shoulder dystocia--ignorant question asked in good faith - Mothering Forums

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#1 of 27 Old 04-17-2004, 10:32 AM - Thread Starter
 
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I've wondered a lot about shoulder dystocia myself, and CPD, and so on, and that other thread got me started thinking... If anyone could explain this to me, I'd really appreciate it, because I realize I just really don't quite understand!

So shoulder dystocia and CPD are totally different things, right? (I mean *real* CPD, not hurried dr./bad position/whatever.) One is shoulder, one is head. I had kind of assumed that in both cases, the "part" (shoulder or head) is getting hung up on the pelvis. So why would an episiotomy help shoulder dystocia (this is my ignorant question asked in good faith)? Does making the vaginal outlet wider help? Or am I mistaken about where the shoulder is hung up?
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#2 of 27 Old 04-17-2004, 11:22 AM
 
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Originally posted by KKmama
I've wondered a lot about shoulder dystocia myself, and CPD, and so on, and that other thread got me started thinking... If anyone could explain this to me, I'd really appreciate it, because I realize I just really don't quite understand!

So shoulder dystocia and CPD are totally different things, right? (I mean *real* CPD, not hurried dr./bad position/whatever.) One is shoulder, one is head. I had kind of assumed that in both cases, the "part" (shoulder or head) is getting hung up on the pelvis. So why would an episiotomy help shoulder dystocia (this is my ignorant question asked in good faith)? Does making the vaginal outlet wider help? Or am I mistaken about where the shoulder is hung up?
My very good friend, who I was a labor coach for, first daughter had shoulder dystocia. From watching her doctor, I say he was a very patient man and us get her in all kinds of positions to try to move the baby etc. He really worked with her but then the baby started to have problems and he had to cut her -- and the cut was bad it was like into the side of her vagina. I've never seen so much blood in all my life. She had to get blood. Oh it was awful. They had to work with the baby to get her really good and going and she got oxygen. The repair took a very long time for mom.

Her next birth though was much better, she barely made it to the hospital to have her mom and a nurse "catch" the baby.
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#3 of 27 Old 04-17-2004, 12:05 PM - Thread Starter
 
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So then is it the vaginal opening that makes it hard to get through? I'm just confused, and I'm having a really hard time visualizing it (and actually, if anyone can direct me to pictures somewhere, that might help, too). I definitely believe that SD is real and happens, I'm just confused about where it is that the baby gets stuck... I know about the Gaskin maneuver, I know about episiotomies (and tearing), and it all just confuses me more.
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#4 of 27 Old 04-17-2004, 12:34 PM
 
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I have attended three shoulder dystocias now. One as a doula in the hospital, the other two as an apprentice at home. One was just a little over a week ago. The first homebirth SD I attended was predicted because the mom had two previous SDs, so the team I was working with went through a full rehearsal of all of the maneuvers that we were going to use and felt prepared. It helped a lot because it can be a pretty panicky situation.

With CPD, the head won't descend into the pelvis. This is a lot less dangerous than SD, because essentially the labor just stops progressing. You can make a decision to do a c-section, then take your sweet time setting it up and the baby will be just fine in most cases. With SD, once the head is out, it is a matter of minutes before the baby is brain damaged or dead. When babies have SD, their heads will often turn purple-black because of a buildup of veinous blood. The babies will often also have a very squished looking face because the chin is outside the perineum and the shoulder trapped behind the bone within. Babies can get nerve damage because the nerves in the shoulder get stretched or torn, causing a kind of palsy. They can also suffer broken bones because of the force used to birth them, either on the mom's part or, more likely, on the care provider's part.

SD is something that scares the life out of a lot of providers because action needs to be taken very quickly and the potential for injury to mom and baby is high. In one study I read recently, the rate of injury to baby was over 30% in the hospital setting. Fortunately, with the three I have attended, the babies have all been fine. One was born white and floppy with a black head and needed a full resuscitation, the others were born with good apgars, but all were in good shape at 5 min. There were postpartum hemmorhages in all three cases, but they were resolved successfully.

There is a maneuver, called the Zavanelli maneuver that involves shoving the baby back up into the uterus and performing a c-section, but the injury/death rate is so high for it that most obs won't even try it. So, in most settings, that is not an option.

The other maneuvers center around two plans of action, or a combination of both -- change the shape/size of the pelvic outlet and change the position/presentation/shape of the baby. Deep lunges, rotating mom to her side or hands and knees, and the McRoberts maneuver, where the mom's ankles are pushed up by her shoulders, are all things that open up the pelvis in one place or another.

