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Your experience with shoulder dystocia

post #1 of 27
Thread Starter 
I am a fairly new birth professional, and have only had the misfortune of seeing two shoulder dystocias so far.

With the first one, the doc was impatient (mom hadn't even been pushing an hour, but I think he had to go assist with a case in the OR), so he vacuumed the baby from way high up. Brought the baby way down and out with one pull. Then, before the head was even out (probably about half way), he called a shoulder dystocia and asked me to do suprapubic pressure and McRoberts. the contraction was long since over, and he was having the mother keep pushing anyway. The body came out pretty quickly, and honestly it didn't seem like any longer than one might have taken to just push when the body was ready.

With the second one, the midwife was being uptight about the heartbeat -- it had been a low baseline (100's to 110's) for the last 30 minutes of labor during which she rapidly progressed from 5-fully. When she started pushing, it was going into the 80's. She was a multip though (4th vaginal delivery), and pushing very effectively, so I thought it was no sweat -- just rapid descent and head compression. Either way, she was calling the shots, so she was having the mom do purple pushing and doing the whole "your baby is in trouble, we need to get it out" thing. So the head started to emerge, and when it was about half way out, the contraction was over. I feel like many other providers would have just let it sit like that until the mom felt the need to push (this mom was unmedicated, BTW), but the midwife said "push hard, give me all you got" etc, etc... So the head laboriously delivered the rest of the way, then we had a one minute shoulder dystocia (episiotomy, McRoberts, suprapubic, no hands an knees even though she was unmedicated!)

SO... I feel like in both of these cases, the providers were very anxious to get the head out, faster than it was ready to come out. Those of you who have seen this more than me -- do you think that sort of rushing to deliver the head can lead to a brief, perceived shoulder dystocia? My sense was that the body just didn't have the time to catch up, -- I mean obviously it will follow along (it is connected, after all), but maybe the rushing prevented the shoulders from maneuvering the way they might have otherwise? And maybe if we had allowed a few seconds, they would have followed on their own?

Thanks for your input!
Cindi
post #2 of 27
My experience at homebirth with SD is that it happens very seldom and is resolved the vast majority of the time through mom's changes of position and NO hands on manuevers by the care provider. Many of us believe that it is the freedom of movement during labor along with other supportive tactics such as freedom to eat and drink at will--essentially, to encourage normal birth by trusting what mothers want and need to support themselves during labor--that prevents SD by promoting an efficient, effective process. No directed pushing--no pushing before the fetal ejection reflex is in play, no pushing according to commands such as when to push, how long to push, etc--these things allow mom and baby to work out their unique dance quite well.

My experience in the hospital with SD is that first, SD is called too soon in most cases--at least when it is thought that baby is 'big'. Manual manuevers are undertaken without giving time for restitution and the next contraction. I've seen also that epidurals greatly hinder normal descent and rotation, but that may be mainly because moms are immobilized--because even in unmedicated labors women's movement tends to be hindered either directly by orders to stay on the bed, in a particular position to give birth, OR movement is difficult because of IV lines and so forth. Also, moms are not properly hydrated or fueled (IV fluids can help, but do NOT constitute physiological proper hydration/fuel)--so they are not operating at maximum power and alertness to support their instinctive knowing of when and how to move in their baby dance. Add directed pushing--forcing moms to push at 'fully dilated' even when baby is still fairly high, and no pushing urge is felt, directing the position of pushing, and the force and duration of pushing--all these things impose upon baby's descent and rotation and mom's ability to aid her baby in being born.

I'd say, in other words, that your feelings about what you are seeing are absolutely right-on! I hate hate hate witnessing a hospital birth where the staff believes SD is occurring or likely--there is so much fear, so much force applied, and these things harm moms and babies both in various ways. Well, I really very seldom enjoy witnessing any hospital birth! But especially where SD or 'fetal distress' is concerned.

Not to go into Fetal Distress too much, but it's another area where med ppl are so afraid and tend to employ so much unnecessary force (such as in the scenario you described)--whereas the same situation IMO is one that simply bears watching, and readiness to help baby upon emergence; but most of the time such babies emerge with high apgars and no apparent sign of distress. It is NORMAL for some babies to have bradycardia during max compression of descent--a normally healthy baby is built to withstand this, has compensation mechanisms that preserve brain and organ function in the presence of lower 02 levels, etc.

