Shoulder Dystocia: the real story

kytriallaw.comEdited and updated: September 2013

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:

Undisturbed birth

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.

Patience

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. Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen. And 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. I have noticed that many babies do not follow the textbook description of the ‘mechanism of birth’ and instead emerge with their shoulders lateral or oblique to the pelvis rather than anterior-posterior. It is probably best not to force a ‘mechanism’ on an individual situation.

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. Initially diagnostic traction may help you know if the baby really is stuck ie. gentle firm traction – if the baby is stuck on tissue rather than bone he/she will move… if not stop. Pulling is the most common mistake people make because they panic. Excess 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.

HELPERR:

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!

DRASTIC APPROACHES

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.

MOVIE

You can watch a movie of a shoulder dystocia occurring during a home waterbirth here

About midwifethinking

independent midwife, lecturer and student of all things birthy
This entry was posted in birth, intervention, midwifery practice and tagged , , , , , . Bookmark the permalink.

128 Responses to Shoulder Dystocia: the real story

  1. Pingback: Nuchal Cords | Midwife Thinking's Blog

  2. Pingback: Pushing – leave it to the experts | Midwife Thinking's Blog

  3. Great post as always Rachel!

    I find that talking with the woman about what is happening is a real must as well. Women move heaven and earth (and their babies) when they realise what is happening and that the baby’s shoulder needs to move off the pubic bone and down. If there has been a concern raised, or the woman has a past history of shoulder dystocia, I have found that preemptive discussion and practice of different movements in late pregnancy to work through what would need to be done is valuable in helping women be relaxed and in charge with any ‘threat’ of shoulder dystocia for the current birth.

  4. mandysri says:

    When ever I explain to medical professionals about my third baby’s birth they always tell me a shoulder dystocia is NOT a “normal vaginal birth.” I’ll disagree with them forever. My two beautiful midwives made the whole process feel normal. I’m so grateful to both of them, they allowed me to have an unrushed, peaceful and joyful birth experience – and knew exactly what to do to give my baby boy the extra help he needed to come into the world. My memory of that moment is so precious and empowering. I’m glad my midwives were my helpers and I didn’t have any HELPERRs. That chart sounds nothing less than terrifying!

    • Freiderike says:

      I had exactly the same experience.

    • raisingcropsandbabies says:

      I’m glad your memory of your shoulder dystocias was pleasant. My homebirth shoulder dystocia was not… moments of absolute chaos when nothing helped to release him (even at home! gasp), baby needing worked on then oxygen, a lifelong injury to him (severe brachial plexus injury), a broken tailbone for me, tearing all the way to anus… shoulder dystocias are NOT rare, but they are not normal. They are deadly.

  5. Tracy says:

    Another great article for us student Midwives. I recently came across a fascinating paper from New Zealand by Ansell (Irving) about the use of axillary traction. It makes so much sense and makes SD slightly less scary…. I have the paper and PowerPoint slides which are great if anyone would like to read them.

    Shoulder Dystocia:
    Effective Management of
    an Obstetric Emergency
    A Qualitative Study

    August 2009

    TracyDonegan@doulaireland.com

  6. Rachel says:

    A 2.5 minute shoulder dystocia with my son was one of the scariest moments of my life. There is nothing like being punched from above, folded in half, and having two adult hands in there to kept that next contraction from coming. Pushing went from being the most natural thing in the world to being nearly impossible. Thankfully, my son is perfect. Now that I am a trained doula I often question whether that situation ever had to happen, running through the choices i made and those my midwives made for me ( like induction at 39w 5d for GD).

  7. Birth Smart says:

    love this post! i gave birth to my 3rd child about 45 minutes after arriving at a US military hospital overseas. unfortunately, the doctor available was extremely active management. as i pushed in an upright kneeling position, he was completely uncomfortable and urged me to ‘lay down on my back’ over and over again. thankfully, he kept his distance because he was so terrified by the situation and my daughter slid out into the hands of her father instead. the ob tried to restrain his comments, but did give me a harsh, “what if there had been a shoulder dystocia?” in reference to my ‘problematic’ choice of birth position. it seemed absurd to me, but i didn’t have much of a response at the time. since then, i have gone over a hypothetical conversation in my mind of my “come back”. thanks for adding to the dialogue. delighted to pass this along . . .

    • DoulaR says:

      I was just at a birth where mom pushed in that position, and there was a shoulder dystocia. “What if?” Well, they handled it. They tried first to resolve it in that position, and when it didn’t work, they flipped mom into McRoberts and got baby out. The minute of anxiety getting the baby out was still better than Valsalva pushing…
      Now re-reading this after having read it only a couple of weeks ago, and replaying what happened at this birth, I’m wondering what the actual cause of the dystocia was and thinking the doc may have caused it.

