Shoulder dystocia questions

[homemademom]

Hello. I hope it's okay to ask a couple questions.

My babies have all been born in different maternal positions. My first baby, a boy, was over 9 lbs and had mild shoulder dystocia. I delivered in a supported 3/4 squat in a tub. He was freed by applying suprapubic pressure after a few scary moments of trying gentle traction.

My next two girls were smaller and didn't have any serious problems (delivered in bed, sitting up with one, and side-lying with the other).

My last baby was another boy, and I was worried again about having a big baby and stuck shoulders. I decided to push on hands and knees from the outset. Well, he ended up having the worse case of SD yet. His head was purple and bruised, his eyes were bloodshot, his collar bone was broken and he was very traumatized (wouldn't nurse, didn't cry or open his eyes, etc.). It was very scary. Oddly, he ended up not being as big as his older brother, and was in fact, only 3 ounces larger than his sisters.

Could there be something anatomically odd about my pelvis, perhaps relating to the shape of my pubic bone? The suprapubic pressure was such an easy fix. It was a bit tricky in the water, but once applied, it worked immediately. Baby flew out. But with the hands and knees pushing (trying to take advantage of the Gaskin maneuver position), suprapubic pressure wasn't done. Obviously I could have flipped onto my back, but I think my midwife was just sure that the Gaskin move would work so she didn't suggest it. It did, but it took much longer and caused much more damage.

I'm pregnant again, so of course, I'm having all kinds of anxiety about this newest baby. I'm just wondering if I should stop trying to be so "progressive" with my laboring and just sit in the bed like every other woman in America! It seems counter-intuitive, but for some reason, my body seems to birth best in that way, and I'm just curious about the possibility that my pelvis/pubic bone is to blame.

[MsBlack]

Sure, there *could* be something about your pelvis--a 'tight spot' or something, that gets in the way of birth when you are on your hands and knees, but not so much a problem when you semi-sit or are side-lying.

As I understand it, an important element of preventing SD (for anyone, but especially for a mom whose already been through it) is avoiding directing of mom during any part of labor or pushing unless/until there is a reason to do so. That is, mom should choose her labor/birthing position more instinctively, in the moment--not in advance, such as taking Ina May's (frequently sound) advice. I mean, maybe you will choose to try H&K in the course of things--just don't figure you'll know in advance what is best.

In general, 'free pelvic expansion positions' are best for anyone--hands and knees is one, but sidelying, standing, squatting, kneeling and variations on those themes are also good--such as kneeling somewhat upright, leaning on something that puts your shoulders higher than your head. Your pelvis is jointed at the sacrum and pubis--you want the ligaments at those places to be able to stretch and open some, to make as much room as possible for baby.

But it's important to continue following your instincts, as you may start out in one position but gravitate toward others during pushing. If you are feeling it through each moment, chances are you will be led to shift as needed. For instance you might want to be on hands and knees, but as you push you find that you want to push your bottom backward toward your heels, even to the point of shifting your head/shoulders more toward the surface you're on. Or you're sidelying and your legs at first are relaxed but you feel a need to grab the upper knee and pull it toward your chin...or roll to your back...and so forth. It may take several position changes, depending on your baby and your labor at the time.

Also, for some sticky or truly stuck shoulders, it is mom's movements at the time that helps to free the shoulders. So maybe you are in sidelying, shoulders stick, so you move to H&K...or you're kneeling and move to squat...it's the movement itself that helps shift things enough for shoulders to come out. For some women, it takes a few moves from this position to another, then shifting again, and maybe even again, that works. This is not only about opening the pelvic outlet more, but about shifting the relationships between baby and pelvis just a bit, just enough to free the shoulders.

Something else that makes a difference is the baby's own physical attitude, the way the baby is holding itself. I've seen some babies come through with both shoulders curved forward--as if trying to meet each other under baby's chin, arms/hands trailing straight down baby's belly during emergence. Shoulders in that position are just unlikely to get hung up on the pubic bone. But a baby whose shoulders are more 'squared', might tend to get a shoulder caught. You can't exactly control the baby's attitude during birth--but again, free/instinctive movement/positioning can help baby find the easiest way out.