With the McRoberts position, it is possible for a provider to use super-pubic pressure, which is essentially an effort to push on the lower abdomen where the baby's anterior shoulder is so that it will pop under the pubic bone.


Almost all of the other maneuvers that deal with the baby involve the provider reaching hands up inside the mom to try and change the baby's position/presentation/shape. This is where the episiotomy comes in. When a mom is on her back, it can be pretty hard to reach in with one or two hands to where the baby is and feel for impacted arms/shoulders, to get a good grip to turn the baby, etc. So, many providers will cut large episiotomies to provide room to reach in on the sides because the pelvis is in the way in the front. In some OB textbooks, cutting the epis is the first step, so if a provider has learned this way, he/she might think of it as being a necessary part of the procedure, no matter what position the mom is in. On hands and knees, it is more possible to reach in and access the baby (because the bones aren't in the way), so epis are often not necessary in that position. In the two homebirths I have attended, no epis were cut, moms were in lunging or hand & knees positions, and they did not tear. In the hospital birth, they used McRoberts and super-pubic pressure and also did not need to cut an epis. I believe there was a 2nd degree tear there.

The other reason why a provider might cut an epis is that he/she wants the baby to not encounter any resistance once it clears the pelvis because he/she is worried about how long the birth has been delayed already. In at least two of the SDs I attended, the baby's chest was considerably larger than its head, so I suppose that this could be a legitimate concern -- essentially that the baby could take a little time passing over the perineum after the shoulders have released.

Cutting an epis will not free a shoulder that is still stuck under the bone, though, and I have heard more than one birth story where there was a SD and the provider just kept cutting and cutting, hoping that the baby will just pop out, without doing anything to change the position of mom or baby. I think that sometimes people just panic and lose their heads.

Hope this helps. Sorry it is so long!

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#5 of 27 Old 04-17-2004, 12:38 PM
 
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I don't remember the term, but my last son had his shoulder stuck. He didn't drop until during labor.
They had me get out of the hot tub and onto the bed and just the motion of moving around eased it.
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#6 of 27 Old 04-17-2004, 12:42 PM
 
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Originally posted by KKmama
So then is it the vaginal opening that makes it hard to get through? I'm just confused, and I'm having a really hard time visualizing it (and actually, if anyone can direct me to pictures somewhere, that might help, too). I definitely believe that SD is real and happens, I'm just confused about where it is that the baby gets stuck... I know about the Gaskin maneuver, I know about episiotomies (and tearing), and it all just confuses me more.
From what I saw, it looks as if the baby is stuck do to their position. Is there a question as if this is really real? I had no idea. Also this baby was only like 7.5 lbs.
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#7 of 27 Old 04-17-2004, 12:45 PM
 
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I wanted to say this too, and forgot, my friends baby head looked weird --- like defense said, blue and stuff. It almost looked "swollen". The doctor was an old school doctor (he doesnt delivery anymore) and he seemed really calm at first, then when repositioning and stuff didn't help, well he was all business in a panick like way.

My friend said he vagina has never felt the same!
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#8 of 27 Old 04-17-2004, 01:14 PM - Thread Starter
 
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Thanks, Defenestrator. That was really helpful.

On the fence said:

"From what I saw, it looks as if the baby is stuck do to their position. Is there a question as if this is really real? I had no idea. "

Oh, I'm sure position could have a lot to do with any baby being stuck (having been in a position where my baby's position was making labor/birth impossible!). I want to reiterate that I'm definitely not doubting the reality of SD at all. I was just confused about what it is that's actually happening/where it is that things get stuck.

FWIW, I was a very large baby myself, had large shoulder then (and now), and my mom is quite small. She had a really experienced dr. who was pretty calm about things, did tear, but otherwise birthed me without a problem. I've wondered how I would handle something like this myself... ds was large, I expect this baby to be large, and nothing has travelled down my vagina yet...
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#9 of 27 Old 04-17-2004, 01:23 PM
 
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I don't doubt that the sd that On the Fence saw was real, even though the baby was only 7.5 lbs. I think that the statistic that I have seen is that 50% of sd happens in babies less than 4kg (about 8.8lbs) and about 50% in babies heavier than that. The size and shape of mom's pelvis can make a difference.