But maybe this is my experience with FD and SD because the moms I've witnessed at birth HAVE had freedom of movement, free access to food and fluids, plenty of support as needed/wanted, plenty of understanding of normal birth, no time constraints upon them and no imposition of over inflated fear driving choices.
post #3 of 27
Thread Starter 
Thanks for your comments, Ms. Black. So much of what I see and do is so counter-intuitive to what I feel and know about birth. I plan on starting midwifery school next year and do NOT want to work within the hospital setting again. I want to do everything I can to prevent myself from buying into my experiences in the hospital and believing that they are right. I want to hang on to what I already know about birth despite those around me in the hospital and not have to "relearn" what I already knew when I get out of there.

I walked away from these experiences disgusted at the violence of the births, and wondering if it was necessary. In your experience, when is a TRUE shoulder dystocia apparent?

As a side note, my first two babies were "rescued" for bradycardia -- forceps and vacuum, respectively. The third was born in a birth center with no such drama. I totally believe the that "rescuing" was not in the least bit needed, and wish they had just let me push myself. If you have a multip who is going to push the baby out within minutes, is it even necessary to listen while pushing? Baby is coming momentarily anyway.

BTW, I am a big fan of yours. Love your posts. I really appreciate your perspective on birth.

Cindi
post #4 of 27
I"ve seen a few cases of sticky shoulders, in hospital. Strangely enough they were both with CNMs. One was in a semi reclining position, the other was sidelying. Both babies started to turn color at the head, but nothing like the SD below. Both were unmedicated births, in multips.

But strangely enough the only true SD I've ever seen was at a homebirth. Ultimatley mom and baby were fine and the MW was able to resolve the dystocia, but it was a very intense time there. Felt like a lifetime.
post #5 of 27
I've seen what care providers called shoulder dystocia three times. Not one of those three did I personally feel like it was a *true* emergent situation, or even a true dystocia. All three times the mothers were shouted at, hips thrown back into McRoberts, and scared out of their wits. One of them the Dr broke the baby's clavical as I watched the entire thing unfold-- and honestly I don't think the baby was "stuck" for any more than 10 seconds.

Just validating your feelings. It makes my stomach flop to think about each of those situations.
post #6 of 27
Thread Starter 
Quote:
Originally Posted by Shell_Ell View Post
I've seen what care providers called shoulder dystocia three times. Not one of those three did I personally feel like it was a *true* emergent situation, or even a true dystocia. All three times the mothers were shouted at, hips thrown back into McRoberts, and scared out of their wits. One of them the Dr broke the baby's clavical as I watched the entire thing unfold-- and honestly I don't think the baby was "stuck" for any more than 10 seconds.

Just validating your feelings. It makes my stomach flop to think about each of those situations.
Breaking the clavicle after only 10 seconds? How atrocious! I don't know if I would be able to see that. Just the suprapubic pressure was way too violent for me...
post #7 of 27
I once saw an OB call for a SD before the baby was even crowning. They were all in place and ready to do pressure and cut her without even any evidence to suggest it was an issue. Baby came out fine, everyone stood down ultimately, but it scared the mother and made her birth really different than it needed to be. I have seen a couple of sticky shoulders that were handled really well by CNMs in the hospital.

I have also seen one true SD that was resolved well by a CNM (we rolled mom over, then the other way) and she was able to work the baby out (VBAC mom, long labor, big baby). There was mild nerve damage that resolved within 48 hours and the baby was fine after about an hour of observation.

So, I guess I am also chiming in to say that many times what is called SD or situations that concern people (big babies primarily) are no trouble at all and simply giving mom freedom of movement, being able to encourage other positions if there is concern, etc seems to be all that is needed. When SD happens, it sucks, no doubt, but not every big baby or sticky shoulder warrants the types of reactions I have seen.
post #8 of 27
I think we tend to be very quick to call a situation SD when if fact it it requires very little additional maneuvering to release the shoulder. The mother is the stuck with this label and it colours her future birth experiences.

I have been involved in a few true SDs and, without exception they have occured when the mother is in the semi-reclined position.

OP, based on what you describe, I would not have called either situation a true SD. And even if it was it certainly can't be diagnosed before the head is fully birthed. Also, as you are aware, there is often a considerable gap between the contraction which birthed the head and the next one to allow for restitution to occur. This is, of course, totally normal and, as you point out, essential to allow optimal positioning. It should be a totally hands off time IMO, except for the mother if she wishes to touch the baby's head. The birth professional should be observing for signs of restitution and for a Turtle's sign which might give a clue to potential problems ahead but there is no way SD can be diagnosed until you try and get the shoulders out.