  8. K says:

    I’m in tears reading this.

    My wife just went through a birth that we believe was induced unnecessarily, knocking us out of the natural birth program that we so wanted. She was high risk for GBS and when her waters broke (the day before she was due) and wasn’t in labour the hospital gave us no option but to take the induction + antibiotics or leave and risk our baby’s life alone. There was no option to stay and get antibiotics but not the induction.

    So what was supposed to be a beautiful, calm, natural birth turned into a 13 hour nightmare. The contractions came hard and fast, the registrar was entirely uninterested in our approach (wanted to give a cervical exam before the antibiotics were in effect, even tho the membranes had ruptured and she was high-risk GBS – we strongly declined that one) and my wife was in terrible pain throughout. Tho she still did it drug free…. so proud of her.

    But at the last my little boy had shoulder dystocia. My wife had been intact physically even after the head crowned, but the dystocia and their seven minute window for birth meant that both the registar (a much better one by this time, thankfully) and the midwife had their hands all the way up to his shoulder to pull him out, causing 3rd degree tearing.

    The hospital did a shocking job of repair, 12 weeks later it’s not healed very well. It causes my wife a great deal of distress.

    We feel that we wouldn’t have been in this position if we’d been left to get into labour naturally. She was already having inconsistent contractions – they would’ve been the right duration and interval to be considered active labour, except any distraction could delay them. It wouldn’t have taken much longer to get into active labour.

    We don’t question the need for antibiotics – GBS is a serious, serious thing with terrible consequences for infected babies.

    But the hospital was willing to just let us go home unless we took their all-in-one approach which I’ll always feel led directly to my wife’s terribly hard labour. We may never be able to have another vaginal birth – even if we can, our birth centre won’t let us come back because a history of shoulder dystocia is one of the conditions which prevents them from being able to take you on.

    • I am so sorry about your wife’s and your experience. It is so often the case that one intervention (GBS screening which is not evidence based) sets everyone on a path they never wanted to take. You wife will be able to have another vaginal birth. A third degree tear and a shoulder dystocia caused by intervention are no reason to opt of a c-section. Perhaps a homebirth with lots of support and de-briefing for you both is an option? It will take work to heal the physical and emotional scars you both have.

      • raisingcropsandbabies says:

        You are horrible! Recommending a homebirth after a shoulder dystocia??? Knowing that they are at an increased risk of having another shoulder dystocia???? Wow. I had a homebirth shoulder dystocia, K, with worse tearing and a broken tailbone. My son is forever damaged by it. You need to be in a hospital for your next baby. A shoulder dystocia is no “variation of normal”. It’s upto you on deciding if you want your wife to have another vaginal birth. For me, seeing my son dead and brought back and now suffer from a lifelong birth injury and knowing my risk was around 7x more for future babies, was enough to steer me to c-sections…. beautiful c-sections with even bigger babies than my first. They are healthy, I healed better after them than my tearing (which took 3 years to recover from and my tailbone never healed).

        • Vicky. says:

          It sounds like you had a truly terrible experience – not one to be wished on anyone and you have my deep and utmost sympathy. But even so, that’s your personal experience, no one else’s, and it’s unfair to call someone trained in birth, who manages shoulder dystocia horrible for suggesting an alternative to what you would choose.

          It’s understandable why you made the decisions you did with your later births. Many, many people would probably choose the same in your shoes, but that doesn’t mean it’s right for everyone. My second daughter died while I laboured, I had chosen a home birth and stuck to that decision even after I PROMed 24hrs before contractions started because all the research I’d read suggested that the infection risk between the wait-and-see approach and induction was, statistically, not much different. Towards the end of labour I chose to transfer to hospital even though there was no indication of a problem (foetal heartrate fine, maternal temperature fine) – my daughter was born with no heartbeat (and I *really* needed to spread my legs because she was 9lb 8 and slightly sticky though not a proper SD). It’s a heartbreaking thing but that’s *my* story and *my* experience and in no way does that give me the right to be angry at other people who might recommend a homebirth or others who want to also choose a homebirth.

          IMO our pain is our own and everyone needs to make their own birth decisions without the influence of other people’s fear. xx

    • KM says:

      Hello, I had a shoulder dystocia with midwife assistance to pull my son’s arm and body out, and a second degree tear. I went on to have another son vaginally without complications. It does get better, I promise!

    • Your story is a complex one–both for and for your wife. Finding someone unbiased, compassionate and effective to help you both come to terms with what happened could be very helpful. I recommend Pam England (who wrote “Birthing From Within), who does long-distance support for women (and their partners) who had difficult or upsetting births. Her website: http://www.bfwnewmexico.com

      Best wishes for coming to terms with your experience — it can be a long hard road recovering (physically and emotionally) from birth.

