

4. Shoulder dystocia

Episiotomies, sometimes including intentional proctoepisiotomy or bilateral mediolateral episiotomies, are commonly described as one of the first steps that should be taken to relieve shoulder dystocia. In a recent review, Piper and McDonald were able to identify only four published commentaries that questioned this assumption, despite the lack of published research to demonstrate its benefit [130]. Without doubt, the performance of a methodologically rigorous trial of any maneuver to relieve shoulder dystocia would present formidable technical and ethical obstacles.

In the absence of reliable data, the clinician must make a reasonable decision of the performance of an episiotomy in this critical moment. Considerations arguing against its use are (1) the concept of shoulder dystocia as a problem of bony disproportion, rather than a soft-tissue obstruction, and (2) the availability of apparently effective non-surgical techniques (e.g., McRoberts maneuver, maternal hands and knees position). In favor of its use are (1) wide anecdotal acceptance of its efficacy, (2) the need for expanded room in the outlet for intravaginal interventions (such as the Woods maneuver), and (3) the need to apply all available methods for a birth complication with such high fetal morbidity and mortality.

I have been able to locate only one published analysis of the use of episiotomy as a prophylactic measure against shoulder dystocia; this retrospective study found that its use did not appear to reduce the risk of this emergency [131].

127. Reynolds JL. The final fatal blow to routine episiotomy. Birth 1993; 20 (3):162-163.
128. Lotgering FK, Wallenburg HC, Schouten HJ. Interobserver and intraobserver variation in the assessment of antepartum cardiotocograms. Am J Obstet Gynecol 1982; 144:701-705.
129. Nielsen PV, Stigsby B, Nickelsen C, Nim J. Intra- and inter-observer variability in the assessment of intrapartum cardiotocograms. Acta Obstet Gynecol Scand 1987; 66:421-424.
130. Piper DM, McDonald P. Management of anticipated and actual shoulder dystocia: Interpreting the literature. J Nurse Midwifery 1994; 39 (suppl):91S-105S.
131. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol 1993; 168:1732-1739.


I believe that shoulder dystocia is not a soft tissue problem; thus the time spent cutting an episiotomy after the delivery of the head can be better spent performing maneuvers which have been proven to help resolve the true problem, which is the impaction of the shoulder behind the pubis.


When I get a shoulder dystocia (I mean a true shoulder dystocia, socked in, brow sweating, resident shoving, attending praying, lawsuit envisioning shoulder dystocia), you can bet, by all that is holy, that I'm gonna cut an episiotomy.


Since shoulder dystocia is predominately caused by impaction of the fetal shoulder against the maternal pubic bone, and not the soft-tissue of the perineum, I have never been impressed that cutting an episiotomy is particularly helpful. Most of my shoulder dystocias are relieved with McRobert's maneuver and/or suprapubic pressure and I don't cut an episiotomy for either. Even a Wood's screw maneuver does not necessarily require an episiotomy. However, delivering the posterior shoulder or doing a Zavanelli maneuver (I have never done this) would probably require an episiotomy in order to make room for your hand.


It helps especially if you have to go after the posterior arm. IMHO.


As shoulder dystocia ( as referred to in European practice ) is due to the shoulders being held up at the pelvic inlet then episiotomy will not help things UNLESS it is done to facilitate access for internal manoeuvres to rotate the shoulders or deliver the posterior arm.


IMHO an episiotomy, large, small, midline or anywhere else is very unlikely to ease a shoulder dystocia.


I honestly can't recall a case of shoulder dystocia where I felt compelled to extend the episiotomy (or tear) beyond what had already been done to accomplish delivery of the head. As numerous posts have noted, the problem is not a soft tissue one. The textbooks seem to be a little out of date regarding episiotomies in general. I've never tried the Zavanelli maneuver so am not sure that in that instance a little more room for manipulation is needed.


I would really like a poll of the clinical opinion of the members of this list. If you like e-mail me privately and I will tabulate the results and post it on the list.


The results are in and the winner is: Don't do it.

I tabulated the responses. The CNM's who answered said NO 7 times and YES only one time.

The MD's were unusually vocal and gave both their beliefs and their practice. 3 of them routinely do episiotomy for SD because they think it helps. 2 do it routinely because they think it will help in court. 8 do it only if it is needed for making enough room to perform maneuvers. and 8 don't do it. I think that really that means 16 will do it if it is necessary to get the baby out.

Then there were a total of 3 who actually believed it helped relieve shoulder dystocia and 18 who believe that it does not have any effect on shoulder dystocia itself.



Breaking the Clavicle



True shoulder dystocia can be such a horrible thing that I think a lot of people panic, whether OBs or midwives, at home or in hospital.

Williams Obstetrics is very clear that breaking the clavicle always works. Every time. No exceptions.

It's not a pretty picture, but, as they point out, it sure beats permanent arm injury, brain injury or death.

Another big reason you need an assistant during a shoulder dystocia is that you need somebody keeping an eye on the clock - time gets so distorted at times like that. When that baby's been stuck for a few minutes, it's time to think about breaking the clavicle. But you can sure try a lot of things in two minutes before you get to that point!


I've read about three different techniques - Elizabeth Davis teaches anchoring the back of the clavicle with your second and third fingers, positioning your thumb on the other side between the second and third fingers, and applying as little pressure as necessary until you feel the give. An alternate on this technique is to anchor the back of the clavicle with your second and third fingers together and then apply counterpressure with the thumb.

