The media have been reporting on shoulder dystocia. Apparently doctors are having to attend special classes to learn how to break babies’ bones because mothers are fat, and make their babies too big. At least that’s the story – women are creating a problem and doctors have to solve it. The reality is that almost half of shoulder dystocias occur with babies who are not ‘big’. This post will discuss how to avoid a shoulder dystocia (if possible), and deal with the situation if it occurs. There is plenty of great information available on the internet about shoulder dystocia. So, I will indulge in some lazy blogging and link where I can.
CETL Learning have a slide presentation available online. This resources gives a comprehensive overview of the incidence, risk factors and the standard approach to shoulder dystocia. In addition references are provided for those who want/need them.
What happens during a shoulder dystocia?
Basically the baby’s shoulder/s get caught in the pelvis. The movie below shows a baby becoming stuck on symphysis pubis (the pubic bone) at the brim of the pelvis.
However, a baby can become stuck in any part of the pelvis (more info about the pelvic brim, cavity and outlet in this previous post). Unfortunately variations of shoulder dystocia are generally ignored in emergency training, and instead the focus is on the symphysis pubis scenario. This misunderstanding can result in problems with resolving a shoulder dystocia as particular actions are ineffective for particular types of shoulder dystocia.
Avoiding shoulder dystocia
A lot of midwifery and obstetric learning resources focus on how to manage particular complications or problems. I prefer to avoid the situation in the first place, if at all possible. Although in some cases shoulder dystocia is unavoidable, there are a number of ways to reduce the chance of it occuring:
When women are able to birth instinctively without direction or intervention they are capable of amazing things. I have seen some bizarre birth positions and movements that made perfect sense once the baby emerged. And in the case of a stuck shoulder, instinctive pelvic movements can release the baby without drama.
The baby needs time to get into the best position to move through his/her mother’s pelvis. When we try to hurry birth, the baby may be unable to make these adjustments. Induction, augmentation of labour and instrumental delivery increase the chance of a shoulder dystocia happening (Gherman 2002). Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen.
I am also convinced (but have no research to back me up) that pulling babies out can wedge their shoulders against the pelvis. Waiting for a contraction when the head is out can feel like forever (could be 5+ minutes), and it’s tempting to tell the mother to push or pull the baby’s head. But, the baby may be using this time to make the adjustments necessary for the shoulders to birth. As long as there is some change with each contraction, and the baby is well, you can wait – bite your tongue and sit on your hands if you have to. Usually the shoulders will be born with the next contraction following the head, but not always. The next contraction may rotate the baby, then the next contraction birth the shoulders. Watch and see.
Being proactive with epidurals
An epidural will completely alter the physiology of birth and the instinctive behaviour of the mother. Once an epidural is inserted ‘active birth’ often goes out the window. In my opinion ‘active birth’ is not necessary when a woman is undisturbed – she will instinctively get into positions that work for her without prompting. However, active birth becomes essential for a woman who has an epidural. Looking after a woman with an epidural should be hard work. As a care provider you now have to help the baby through the pelvis by prompting and assisting maternal movement and position. This is where the ‘creating space’ tricks become important.
Birthing in a semi-recumbant position increases the chance of shoulder dystocia because the pelvis is unable to open ie. sacrum move back and coccyx uncurl. This is often the default position for women with epidurals. However, most women are able to get into an alternative position with assistance, and most hospital beds are adjustable. It is possible to get into a squat using a bar attachment to hold, and women can kneel up and lean over the back of the bed despite a lack of feeling in their legs. A lying lateral position is always available if movement is really difficult. Lots of position changes during pushing may be difficult but can make a huge difference to the outcome.
Management of a shoulder dystocia
Despite anything and everything mothers and care providers do – some babies will still get stuck. Even though shoulder dystocia is relatively rare (1:200), knowing what to do is useful. Firstly, it is important not to make a bad situation worse, therefore:
- Do not pull the baby as this will impact the shoulder further. This is the most common mistake people make because they panic. Traction can result in brachial plexus injury to the baby (see movie above). Unfortunately the care provider can then find themselves facing litigation. An article by Johnson outlines the medico-legal perspective ‘…for many years it has been accepted that OBPP [obstetric brachial plexus palsy] is an injury caused by excessive traction on the head when the anterior shoulder is impacted above the symphysis pubis.’
- Do not cut the umbilical cord if it is around the baby’s neck. While the cord is intact there is still a chance that the baby is receiving oxygen which gives you more time and assists with resuscitation afterwards.
- Communicate with the mother. You always have time to explain what is happening and why you are doing what you are doing, or asking her to do something.
Here is a video illustrating why pulling babies out is bad practice:
We all learn and retain information differently. As a lecturer I teach two types of approaches – ‘standardised/general’ and ‘situational’.
STANDARDISED / GENERAL APPROACHES
These structured approaches are good for those who find it easier to remember systematic step-by-step information and prefer to systematically work through set techniques.
This is the standard approach taught within the hospital system to doctors and midwives.