When the majority of babies are born, they crown on the perineum looking almost straight down toward mom's rectum (or up as it may be). Then they rotate a lot of the time to the right or left about 90 degrees and are born with their shoulders pointing up and down and their faces looking right or left. Some sds occur when this rotation has not fully completed and helping the baby to rotate is enough. Others occur when an arm gets trapped behind the baby's back and pushes the shoulder out at a funny angle. Others occur when the shoulders are just a tight fit, even in the best position. In these cases, it is sometimes necessary to do something to collapse the shoulders. Some things providers might try include rolling one shoulder forward, breaking the clavicle so that the shoulder can roll even further forward, or hooking a finger under an elbow or armpit to pull one arm out so that the shoulders tilt and the other one can slide past the bone.

In true sd, the shoulder is caught on the bones of the pelvic arch.

It sounds like the doc in On the Fence's situation acted competantly and did everything he could before cutting. There is a certain point in sd births where the provider may have to decide to hurt mom or baby in order to prevent the death of the baby. No one can say for certain exactly when that moment is. There have been babies who have been brain damaged in 3 minutes and others who have not been damaged in 10 minutes. I know a couple of competant, gentle midwives who have broken clavicles to get babies out.

I think I have a picture somewhere of a baby with a sd and what the head looks like. I will see if I can dig it up.

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#10 of 27 Old 04-17-2004, 02:10 PM
 
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my friend that had SD said that the birth was very traumatic for her and the baby. The baby was 9 1/2 lbs (not SUPER huge) but she was stuck. they had been filming the labor, but when all of this happened, the nurse grabbed the camera..turned it off and made the dad leave the room. Thek doctor cut her all the way through to her rectum. now she has all kinds of problems down there. she said the blood was really bad too.

but i guess the bottom line is that both mom and baby (she's 8 now) are fine. I just come from such a different experience. all three of my births were magical and beautiful. i feel like she has missed out on that aspect of birth!
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#11 of 27 Old 04-17-2004, 02:20 PM
 
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Sometimes what frees the baby is breaking a bone. Breaking the collarbone can release the shoulder to come down under the bone.
I think it is so worrysome because things are going fine, and then the baby is stuck. And there's no way of knowing how the baby is stuck.
So, if switching from on the back to on-all-fours (or vice versa) frees the baby, then it's no big deal.
But if that doesn't work, then you move into other things like pushing on the mother's belly and pushing the baby back in a little to give it room to move.
But, then, the techniques that are harmful to mother and/or baby come into play. Breaking bones, etc.
If that doesn't work, a c-section is performed.

If you somehow knew the first two or three things weren't going to work, you'd know to move down the list. But no-one can know what will or won't work. It's the kind of thing where second guessing is so much a part of the aftermath, expecially if there is an injury. I mean, who wouldn't have a scheduled c-section if they knew that vaginal birth would leave them with a huge episiotomy, a baby with a broken shoulder, and a bunch of unanswerable questions? But a schedule c-section is NOT the answer.
Boy, that was too long and didn't really explain anything.

On review, I cross-posted with the person above me, but our posts do seem to go together.

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#12 of 27 Old 04-17-2004, 02:34 PM
 
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Most of what I would say has been eloquently said by Defenestrator, but I will add that I honestly believe that shoulder dystocia, for the most part, does not require an episiotomy. SD is a BONE dystocia, not a tissue dystocia. Defenestrator was right when she said the epis is done to get the provider's hands in.

I've had my hands up along side two babies in my practice while only their head was born - and neither woman tore.

Guess it pays to have a provider with smaller hands!
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#13 of 27 Old 04-17-2004, 02:49 PM
 
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Originally posted by Defenestrator
I don't doubt that the sd that On the Fence saw was real, even though the baby was only 7.5 lbs. I think that the statistic that I have seen is that 50% of sd happens in babies less than 4kg (about 8.8lbs) and about 50% in babies heavier than that. The size and shape of mom's pelvis can make a difference.


It sounds like the doc in On the Fence's situation acted competantly and did everything he could before cutting. There is a certain point in sd births where the provider may have to decide to hurt mom or baby in order to prevent the death of the baby. No one can say for certain exactly when that moment is. There have been babies who have been brain damaged in 3 minutes and others who have not been damaged in 10 minutes. I know a couple of competant, gentle midwives who have broken clavicles to get babies out.

This was almost 8 years ago but its something that stuck with me a long time.