I really feel for you. I have been in a number of situations where I am not the birthing woman's primary carer and therefore am unable to manage a situation in the way I feel is best. It is extremely frustrating and disempowering. I don't really have any answers except to say do what you can to advocate for the woman and vent to sympathetic colleagues.

Regards
Kate
post #9 of 27
Thread Starter 
Quote:
Originally Posted by BrooklynDoula View Post
I once saw an OB call for a SD before the baby was even crowning. They were all in place and ready to do pressure and cut her without even any evidence to suggest it was an issue. Baby came out fine, everyone stood down ultimately, but it scared the mother and made her birth really different than it needed to be.
A week or so ago, I came in to take over a pushing patient, head was barely visible with pushing, but she had been pushing for a long time (2 hrs and it was her second baby), and they thought the baby was really big. They were highly anticipating a SD. I don't know that they really mentioned it to the mother though (unless it had been discussed before I got there and she wasn't too worried about it, because she never mentioned it). They even let her 9 year old and 5 other support people stay in the room, which surprised me.

For delivery, they had three nurses (usually we have 2) and a pediatrician, so we were all ready for the SD. BUT, in contrary to the situations I posted before, as SOON as the head emerged (without laying hands on or apparently assessing anything), the OB said immediately "we're fine here." Meaning there was no SD. I feel like the other OB I described before would have had me slamming on her belly before the head even came out...
post #10 of 27
Chiming in from the other side (i.e. not as a professional, but as a mother laboring with an SD baby), there was a distinct *feeling* when ds was stuck. Very different from birthing my first baby. (And thank goodness for having that comparison, because that's what first let me know we were having a real problem). My first was posterior and it was hard to move her down through my pelvis, but while it took a while, she always moved -- backward, forward, there was at least a tiny bit of movement during and at the end of contractions. Once he got stuck, DS didn't move back at all after contractions. His head came out to about his nose and was STUCK. I couldn't bring him down any more at all, and he didn't slide back at all once the contraction was over. I have no real measure of how long he was stuck, but I know I tried to move him with no luck through at least three contractions before telling the doctor he was stuck, then one more contraction while the doctor felt his head and position, then I'm guessing another few while dh ran for the crash team and they came in, got positioned, and helped us maneuver ds out. Before and during the time he was stuck, I changed positions numerous times in the water to open my pelvis and bring him down. (And yet another thank goodness for being in the water!)

Anyway, I just wanted to say from this side of things that there was a very distinct *feeling* to it. I know it's hard to describe to someone who hasn't felt it, but I wonder if that utter lack of movement could be used to help distinguish between stickiness and SD. (Assuming that my experience was typical for SD.)
post #11 of 27
I had kind of what you described happen to me. I was giving birth to my 2nd son, a vbac. I can't remember it real well, but I was pushing and remember that his head came out and within seconds I remember the nurse practically jumping on my belly and he came all the way out. His clavicle was broken. Then the doctor came up to me afterwards and told me to never try a natural birth again. He was 9lbs 2oz. My husband and I have been feeling like we want another baby, but I am terrified that the baby would get stuck. I just remember thinking afterwards that I didn't understand how they knew he was stuck cause they didn't even give me a chance to try to push him out.
post #12 of 27
Well for the new providers out there, when I first began practicing I thought that I had seen a dystocia when I was in training, when I hadnt. In my first year of practice I did have one though, and when you have one you will recognize it,you will know it. Its the baby head that delivers to the chin, and stops, its like you have to peel the perineum off the head. I remember thinking this is it, I dont even have enough of the head to even get close to the shoulders. Whats important to remember is that you have more time than you think you do, Remain calm which is very hard with a blue baby head in a vagina, always know your baby's position, see the baby in your mind. If the shoulders are really locked, you have to displace them by rolling the baby. I find the easiest thing is to put two fingers on each shoulder blade and roll the baby forward and then bring the baby out with the shoulders oblique. When mcroberts and suprapubic didnt work, we waited for next contraction, take your hands off the baby, and then try again, when I couldnt get the baby to budge we hit the code button, rotated mom, cut an epis, (no epidual or local) and then put both my hands in the vagina to corkscrew the baby out. The baby was handed to NICU and had a full resus. I almost cried while I was stitching when I heard them call for the epi. My backup ran in when I was pullling the baby out. The baby did well, is now three and healthy. But I will never forget that delivery, and you will learn what snug is and what dystocia is in time. You have to use the moms power. From this I learned to always deliver the babys head at the the beginning of the contraction, because If the baby gets locked I want more uterine power for the shoulders, and flip the mom, or pull her bottom off the end of the bed. When you are pulling down you dont want the bed interfering, its a hard surface, and if I truely think the baby is in the 10pound range,I deliver the head and anterior shouldr in one push so they cant restitute and lock behind the symphysis. This was also a VBAC who labored very rapidly and pushed for 10 minutes, so its not always your slow second stage that has the dystocia.
post #13 of 27
I've had 4 experiences with real shoulder dystocia.