I’m sorry, but I have a strong aversion to mnemonics. I get particularly frustrated by mnemonics that don’t fit the letters to actions = actions being crow-barred into the word, or another letter being added so it is no longer an actual word. In the case of HELPERR the first E is for ‘evaluate for episiotomy’ – which I am yet to see anyone seriously do in real life. Firstly, you would have to be very brave to attempt putting scissors in such a tight space next to a baby’s head/face. Secondly, if you really need to get your hands in – you will, and a tear will be the least of your worries in that moment. I have recently heard that ‘E’ is now used for ‘explain’, which is much better. Another problem with HELPERR is that it assumes the woman is on her back – which I guess she usually is if the baby is stuck. The first two manouvres ‘McRoberts’ and ‘suprapubic pressure’ are only effective when the shoulder is stuck on the symphysis pubis. Otherwise they are a waste of precious time.
OK, rant over. I know that some people find mnemonics assist them to remember sequences, and that hospital staff are expected to follow them. I can see the place of this approach within a hospital setting where a range of practitioners with a range of skill and experience may be dealing with an emergency. At least everyone knows what comes next and I have seen it work well for a ‘group’ approach to the problem. In addition, for legal purposes (see above article) it looks good if you have documented evidence of working through the HELPERR sequence. Because HELPERR is the standard approach I will not list ‘how to’ here – the links provided at the beginning of this post give instructions to follow. However, I have added a movie showing how McRoberts works (with classical music!?):
However the limitations of the HELPERR approach become apparent when assumptions about position (reclining/on back) and environment (on a hospital bed) are removed. If a shoulder dystocia occurs in a small toilet cubical with an upright woman – how do you perform McRoberts? Or, if the baby’s shoulders are stuck mid pelvis, or on the ‘sit bones’, the first techniques in HELPERR will be ineffective.
FlipFLOP (Gail Tully):
This is another standardised/general approach that works well with a mobile un-epiduralised woman. There are less steps in this to remember and it makes more sense from a physiological perspective because it allows you to make the most of the space in the back of the pelvis. You can find information, pictures and a movie on the spinning babies website.
A SITUATIONAL APPROACH
Considering the range of positions, environments and situations birth takes place in; and the variety of places shoulders can get stuck, another approach is to think and act beyond a mnemonic. We also need to keep it simple and quick. When a shoulder dystocia occurs one or both of 2 things need to happen to release the shoulders:
1. Change the size and position of the pelvis (mother)
This can be done by encouraging the mother to move and change position. The best option will depend on the position she is already in. Often just the movement of getting into a position will release the baby. You can ask or assist a mother to change her pelvis by:
- Lifting a leg up and/or outwards eg. onto the side of the birth pool or chair. This can be accompanied by a rocking back and forward of the pelvis (thrusts).
- McRoberts is easy if the mother is already reclining. If on all fours, flipping over onto her back might be possible and the baby may release during the movement.
- Gaskin manoeuvre – rotating onto all fours from a reclining position (a bit like a reverse McRoberts). If upright, dropping to all fours might work.
- German approach – a German midwife friend sent me an interesting article about maternal movements for shoulder dystocia. A German midwifery student has kindly translated/explained the text and provided more pictures. I’ve made a pdf of the information.
2. Change the size and position of the shoulders (baby)
Adducting the shoulder/s will make the diameter of the shoulders smaller. Rotating the shoulders into the oblique diameter of the pelvis will make use of the extra space available (see pelvis info in previous post). Again you can find explanations of the following manoeuvres in the links provided at the beginning of this post.
- Suprapubic pressure (sometimes called Rubin’s I)
- Rubin’s manoeuvre (sometimes called Rubin’s II because it is attempting to do the same as the above manoeuvre only internally)
- Woodscrew manoeuvre
- Reverse Woodscrew manoeuvre
- Removal of the posterior arm
- Axillary traction (described in Ansell 2009 Chp5 of thesis) or the posterior axillary crease pull (axillary traction without putting fingers into the armpit – instead placing them in the shoulder crease)
There is no particular order in which you can try the above positions and actions. It will depend on how well the mother can move; the position she is in; and the access you have into her pelvis ie. how and where you can get your fingers in (if needed). For example, Rubins (II) will be easier to do than suprapubic pressure on a forward leaning mother. Bascially there is more room in the back of the pelvis… and this room is best accessed when a woman is forward leaning.
It really doesn’t matter what the manoevres are called, or where exactly you place your fingers. Or even where the baby is stuck – if you don’t know. Essentially, put your hand in, find the baby (shoulder, back, chest) and push him/round and out. Ideally you will be applying pressure to the back of the shoulder, but if not the baby is still likely to rotate… the shoulders/chest are all connected and will move together. The important thing is to get the baby out and getting caught up in exacts can create more stress and delay.
A situational approach assessing the situation and using the appropriate movement or action at the time. I have created a list that combines manouvres and when they are appropriate. I use this when teaching workshops and demonstrate the manouvres. So, unless you attend one of my workshops you will have to do without the visuals!
There are options if all else fails which usually involve damage to the baby or mother (again, see links provided). These desperate measures have their place – after attempting everything else. I know a healthy 2 year old who’s mother had a c-section following a successful Zanvanelli manoeuvre. In this case the umbilical cord was most likely intact and functioning. Unfortunately sometimes regardless of what is done a baby will not survive.
You can watch a movie of a shoulder dystocia occurring during a home waterbirth here