The third technique, advocated in Williams Obstetrics, is to position the baby so that the clavicle is next to the pubic ramus (hard bone next to the pubic arch), and press on the baby's back so that the clavicle is pressed against the pubic ramus.


How much pain does breaking the clavicle put the baby in? I would never want an unnecessary cesarean; however, I would want the least traumatic route for my baby, if that were to happen to me. Are the problems from the pain from a broken clavicle less than the problems from medications and other things in a cesarean delivery? I would imagine that the most desirable result is a baby who is the least traumatized as possible.


Some surprisingly large number of babies (0.3%?) have broken clavicles that wouldn't have been detected if they weren't in a research study. It's not known whether these breaks occurred during pregnancy or during seemingly uncomplicated deliveries.

I can't find anything anywhere about the pain associated with this, but I would guess that if there are babies with undiagnosed breaks that heal just fine, there can't be a terrific amount of pain involved afterwards.

As for the pain of intentionally breaking the clavicle, I don't think the babies are physically present enough at that point to feel much pain. Most babies seem to be in some kind of altered state until they're fully born, although one does hear stories of babies crying with just the head out. And by the time you get to breaking a baby's clavicle, the bloodflow has been diminished enough to bring some level of numbing to that area as well as to the brain.

I don't mean to say that they wouldn't experience the breaking of the clavicle as a negative thing, but I've never heard anybody mention the pain as an issue.

And, really and truly, if I were making the choice as a baby whether to be born vaginally with a broken clavicle or to be born by cesarean, I'd choose the broken clavicle, mostly because then I'd still get my bonding time with mom, which suffers so badly in surgical deliveries.

And, of course, shoulder dystocia is completely unpredictable, so there aren't those choices to be made.



Transverse "Shoulder Dystocia"



At a birth yesterday, for a small build G5 mom, the 4.3 Kg (9 lb, 7 oz) baby's body did not turn, after the birth of the head. The birth went perfect, only that the head didn't turn after the birth of the head, as is normal, and the body of the baby was born, "chest down".  I have never seen this before. Is this common?


Not particularly common. During my training, one of the 'old' docs I worked with referred to this as 'military shoulders'. See it occassionally on small babies born over big lacs (they just 'fall out') and big babies born through tight pelvis (no room to move). Whatever, long as they come out.


I have also heard that babies with some kind of physical disability (CP, for example) because they're not "helping" themselves get born.



Individual Situations



A Mom's Story

When my daughter was born, they used vacuum extraction and then there was a double shoulder dystocia.  Her upper left arm was broken, causing nerve damage, and they cut a HUGE episiotomy which tore and has left me incontinent.  My daughter is now three years old and has cerebral palsy. What methods (aside from caesarean section) are used as a precaution in these cases? How often are 12lb babies delivered safely? What precautions can I take to insure this doesn't happen again? Ie: how do you safely estimate birth weight, size of pelvis? I'm planning on having 1 more before I have my repair work done since it won't be possible afterwards.

It's not possible for me to know all the circumstances at your birth, so I can only make general comments that might apply to your situation.

Vacuum extraction is a known risk factor for shoulder dystocia. Anytime you mess with the normal progress of labor, you increase the risk for causing complications.  In particular, a double shoulder dystocia is a clear indication that the head was extracted before the baby's shoulders had rotated into the proper dimension to fit into the pelvis.  (The typical female pelvis is oval shaped, with the wider dimension being from side to side.  When they force the head out before the shoulders have rotated sideways (either by vacuum extraction or by use of the Ritgen Maneuver), the force of the head outside the pelvis pulls the baby's shoulders against the pelvis so the friction inhibits them from turning.  The common solution to shoulder dystocia is to get the mom in a hands-and-knees position so that the baby's back rolls towards the floor, moving the shoulders into a sideways position so they can fit into and through the pelvis.

It is impossible to predict shoulder dystocia from estimates of the baby's weight.  In this case, it really sounds as if the baby's size wasn't the biggest problem - trying to get the shoulders through the pelvis the wrong way was the problem.

There aren't a lot of 12-pound babies born, but midwives certainly talk about healthy births with 12-pound babies.  Again, I don't think it was the baby's size that was solely responsible for the difficulty.

Ideally, the way to avoid shoulder dystocia is to have a mom who isn't drugged (so she's able to move around) giving birth in a place where she's able to move around.  A midwife learning of your history might even suggest giving birth on hands and knees to assist the shoulder rotation before it becomes an issue.

Depending on the exact situation, you might want to consider encouraging labor to start early with your next baby, possibly even considering some pharmaceutical approaches (Cytotec) that would still enable you to be moving around freely.  It's probably best to start with very low dose to ripen the cervix and then encourage labor to start "on its own" in a natural rhythm without further pharmaceutical encouragement.

I would suggest asking these questions of care providers that you interview for your next birth, since they're the people who you're going to have to rely on for assistance.

Oh, also, some people would suggest waterbirth . . . the reduced gravity makes it easier for the mom to move around and for the baby to rotate.  PLUS . . . if there is a problem, the warm water on the cord may make more oxygenated blood available to the baby immediately after the body is out.  (Oh, I assume that at your son's birth, they cut the cord right away to take the baby across the room . . . if they had left the cord attached, your baby would probably have gotten a higher concentration of oxygen to his brain faster than through resuscitative efforts, or in addition to what he was getting through his own breathing. So you might find a care provider who appreciates the oxygen the baby continues to get for up to five minutes after the birth.)

 




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