    • VW says:

      I’m so sorry about what you went through. Although I did not receive any disrespectful treatment during my daughter’s birth in hospital, I know that just processing a physically traumatic birth experience is a long process of ups-and-downs. It’s especially difficult when the history then prevents you from having the birth you want in a subsequent pregnancy -I sometimes wonder whether it would have been better to just have had a c-section, because at least I would be able to VBAC at home.

      Your wife is very lucky to have you as a support person and as an advocate. Our experience created a lot of friction between my husband and me because he simply did not experience our daughter’s birth as traumatic and thought I was overreacting a bit to what happened. It’s been hard work for us as a couple to even be able to discuss this in detail.

      If you don’t mind, I’d like to offer some tips from the trenches (in no particular order), so to speak:
      *if you possibly can, limit the amount of contact you have with people who like to play the “all that matters is a healthy baby” card. These people are clueless and often cannot be clued in.
      *please watch out for signs of postnatal depression and/or PTSD in both your wife and yourself. PTSD from birth trauma often gets misdiagnosed as PND, but they are not the same and require different treatment. Two organization that provide wonderful support for both women and their partners affected by traumatic births are http://www.solaceformothers.org (based in the US) and http://birthtalk.org (in Australia)
      *as much support as you may be giving your wife, make sure you have some support for yourself. Both of you went through a traumatic experience, and the supporter needs support as well.
      *know that the grieving process can take a while. I did not start to feel any real improvement until after my daughter’s first birthday, with her actual birthday being a very hard day for me emotionally.

      For what it’s worth, I had to have a revision surgery on my episiotomy scar that had healed wonky when my daughter was 9 months old, and I was surprised to find it a relatively liberating experience, both emotionally and physically, since it resolved the daily pain I was feeling (and thus reminder of the birth) and healed well and quickly, given that the tissue wasn’t already traumatized by the birth process.

      Best wishes to you and your wife.

  9. Gloria Lemay says:

    So glad for this post, Carolyn. Nice to see someone talking about SD without thinking of the woman in lithotomy or medicated.

    A couple of things I would add:
    1. beware the temptation to “tidy things up” by telling the woman to grunt the chin out between sensations. Keep that little chin inside as long as it wants to be in there because that gives more space for the correct rotation of the shoulders, too.

    2. remember that the thing that will really get the baby out is a strongly contracting fundus pistoning down on the bum. We forget in this dramatic scenario that the woman is the best asset. Often she is “done” or “wilted” at this point in the birth. I find that urging her to quickly drink down a glass of juice at this point in the birth works magic. (I think of it like a droopy house plant with leaves hanging down and you give it water and it perks right up). We work in such a ‘practitioner heroic’ field that sometimes we lose sight of who really births that baby.

    Thanks for another great post. Love Gloria Lemay

    • Thanks for adding your wisdom Gloria!
      Ps. It’s Rachel not Carolyn ; )

    • enjoybirth says:

      I have always wondered about this as a doula:

      1. beware the temptation to “tidy things up” by telling the woman to grunt the chin out between sensations. Keep that little chin inside as long as it wants to be in there because that gives more space for the correct rotation of the shoulders, too.

      I see OBs in such a hurry to get the head out. Mom is pushing and baby is crowning and suddenly they want the head out. Even if mom has been pushing well and her contraction is ending, they urge her to keep on pushing. Then the head is out and they start worrying. The few times I have seen “sticky shoulders” (never seen SD, but quite a few sticky shoulders) this has been the case – where they force mom to get the head out before her body really wants to.

      I can’t help but wonder if mom was allowed a break and then to push the rest of the head out with the NEXT contraction if that would have prevented that.

      • Obs (and midwives) are taught that the head should deliver with one contraction and the shoulders with the next. This is rubbish and leads to lots of unnecessary instructions, fiddling and sometimes panic. I expect to see a change with every contraction ie. something happen. Sometimes it takes a number of contractions to birth the head – eyebrows, nose, mouth, then chin. I’m sure Gloria would agree that as long as baby looks OK everyone can just be patient.

        • enjoybirth says:

          Ahh, that explains their (OB’s and nurses) feeling of urgency. I wish I could somehow change this phase of birthing for moms, but as a doula there isn’t much I can do, except tell moms to follow their body and that they are doing great.

          When everyone else is yelling at them to “PUSH, PUSH, you can do one more push.” Me whispering in their ears is hard to compete against that.

          This is why I try so hard to emphasize to my students and doula clients – Choose your care provider CAREFULLY!