I think it's also important to avoid direction of pushing: you should push only *when* you truly have the urge, and only following the urge of your labor. So--this means, don't push just because you're 'fully dilated'! Wait until you're really feeling expulsive efforts that you can't resist--this can give time for baby to find the 'perfect attitude' on it's way out. If you and baby are doing well, there is no need to hurry 2nd stage. And only push as long/hard as each contraction directs, NOT trying to add extra effort, not holding your breath or counting to 10. I like to say "breathe when you can, push when you really have to". This may or may not make for a longer pushing phase--moms who do this tend to be more relaxed, and being more relaxed tends to allow mom to open up, and the baby to descend, more efficiently. Another effect of this kind of instinctive pushing is that you are less likely to tear, along with being less likely to have stuck shoulders.

[loveneverfails]

Mom with history of shoulder dystocias here...

I had 2 mild shoulder dystocias (really more cases of sticky shoulders), 1 serious shoulder dystocia, and 2 babies without dystocias. Here is what I've figured out for myself:

My dystocias have not been "normal" dystocias. Generally speaking, shoulder dystocias can be seen in the works. Labor can be long, pushing can be long and very hard with very slow progress. By comparison, my labors are always short, and pushing fast and easy until something has seemed to change during descent and then we're doing maneuvers. So, not the typical dystocia profile, and unlikely to have the same mechanisms working as in your typical shoulder dystocia.

In working with some very good midwives and physical therapists, what we figured out was that my sacrum was rotating during descent. I had serious strength disparities between left and right sides of my lower back, and the strong side was puling the joint out of alignment, and a sacrum that's rotated makes the pelvic diameter smaller. Not good. It was probably the result of an old injury from when I fell and broke my foot, and therefore was limping (while pregnant, ie. on relaxin) for 6 weeks, so using one side of my body more than the other one. So, I did physical therapy to balance out that strength disparity, and my pelvis became much much much more stable. My last birth, my sacrum stayed stable and there was no shoulder dystocia.

There is nothing "wrong" with being a woman who does best in hospital based positions. I am planning on delivering in stranded beetle McRoberts for all future births. Suprapubic pressure also works extremely well for me and the Gaskin maneuver is useless for me, which is part of why I'm wondering if you've got maybe some similar issues that could be addressed by physical therapy to stabilize the pelvis. It would make sense, because McRoberts with suprapubic pressure would essentially use the weight of the baby as counterpressure against the sacrum whereas Gaskin doesn't have that couterpressure to make the bone get aligned and the problem stays unresolved.

And I strongly agree with the advice to listen to your own instincts in the moment in terms of what position to take.

[mwherbs]

excellent post by MsBlack
here is what I would add walking, doing squats, belly dancing to tone the muscles in order to help with getting everything where it could be - there is an interesting video on pelvic floor - basically kegels are great but glutes have to balance that out to provide more strength and space--

http://www.youtube.com/watch?v=IOoTC...eature=related

[homemademom]

Thank you all so much for your posts.

Ms.Black, I had wondered about the fact that I didn't do much moving around during pushing despite delivering in hands and knees and wondered if that lack of movement was just as much of a problem. Thanks for your thoughts. They were very helpful to me.

loveneverfails, my labors were very much like yours. I also had fairly short labors. I appreciate hearing your experiences because it sounds like our bodies might be built somewhat the same way! And even more strange, I limped at the end of my pregnancies with my two SD boys and not my girls! How did you go about finding a physical therapist who knew about these kinds of problems?

mwherbs, thanks for that information and for your link. That might play into the issue that loveneverfails mentioned, that a certain muscle weakness contributes to the overall ability of the pelvis to do the work it needs to. Off to watch the video!