The most intense was while I was overseas and I was the only one in the delivery room (no assistant at all), and I only knew enough of the native language to have basic conversations and talk about normal labor and birth. Some of the things that are normally first steps for me were out of the picture; she didn't understand my asking her to go to hands and knees, or lunge, and there was nobody there to do suprapubic pressure. She did understand when I had her pull her knees back further and actually did better with that than a lot of assistants would have. At just past 7 minutes, after an uncounted number of maneuvers, baby came out (corkscrew/ Woods Screw was what worked in the end, although I'd already tried it once before). I did not cut an epis because I was able to get both hands into the vagina without difficulty; mom's perineum was intact at the end of the ordeal! Baby's 1 minute APGAR was 2, but she came around with PPV and her 5 minute score was 9.

The other dystocias I've seen (true ones, as opposed to "baby isn't coming yet OMG" episodes that sometimes happen) weren't so dramatic. In some senses they all are, and at two more of them PPV was needed after delivery, but none of them had me so worried that the baby just wouldn't come out.
post #14 of 27
What midwifemom3 suggests is indeed what I have seen in hospitals when suspected SD is in play. I have seen some 'suspected SDs' but never a true SD in the hospital (where I am a doula, not primary care), because the HCPs react very quickly with what they consider to be 'helpful manuevers' just as Mwmom3 described--but things that I would not do and consider mostly unhelpful especially when initiated so soon.

Gail Hart, homebirth midwife and researcher/author of vast experience (from OR) puts on a fabulous SD workshop for the big midwifery conferences. She says unequivocally: do NOT peel the perineum back, because once the peri is behind the baby's chin, you may have a baby stuck at 'both ends'--baby's head can't move back, because of chin being hooked by perineum, shoulders may become lodged by pelvis (with or without restitution occurring). She says that first, prevent SD by encouraging moms to move and position freely through labor, and choosing their own instinctive birthing position; also do not direct pushing at all, but let mom and the fetal ejection reflex have their own way. Then, if you do have a very slow 'sticky' delivery of head where head is born to the chin (but chin does not actually emerge), remain hands off at first. THere is no reason to 'assist' delivery of head by peeling peri past the chin; it may be best NOT to do so.

If it is clear that restitution is not occurring between then and next contraction, then the next step is having mom change positions--either getting into hands and knees, or if she already is on her knees, then she can lift one leg to plant that foot flat on the bed in 'runner's start' position (on one knee and one foot with that knee up). She can move her bottom around--pelvic rock kind of things, pushing her bottom further back, things like that. If restitution still does not occur then mom can move around more--stand up, then lower herself into a squat (assisted if needed). Position changes like these will not only potentially create more room for the pelvis to open more, it will also shift the relationship between baby's shoulders and mom's bones, potentially allowing just enough normal mechanical 'joggling', or more space, for baby to rotate or simply emerge without rotation. Only after attempting these things should the HCP initiate things like episiotomy and internal manual manuevers.

I do know some homebirth mws who also believe that it may be best, if slow delivery of the head is occurring, to have mom continue pushing beyond the end of the contraction, using conscious power instead and trying to get baby out before shoulder restitution. It is thought that allowing restitution may only *cause* a SD by allowing shoulder to get caught under the pubic bone. I have not so far seen this to helpful--I mean, some moms can indeed get the baby out this way, but in a couple instances where I saw this, I did not see that it was helpful to mom or baby. It did however have a panic-making impact on both the parents the mws involved!

All that was described sounds by mwmom3 sounds like it would probably be most helpful for an epi mom who simply could not move/reposition herself. Also sounds like standard hospital treatment of SD, where with or without epi, HCPs rely much more upon their own manual manuevers than on the natural forces of birth and moms' power. Any mom who is med-free is safer--as is her baby--if such moves/position changes are tried prior to any internal manipulations.