          • You are doing all you can do. Women need to choose care providers who will support the birth they want. Unfortunately most care providers have never actually seen a physiological birth and actually believe their interference helps. Their intention is good but misguided.

  10. VW says:

    This is a very timely post, as my daughter suffered a serious SD during her forceps delivery (plus heavy epidural -I couldn’t move) that resulted in an APGAR of 3, one of her lungs collapsing and a stay in the NICU. I’m newly pregnant with #2, and trying to find a midwife here in NZ that will not be freaked out too much by this history. I understand that there is a sizable risk of recurrence (although it doesn’t look like the research controls for iatrogenic factors when looking at recurrence rates for SD), and have thus given up on my dream of a home birth (we transferred to the hospital last time) in order to have advanced resuscitation equipment available if it is needed, even though research shows that the risk of a lasting injury from a SD is pretty small (0.1%). Other than that, however, my desire is to attempt to have a physiological birth in the hospital, if such a thing is possible.

    Unfortunately, my wonderful midwife from last time has retired, so I met with a new MW this week. After reviewing my history with me, she said it would be fine to aim for a ‘natural’ birth, but that I would a) have to have IV access (I’m ok with that), b) wouldn’t be allowed to birth in the pool, and c) had to have active management of the third stage b/c I suffered a PPH of 800ml the last time.

    When I made a face showing my displeasure at the last 2 ‘requirements’, she said “well, of course in the end it’s up to you what you do” but it created some doubt in me whether this MW would be able to support and enable my choices when push comes to shove (no pun intended). My thinking is that being in water will allow me much greater flexibility/mobility as well as the chance to stay away from an epidural. I also know that the most recent research shows that active management of third stage can increase the risk of PPH, and that in any case, PPH is more common after SD (so if there isn’t another SD, it’s not a given I’ll hemorrhage again).

    I guess I’d like to get a sense of what other birth professionals think about is. Would you consider a water birth and/or a physiological third stage under these circumstances? Why or why not?

    PS: My daughter was 4.2kg, so not small, but I had no sign of GD during the pregnancy, and she didn’t look like a GD baby. Nonetheless, I aim to eat a low-carb diet and monitor my blood sugars regularly this time to see if I can grow this one just a tad smaller.

    • Thanks for sharing your story. As a birth professionals we all have our own fears and boundaries. At the end of the day it about you deciding what is best for you and then finding someone who can support you in your choices. It looks like you are getting yourself well informed and have a good idea what you would like. Your previous experience was most likely a result of the situation. If the situation is different there is no reason it will happen again. I hope you find the support you deserve.

  11. Carrie says:

    Both my kids had shoulder dystocia. The first was at home. Labor had come-on naturally and was mellow but only 6 hours long. He was “sunny side up” and 8 lbs, and when my midwife realized he was stuck, she had me get into the McRoberts position and then had my husband and her assistant push on my belly after she reached in and turned him a little. Then he just popped-out. It was a very quiet and serene delivery, even with the need for emergency techniques. I had some tearing, but not bad, and he was uninjured.

    The second labor I had started with artificial rupture of the membranes (ARM) due to severe pain from a pregnancy-related injury in my ribcage. I just couldn’t take it any longer. Labor was too intense, I felt the need to push at 4cm, and transferred to the hospital from our planned home birth to get an epidural so I could stop pushing. She was also “sunny side up”, but 10.5 lbs, and when my doctor realized she was stuck, she had me get into the McRoberts position and then pulled as hard as she could, with the help of 2 nurses, on my daughter’s head. She also had hit the panic button, so in a matter of seconds, my room was filled with around 12 nurses. As she pulled on her head, she had her foot on the bed and was actually pushing with her foot as she pulled. It was insane, and I think my mom will always have nitemares from having seen that. My daughter had a birth injury of course. It was just like the video showed. And resulted in Erbs Palsy (she could not move her right arm). After a month of physical therapy, she regained full function of that arm, and her ped could not tell which arm had been injured.

    I regret not waiting for labor to begin naturally. For 2 weeks prior, I had taken herbs and done acupuncture to get labor started early. And I attribute those interventions, along with the ARM, to the unusual contractions and premature need to push. If I had been able to stay at home, I am confident that my midwife could have delivered her as gently as she did my son. I am so grateful that her injury wasn’t permanent.

    • Melissa Marks says:

      Thank you for sharing this story, Carrie.