In the delivery room, my friend got an epidural at 9 ( I almost begged her not too she was going so fast, and this was her first) She is a small girl, prepregnant weight was 98lbs
She pushed for over 3 hrs. They had the labour bed broken down and she was in an upright position with her legs in like a squat (hard to describe) Even with an epidural she said her back was killing her. So finally, she is lying back and the bed is more reclined and she begins to push and this is when the head starts coming out and for the record, the doctor has been there for a good two hours or so waiting, and he immediately knows that the baby's shoulder is stuck. He even says something to the fact. So they have her roll to her side and one leg they pull up really high, and she is pushing and then they try rotating her and it seems like its taking forever and she is bleeding pretty bad already because she has a tear so he goes ahead and does a regular episiotimy. Well my friend is really tired. And says she doesnt want to go any further, so he tries something else that doesn't work and that is when he starts to get really business like with panic and he cut her, like into the side of her vagina -- not down. I was very sick feeling because there was so much blood. Her next baby weighed the same but was a little longer and as I said came right out, virtually pain free.

Kim
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#14 of 27 Old 04-17-2004, 02:52 PM
 
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Originally posted by hnybee
my friend that had SD said that the birth was very traumatic for her and the baby. The baby was 9 1/2 lbs (not SUPER huge) but she was stuck. they had been filming the labor, but when all of this happened, the nurse grabbed the camera..turned it off and made the dad leave the room. Thek doctor cut her all the way through to her rectum. now she has all kinds of problems down there. she said the blood was really bad too.

but i guess the bottom line is that both mom and baby (she's 8 now) are fine. I just come from such a different experience. all three of my births were magical and beautiful. i feel like she has missed out on that aspect of birth!
My friend was cut down and to the side, like towards her leg! She couldnt hardly sit. She said the ride home was horrible and that sex was "not the same" she cried whenever she went to the bathroom. She said she would have rathered had a csection! I guess her doctor thought the situation was dire enough to do it that way -- he just seemded to be taking fast action...
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#15 of 27 Old 04-17-2004, 02:53 PM
 
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Originally posted by Defenestrator

SD is something that scares the life out of a lot of providers because action needs to be taken very quickly and the potential for injury to mom and baby is high.
My son got stuck after his head came out and my midwife freaked out a little. She jumped up on the bed and started yelling for an OB. The thought of an OB coming into the room scared me more than what was going on. :LOL I just kept thinking, just wait for my next contraction and it will be OK, and it was. I had everyone telling me to push, people pushing on my stomach, someone else pulling my legs up to my head. : I remember yelling that they were killing me. Thank God he came out before the OB got in there, that's all I can say. Oh, and I was not cut. I was for my other three, even though I told 2 of the docs not to cut me. : For one of them I was cut off to the side toward my leg.
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#16 of 27 Old 04-17-2004, 05:06 PM
 
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Is pulling the legs up like that more effective than the hands-and-knees position?
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#17 of 27 Old 04-17-2004, 05:16 PM
 
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For one of them I was cut off to the side toward my leg.
Yeah, that was in vogue for a while, especially taught in Europe. It's supposed to prevent extentions of the cut into the rectum. They are called mediolateral in case you want more information.
From this site: http://members.efn.org/~djz/birth/obmyth/epis.html
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According to Williams Obstetrics,(Cunningham, MacDonald, and Gant 1989) midline episiotomies are less painful, heal better, are less likely to cause dyspareunia (coital pain), and cause less blood loss, but they are more likely to extend into the rectum.
Having quoted that, I can't think of anything worse than having one of each. I'm sorry.

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#18 of 27 Old 04-17-2004, 10:47 PM
 
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this is my experience:
my ds who was born this past january was stuck. he is my 3rd baby and we had him at home. everything was going great in the labor but the pushing just seemed to take longer than i expected for a 3rd.
i had settled into the most comfortable position, which was knees on floor arms/head resting on bed (basically hands and knees). well his little head came out and stayed and stayed and stayed......we have pictures that the assistant took of his little head darkening in color
i remember her saying at first to "push and pant him out" but then when he started to get stuck she said in a much more urgent tone to push with all i got but it was so hard because there wasn't a contraction to help me and I was stretched to kingdom come....man i will never forget that feeling....
anyway then she told me that the situation was really serious and I had to get on the floor right then which somehow I did and yanked my legs up to my ears, apologized for possibly causing any pain and reached up inside me and tried to unhook my boy. he slithered out but was fairly limp and very dark. he got some oxygen and was rubbed down well and slowly pinked up.
he had no palsy and i did not tear. my midwife was a wonder!!!! i shudder to think what would have happened to me or my baby if i had been in a hospital.
oh, and he was 9lbs 14oz
i am so fortunate that there weren't any complications!!!
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#19 of 27 Old 04-17-2004, 10:59 PM
 
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Originally posted by Greaseball
Is pulling the legs up like that more effective than the hands-and-knees position?
It can be. This is what is known as the McRoberts position. It does help open up the pelvis and also allows for super-pubic pressure, which is hard for a provider to do if the mom is not braced against an object like a bed. To be fair, as well, in many of the hospitals in my area more than 80% of women will have epidurals, so when you are doing staff teaching about emergency procedures, you are probably going to pick a first course of attack that moms who have had epidurals can manage, and most of the other position shifts are difficult to do with loss of feelings in the legs.