Hart mentions that when women are supported but not managed in labor, can indeed move and position freely, and the most hands off approach is utilized during baby's emergence (when it comes to head/shoulders issues as above), a mw should see very few shoulder dystocias....and *extremely few* severe dystocias. I have seen this to be true.

We need to remember that for any manuever that we can imagine being helpful, there are risks involved--and those manuevers may well create more stuckness, and more potential harm to mom/baby, than 'help'. If baby's head can come out, so can the shoulders!
post #15 of 27
I pretty much agree with MsBlack. The first thing I think about is repositioning mom, typically --> h+k (if not there already) --> lunge. I just wouldn't consider it a shoulder dystocia if that works. It's just giving baby a little extra motion and opportunity to find a good path through.

I have seen hospital practitioners jump to really significant downward traction really fast, which bugs me. I've never really been keen on worrying about a dystocia until a second contraction passes (after the head is out) with no significant progress.

I should add that I'm a new practitioner (don't know how to put that in my signature without it sounding weird), so feel free to not take me terribly seriously. I do think I saw more of this in training than perhaps most people do, and had more experience than some students get with no senior MW present to jump in (or a very trusting senior MW present who got supplies ready and helped with repositioning, but didn't take over). I also know that my POV on this might change over time, but with what experience I do have with this, I don't think it's worthwhile worrying about a dystocia until you actually have one; most of those babies you're worried about just come out without interference, so why add that stress?
post #16 of 27
Quote:
Originally Posted by nikirj View Post
I also know that my POV on this might change over time, but with what experience I do have with this, I don't think it's worthwhile worrying about a dystocia until you actually have one; most of those babies you're worried about just come out without interference, so why add that stress?
I just had a 5 min dystocia last night, baby wasn't even 8lb. She chose hands and knees for pushing, no directed pushing at all... in fact there wasn't even time after I arrived to do a VE so I only knew she was complete and pushing because her vulva was bulging.

I don't think it does any good to worry about dystocia, but I am glad over the summer I've had the sense that I should be prepared and mentally practice the maneuvers... and I've seen/managed 3 shoulder dystocias since August. I would think we were doing something wrong, but honestly this year everything has come in groups- butter births, long births, precip births, hemorrhages, battledore placentas with trailing membranes, shoulder dystocias etc.

Quote:
Originally Posted by nikirj View Post
I do think I saw more of this in training than perhaps most people do, and had more experience than some students get with no senior MW present to jump in (or a very trusting senior MW present who got supplies ready and helped with repositioning, but didn't take over).
I can't even express how thankful I am for having such a preceptor!

Quote:
Originally Posted by MsBlack View Post
Also sounds like standard hospital treatment of SD, where with or without epi, HCPs rely much more upon their own manual manuevers than on the natural forces of birth and moms' power. Any mom who is med-free is safer--as is her baby--if such moves/position changes are tried prior to any internal manipulations.
post #17 of 27
Thank you for this thread and your wisdom!! I needed this.

Quote:
I've had the sense that I should be prepared and mentally practice the maneuvers...
I have had that lately as well. I think part of it is the fact I haven't yet encountered a true SD let alone be primary on one, so I have what I guess you could call the fear of the somewhat-unknown. I've read and mentally practiced maneuvers and talked them through with my preceptor/partner but I think it's something that you don't fully "get" until you have to do it.

Now that I'm taking on primary (under supervision) this is the one thing that makes me nervous. So this thread has been very helpful and reassuring!!

Quote:
I would think we were doing something wrong, but honestly this year everything has come in groups- butter births, long births, precip births, hemorrhages, battledore placentas with trailing membranes, shoulder dystocias etc.
Here too!!!
post #18 of 27
Yup, things do seem to come in groups....weird but true!
post #19 of 27
Quote:
Originally Posted by mrshoobydoober View Post
I've read and mentally practiced maneuvers and talked them through with my preceptor/partner but I think it's something that you don't fully "get" until you have to do it.
Oh, I totally agree!
post #20 of 27
This is a great thread, I'm just home from attending (doula) a 48 CNM hospital induction of labor. It culminated in mom semi-lying and directed pushing with pit and the team preparing for a SD. How they anticipated that I have no idea and didn't get a chance to ask. Mom pushed baby's head out and it sat on the perineum then she corkscrewed baby out while McRoberts and suprapubic pressure was applied. No episiotomy or local, 2nd degree tear. Still are there any warning signs of SD in labor?
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