    • cathi Cogle says:

      I am so glad everything turned out OK with your daughter- what a nightmare! I have heard of babies being decapitated with that method…yikes. I have seen 2 clients have SD, but both were resolvable, thru position change and Woods Manuever(and Gaskins is always first if mom isn’t already there…) both babies were over 11 lbs, and both had apgars of 9+9, afterwards, and mom was fine as well… Hope you are able to still have homebirths, I find it’s the easiest way to AVOID shoulder distocia…since mom can move around freely! I would also recommend learning about posterior positioning of the baby, and helping baby move to anterior before labor starts…www.spinningbabies.com :)

    • raisingcropsandbabies says:

      Having 1 shoulder dystocia puts you at higher risk of having another. Many women have multiple shoulder dystocias and then go on to choose c-sections. My homebirth baby was a shoulder dystocia. His brachial plexus injury did not resolve and he’ll be limited for his life (even with surgeries, therapies, work). My babies got bigger and bigger and I chose c-sections because I couldn’t risk another lifeless baby needing brought back and another child going through a lifetime of pain and work.

  12. Gloria Lemay says:

    RACHEL, what a senior moment! I linked to the article from a “Tweet” by Carolyn Hastie so I had gratitude to her on the brain at that moment for directing me to a great article. Feel free to edit me above, ha ha. Love Gloria

  13. Ha ha – we are all entitled to a ‘senior moment’ every now and then. I call them ‘brain clouds’ and I have them frequently.
    Rx

  14. sarah says:

    I made up my own mnemonic while I was in midwifery school, PRAY.
    Positions – Gaskin maneuver, McRoberts, etc.
    Rotations – rotating the shoulders (Woods, Rubin).
    Arm Extraction – I suppose axillary traction could fit here too.
    Yoniotomy – so it’s a made up word, but if you’ve gotten this far it might be time for it.

    The assistant should be doing suprapubic pressure throughout the various attempts.

    Also, how telling is it of the surgical training of obstetricians that getting out the knife is first thing on their list!

    • Robin says:

      Thanks Sarah, I much prefer your mnemonic, and ‘Yoniotomy’ is BRILLIANT! I am going to adopt that term permanently!

    • Neat! This is very similar to the one we use in Canada (where I live): ALARMER. Ask for Assistance, Lift the Legs (McRoberts), Anterior shoulder disimpaction, Rotate the posterior shoulder forward, Manually remove the posterior arm, Episiotomy, Roll the mother over onto all fours. From what I was told, McRoberts by itself will solve 70% of SD’s.

  15. Pingback: Curiousity is not just for cats | welcomingtree

  16. April says:

    It’s so refreshing hearing about situations such as these that can most of the time be best dealt with naturally. Although I do find it sad that the average woman knows nothing about “complications” such as shoulder dystocia except for what they hear from the Doctors who are naturally pushing for the easier and faster C-section. It would be great if all Mommas could be told that their body and their baby have a wisdom all their own and when left to birth in their own time and in their own way kinks often work themselves out. Do you do any educating your clients on potential complications and what the best way is for them to deal with them or is that an area that maybe should be adopted by natural childbirth educators and taught in classes?

  17. Hi April
    I don’t discuss managing a shoulder dystocia with clients (unless they ask). I do talk about communication in labour and that if I feel there is a problem I will let them know and act. The problem is if you cover every emergency it can feed fear and emergency is very rare. I need to be prepared for complications more than they do – that’s why I am there.
    Antenatally I focus on helping the woman to build her self trust and tune into her intuition and expertise. That way emergencies are less likely to happen, and if they do she might be able to manage it instinctively without me diving in. I recently watched a mother release her baby’s shoulders with instinctive movement. However, if I’d told her beforehand all about stuck babies she may have become fearful and looked to me rather than just moving in a way that felt ‘right’.

  18. AP says:

    I enjoyed reading this article. Well written with a lot of common sense and a few suggestions I had not thought of before.
    Shoulder dystocia is one of the scariest situations a care provider in obstetrics can be in, and anything that is helpful to successfully assist the mother to birth their child with as little complications to the baby as possible should be encouraged.
    This is a situation where you want the most experienced midwives and obstetricians involved.
    Well done and thanks.

  19. Thanks AP. Shoulder dystocia is extremely scary for all involved. The only poor outcome ie. death I have been involved in was in hospital with Cons, senior reg, paed and very experienced midwives present (ventouse delivery). Sometimes it doesn’t matter who is there, or what is done the baby won’t survive. Luckily the problem is usually resolved quickly using the techniques described.

  20. AP says:

    The other point to say is there are degrees of SD as you know.
    I have had a few mild SD which required mcroberts \- suprapubic pressure. These are a little tense, but manageable. However I have also been involved in a very severe case of SD. This was horrendous. The baby did eventually come out with removal of the post arm but two registrars tried unsuccessfully before the consultant came and needed a lot of force to get the baby out. Outcome was good thankfully for both mother and baby because of the expertise of the experienced staff on hand.