[loveneverfails]

I asked my family practice doctor for a referral for physical therapy because my sacrum just would not stay in place, and it was causing a lot of pain. He gave me a referral to a physical therapy group, and I looked on their website and found a therapist who was interested in and lectures on sacroiliac joint issues.

It's the sacroiliac joint that would be causing problems for you if this is what's going on. Look for someone who specializes in that area and tell them that you are trying to strengthen the muscle groups that hold the sacrum in place. If you were limping, I can almost guarantee one side of your pelvic area was stronger than the other. And even a relatively small subluxation of that joint can alter how the joint functions.

I hope this helps!!! In your opinion, are your babies too big for your body or is that a non-issue?

[terra-pip]

This is all very interesting to me. With my first he had SD. I labored and pushed in every imaginable position it seemed. By my own wanting, not directed. Mainly I sat on a birthing stool or squatted a lot. I felt like a cat looking for a drawer!! lol. I pushed out his head in the position of sitting leaning against husband with legs spread and MW quietly said that the shoulder was going to be a problem...and asked me to move onto my hands and knees. She did use counterpressure and he slid out no problem. With my second I was more restful while in labor but wanted to stand and walk a lot. And started out in a squatting type position when I felt like pushing but when my OB mumbled something about "big" something clicked in my brain and I moved onto my hands and knees...so I pushed him out either on straight hands and knees or a back and forth rocking position. Only a slight SD this time...no problem. I also asked for counterpressure while pushing. It also seemed to help me to do like Msblack said..not to try to push too hard or hold my breath..but to pant out their heads and just exhale out their bodies...if that makes sense.

I fell in college and got a very painful tailbone injury...never wondered if that was a part of it...but I do know that without the perineum and sacrum support I feel more uncomfortable in labor.

[LauraCochran]

Hands and knees is a good way for lots of women to push and creates and ample amount of room in the pelvis. But part of the reason it resolves shoulder dystocia is because you move into it while the baby is stuck. The movement of the pelvis helps to shimmy the baby out or dislodge the shoulder. It is a frequent misconception that pushing in that position from the start prevents sd.

[Engineering_Mama]

subbing

[homemademom]

Originally Posted by LauraCochran

Hands and knees is a good way for lots of women to push and creates and ample amount of room in the pelvis. But part of the reason it resolves shoulder dystocia is because you move into it while the baby is stuck. The movement of the pelvis helps to shimmy the baby out or dislodge the shoulder. It is a frequent misconception that pushing in that position from the start prevents sd.

Which is something I really wish I'd known or my mw had known.

[homemademom]

Originally Posted by terra-pip

This is all very interesting to me. With my first he had SD. I labored and pushed in every imaginable position it seemed. By my own wanting, not directed. Mainly I sat on a birthing stool or squatted a lot. I felt like a cat looking for a drawer!! lol. I pushed out his head in the position of sitting leaning against husband with legs spread and MW quietly said that the shoulder was going to be a problem...and asked me to move onto my hands and knees. She did use counterpressure and he slid out no problem. With my second I was more restful while in labor but wanted to stand and walk a lot. And started out in a squatting type position when I felt like pushing but when my OB mumbled something about "big" something clicked in my brain and I moved onto my hands and knees...so I pushed him out either on straight hands and knees or a back and forth rocking position. Only a slight SD this time...no problem. I also asked for counterpressure while pushing. It also seemed to help me to do like Msblack said..not to try to push too hard or hold my breath..but to pant out their heads and just exhale out their bodies...if that makes sense.

I fell in college and got a very painful tailbone injury...never wondered if that was a part of it...but I do know that without the perineum and sacrum support I feel more uncomfortable in labor.

Do you mean counterpressure on your sacrum or your pubic bone while pushing? Throughout labor, I beg my dh to press on my sacrum because it's offers the most relief for contractions.

[homemademom]

Originally Posted by loveneverfails

In your opinion, are your babies too big for your body or is that a non-issue?

Sorry I forgot to answer your question before. No, I don't think they're too big for me.

[loveneverfails]

Ok, then just get thee to a physical therapist!!