The big disadvantage of McRoberts is that it can cause symphisis pubis injuries because the legs are spread so far apart. I would think it might lead to more tearing as well.

In the first homebirth I attended, we tried McRoberts first, then switched to hands and knees, freed some trapped arms, then had her do a runner's stance (one knee down, the other foot flat on the floor, like a starting sprinter) and that finally freed the baby.

Hands and knees provides good access for providers who have to go in and try to free a baby internally, but it is the lunging movement within the act of turning itself that often frees the baby.

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#20 of 27 Old 04-17-2004, 11:07 PM
 
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Originally posted by Greaseball
Is pulling the legs up like that more effective than the hands-and-knees position?
I don't think I could have gotten into the hands-and-knees position. I had terrible hip pain and could hardly move at that point. My son was 10 lb. 11 oz. I also hemorrhaged after. My son saw a picture of me holding him in the hospital and asked if I was sick. I looked more like I was dead. :LOL
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#21 of 27 Old 04-17-2004, 11:07 PM
 
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From many of the stories I've read, it seems to be the "flip" that helps.
Hands and knees used to seem the answer to me, but I've heard of quite a few now that happened in that position to start with. (thanks for the story, carrots)
I think that there is a lot to just trying what you are NOT doing right now. A reversal, or sorts, to one of a few maximizing positions. To find the release that will allow the baby out.

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#22 of 27 Old 04-17-2004, 11:11 PM
 
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Boy, this has been a scary thread. I knew it was serious from the mw' tone of voice, but deliberately never sought out more info. after.

Guess it was the "flip" that did it for us.
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#23 of 27 Old 04-17-2004, 11:16 PM
 
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Boy I'm feeling talkitive tonight, but I think that's one of the coolest things about having a midwife, you know when her voice is serious and commanding.
Seems like you can tell when it's a request and when it's an order, but in a nice way. That make sense?

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#24 of 27 Old 04-17-2004, 11:18 PM
 
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Oh yeah, her words were totally normal but something about her voice was like cracking a whip. I jumped out of the tub and onto the bed so fast they hadn't even put a sheet down yet. :LOL
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#25 of 27 Old 04-17-2004, 11:18 PM
 
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So, if you think you may have a large baby, should you just start out pushing on your hands and knees? Will this prevent most s/d cases?
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#26 of 27 Old 04-18-2004, 12:12 AM
 
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My dd got stuck when she was born. Her case was more urgent because her heartrate had already gone down to 13 once and was around that low again(fetal scalp monitor)when she crowned. I had 2 nurses and the dr yell at me to get my legs back as far as I could, before I could react they did it for me. She crowned with her hand up by her face. The dr reached in and pulled her out. She was 2wks overdue and only 6lbs 5oz. He did not need to cut me or break her collarbone.

About 3 weeks before I had her, an online friend had her son. He was stuck and they had to break his collarbone. When it healed, it caught a nerve and he still has limited mobility and pain in that arm.
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#27 of 27 Old 04-18-2004, 11:57 AM
 
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Quote:
Originally posted by Greaseball
So, if you think you may have a large baby, should you just start out pushing on your hands and knees? Will this prevent most s/d cases?
I think that moms should be able to choose their own positions for pushing, no matter what the size of the baby is. Moms will naturally choose positions that alleviate pressure that they feel internally, so they will have an advantage over any midwife or doctor in picking the position that works best for them. Certainly pushing in a squat or a hands & knees or sidelying is better than semi-sit in most cases because the pressure is taken off of the tailbone, but I think that when we impose a specific position on a mom because we are afraid of a complication, it can be counter-productive.

Positions that open up the pelvis help, but there is a varient on nearly every position that achieves this. For semi-sit, mom can be tilted back for McRoberts. For sidelying, if there is a tight fit, you can bring up one knee to simulate a lunge. For squatting, squatting deeper or wider can help (though squatting itself does a lot already. For standing, lunging can help. For hands and knees, doing the runner's stance helps. A lot of times, when there is a tight fit, the mom will feel the internal pressure and shift on her own, if she is in an environment where she feels comfortable doing so.

Stacia -- intrepid mama, midwife, and doula. Changing the world one 'zine at a time.
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