  21. Pingback: Birth from the baby’s perspective | Midwife Thinking's Blog

  22. jespren says:

    I’m late to the discussion but wanted to chime in. My 1st baby was a severe SD. It took 2 experienced midwives, the Gaskin and Woodscrew manuvers, and (according to my chart) all “four hands on baby” to resolve. The killer? I have. Hypermobile joints (Ehlers-Danlos Hypermobility) that everyone (3 obgyns, 1 family practice doc, 1 high risk ob, and my midwife) assured would make baby getting stuck “the last thing I needed to worry about”. with how loose my joints are everyone thought, if baby needed more room, i’d separate my pelvic arch or dislocate a hip or my tailbone. (I have bad hips so SD did come up on my list of things to discuss prenatally) yet, there I was, out of the tub on the livingroom floor with no understanding of why they were yelling at me to push or why it felt like baby was being pulled, pushed, and twisted. They didn’t have time to explain because the birth of the head and subsequent SD discovery coinsided with the loss of his heartbeat. My 2nd birth, however, baby was out in 3 pushes after a labor less tha 4 hours start to finish. I think chiropractic care made a huge difference in making sure all my joints were (more or less) correctly aligned for the birth and is the one thing I would urge moms worried about SD to check out. Making sure all those interdependant joints are moving freely and in correct position in late pregnancy can make a world of difference.

    • Thanks for joining the discussion and sharing your story. I wonder if because your pelvis is hypermobile it can easily get itself into un-helpful positions/alignment too? I don’t know – just thinking out loud. Sounds like you found the solution for your 2nd birth!

    • bryony bair says:

      I also have ehlers danlos hypermobility type.I have two children.7 year old girl,4 year old boy.I experienced SD with both of my children! my labors were both 36 hours! I checked out this site to see if anybody else with EDS has had Issues with SD.I’m wondering how many others have had issues with it? I may bring this up at my next EDS support group meeting! I saw a physical therapist with my second pregnancy..(for my lower back and hip issues),it didn’t make a difference for my labor however.lol

  23. J Clark says:

    One of my patients had a non-working epidural and was desirous & capable of moving into hands/knees. . . the MD came in an yelled at us to get her on her back . . . because (drumroll) . . . “We’re afraid she’s at risk for a shoulder dystocia and we need to be able to intervene if necessary.” WTF? Tried to explain H&K and Gaskin Manuveer later in the nurse’s station. . . . unteachable, unbelievable

  24. Brandy says:

    clap clap clap… as a mom who experienced shoulder distocia purely because of of the list above (OB and ignorance of youth) and it was a horrible nightmare i don’t want to relive but thankfully the student that came on shift had experience with midwives and tried to get my son out with the McRoberts procedure above before trying with forceps and McRoberts combination which was successful… (my doctor was there but unable to practice because of some mysterious reason and was not my doctor after that day).. however I was able to delivery without a c-section, no tears, no episiotomies, nothing and my son had no lasting effects.

    BUT the point is if the birth had been treated right it may have never happened. Yes he was larger 9lb 4oz but I was able to birth him but had I been allowed to change positions I likely could have been able to do it on my own etc… So long story short- thank you …. keep doing what you do and I am thankful …

  25. Mothercat says:

    It is interesting that in both the photo linked to this blog post on FB and in the video that you have embedded that the posterior shoulder seems to have entered the pelvis first and seems to have a lot of room. Where did we get the idea that the anterior shoulder always comes out first?
    If the posterior shoulder entered first and we try to always deliver the anterior first aren’t we going to cause SD by creating a much wider shoulder diamter than would usually be present?

    • A very good point! The assumption that the anterior shoulder ‘delivers’ first is based on observing women on their backs = the first shoulder you see is the anterior. Especially when you are pulling the baby’s head in a downward direction. When women birth in upright/forward leaning positions the posterior often births first. Unfortunately practitioners learn about birth from text books that are based on information gathered by observing women birth in the most un-physiological ways.

  26. Lilah says:

    Great blog! I don’t comment, but I read often. Any chance you can provide the correct URL for the information leaflet from midirs? Thanks!

  27. Wow, another amazing informative post. I have learnt so much from your posts since I found your blog. Thank you for passing on such interesting information.

  28. Great post. My sixth baby had shoulder dystocia. Had an active birth without any pain meds at home and I was on all fours. Only position I could cope in. Pushed the head out fairly easily, I say fairly, lol, because she had a huge head and then she just wouldn’t budge.

    When the mws realised they made me turn over, pushed legs up round my ears (how dignified) but with the next contraction out she popped, all 11lbs 12 oz of her!

    She was a bit shocked and bruised, but otherwise fine and I didn’t even graze. Incidentally she was also born in the caul.

  29. Oh dear, placenta brain, she was my seventh, not my sixth!! Forgive me, 39 weeks pregnant with baby number nine, who is expected to be her size, so my brain is gone completely :-)

  30. Kitty says:

    I had SD with my second baby who was thankfully birthed after mcrobert’s and the consultant practically climbing on in to pull her out. Amazingly I suffered no tears or damage. What upset me the most was that after this very intense birth with 10+ people in the room, baby emerging with apgars of 3, they all just abandoned me as soon as 3rd stage was over and they had given her back to me. I was left sat in blood, with drips still attached, which made breastfeeding incredibly difficult. I didn’t even know what had gone on until I read the details in my notes!
    It was an IoL at 38w, because 36w scan indicated baby was already 10lbs, which I could confirm as I felt significantly heavier and more uncomfortable than my first (10lb @40w). She was larger at birth 11lb1, but I believe if we had just waited my body would have gone into spontaneous labour, and not allowed me to grow a baby I couldn’t birth. I had a long discussion with my consultant when we were looking at the way forward. I wanted a home birth, but felt I would have been taking too much of a chance to do this. As a compromise I was happy to go into hospital after going into labour spontaneously. He explained worst case scenario was SD, and the bigger the baby the more likely it was. I countered this with saying that IoL probably meant an epidural, non-active labour also meant SD was more likely. After much guilt-tripping, and to avoid the worst thing in my mind;a c-section, I surrendered to the IoL @ 38wks. I was coping well with no drugs, really in the zone for my contractions, and having strong regular 4-in-10 contractions, until they HAVE to increase the drip every hour, as the manual tells them. Every time they turned that damn drip up I would begin having unmanageable back to back contractions, and they would turn it down for a bit to ‘give me a breather’ and then whack it back up again. Inevitably this led to an epidural as I was physically exhausted, vomiting with the pain and completely out of control. (A bad reaction to pethidine in a previous labour ruled this out for me, and entinox was also horrendous!)
    I really don’t understand why they couldn’t have invested that little bit more time in me, to let me labour at my own pace, which I’m sure would have meant no epidural, and a much better birth.

  31. Simone says:

    You are the absolute best! Was looking for research for a friend and this is just what I need!

  32. I would like to give another view from Gail Tully, CPM; The Spinning Babies Lady. She also made a DVD on Resolving Shoulder Dystocia, which is the best I have ever seen. She is very intuitive and trusting in the womens ability and the baby’s involvement as well. We would all be able to address shoulder dystocia with her approach.
    I believe you can get the DVD on her website; http://www.spinningbabies.com and maybe even on Amazon.

  33. For anyone following this comment thread – I’ve added a link to a movie at the bottom of the post :)

  34. Great article.
    I had a severe shoulder dystocia birth with my 3rd child. I can relate to alot of what others have written here. I agree with you that the mid-wife’s should explain what is happening. Nothing was explained to me during it was all happening. And to be honest it was never explained very well afterwards.

    My labour was not progressing well (at 5cm for 4 hrs) so with my permission the mid-wife broke my waters. If I could turn back time I wouldn’t have allowed this. But I guess you take the advice of your mid-wife after who else can you trust?
    After my waters were broken the contractions came hard and fast. I was in extreme pain and this labour didn’t feel ‘right’…I couldn’t move to get up for the toilet. I was told to lay on my side to open my pelvis and push at 8-9cm as baby’s head was not descending. Anyway, babies head finally came to crown after about 1hr of pushing. I was turning over to my back , a sitting position. And evaluated for a episiotomy and this was carried out and extended twice. I was pushing with my legs up to my chest and chin tucked down. This was proving my most difficult labour. Finally baby’s head was born…I felt so relief. I pushed through the next 2-3 contractions but nothing happened. My baby’s face had turned from pink to dark blue by now and my mum was really panicking.
    The mid-wife asked the student mid-wife to push the emergency buzzer, I was told not to panic.
    The room filled very quickly. The bed was lay flat and I was put into the McRoberts position. Supra pubic pressure was carried out. A failed woodscrew. An ob took over and did another woodscrew (maybe a reverse) and got him out. My baby was born white and flat. A 35min resuscitation followed and then my baby was taken to special care on a ventilator. He had to transferred to another hospital where he made a quick recovery and spent 7 days there. He suffered an Erb’s palsy injury and is doing really well with this…he has full range of movement and just a little muscle weakness.
    Now he is almost 3years old (in 4 months time). He has mild cerebral palsy, sensory processing disorder and very possibly is on the Autism spectrum (being assessed).
    As a result of my experiences I set up a Facebook support group for those who have suffered a Shoulder dystocia birth, we welcome members from all over the world.

    https://www.facebook.com/groups/Shoulderdystocia/

    • Thanks Emma. Shoulder dystocia can be an extremely traumatic experience. I have known women who felt unable to attempt another vaginal birth with subsequent pregnancies, and opted for an elective c-section instead. It is great that you have set up a support group :)

  35. Nicola Pennington says:

    my baby was born with shoulder dystortia which caused me to have a 3rd degree tare, I got examined at 4pm no pains I was 2cm then at 4.20 I wet straight to 10cm by 8pm I was still pushing with no pain relief, and the midwife asked for help the doctors were all v busy eventually when she pressed the alarm I got an episiotomy and the room filled with people, I got taken off to theatre as my baby was being rescusitated , she was 10lb this was a Saturday the previous Tuesday I had been crying at hosp to my doctor as I knew baby was huge he did a sweep and said she was average size not to worry .

    • I am sorry that you had such an awful experience and that you weren’t listened to re. your concerns about baby’s size. I am surprised your midwife managed to give you an episiotomy with the baby’s head out… also an episiotomy increases the chance of a 3rd degree tear. I hope you recover well from this.

  36. laurel says:

    Maybe this is why, with my second child, I had two almost-15-minute breaks between contractions after her head was crowning. Everything was fine–if there was shoulder dystocia, it was resolved on its own! My midwife was very hands-off. She was a fairly large baby, 9 lb 3 oz, and I am fairly small, 5 ft 2in. Yay for natural birth!! :)

  37. Thank you for posting this info about shoulder dystocia… Both of my babies were born this way & both times I was on my back… In both instances the attendants panicked & I ended up with a lot of, what I now feel, unnecessary damage. It may be uncommon, but more awareness needs to brought to how to react to this situation in a calm and productive manner.

  38. Sherry says:

    Love how you laid it out…from ‘do nothing’ all the way through ‘break and enter’….this is the only way that protocol that should ever be developed for anything health or birth related (in my humble opinion be laid out like this)! It is so intuitive and logical. All women would be satisfied with their births knowing that everything was done in the realm of prevention and ‘following their bodies’ before using any invasive techniques. When it doesn’t occur this way, woman are left rightfully confused, disappointed and even resentful when they discover that their care providers skipped straight to forceful and painful protocols and left out all the steps in between (and they have every right to be).

  39. Guggie Daly says:

    Thank you for mentioning that not all SD cases are with macrosmic babies or GD babies. I’ve birthed two 11 pounders and a 10 pound baby and they all birthed quickly without any sticky issues. I do not have GD either. It makes me angry to think of the many women I know who were scared into unnecessary interventions to somehow “prevent” a big baby or SD…meanwhile those very interventions ended up harming the mama and/or baby. :(

  40. Diane says:

    Recently attended a birth where contx were 7-9 min apart throughout. Baby’s head was out for 9 minutes before the shoulders came. No dystocia, baby was pink so I just waited. No problems!

  41. Vonda Gates says:

    Great article! I was reviewing your “creating Spaces” list (awesome) and don’t know ‘chugging’. Can you define that action. Thanks!

  42. Vonda Gates says:

    oops…’chunging’

    • Ohh this is going to be hard without a visual.
      Basically it is ‘vibrating’ the soft tissue. So, you can hold a woman’s thigh (someone else do the same to the other thigh) and basically jiggle the tissue. You can do the same with the heel of your hand on their buttocks. It helps women to relax the area… I have seen it work really well and it feels good to. If you can get to one of my Capers Retreats we will be practising this.

  43. inanna says:

    a little off-topic, i know, but i just wanted to say that i discovered ‘chunging’ completely spontaneously during my 2nd son’s birth. it seemed an obvious way to deal with contractions when i was probably about 6cm dilated. i felt compelled to stand at the end of my bed as a contraction began, lean forwards, widen my stride, rock a little, then rise up onto my toes and jiggle about so the flesh on my thighs and bottom vibrated. every time the contraction receded, i thought how strange it must look, how glad i was that no one was looking, and how helpful it was! (baby was born in 4 hours in the pool – no chunging there! – with apgars of 10).
    rachel, i love your site. i’m researching for the imminent birth of number 3. thank you!

  44. shellie says:

    my daughter had sd..she was stuck for 6mins.. it was the worst 6mins of my life.. her little body came out pink and her head was blue from having no oxygen..she weighed 9lb 3oz..i am on the smaller side myself..i was told by the docter who delivered her i was not able to have another natural birth..which has totally put me off having anymore children.

    • I am sorry you had such a frightening experience. I am also sorry that the doctor told you that you would not be able to have another natural birth. Plenty of women go on to have normal births after a shoulder dystocia. The chance of you NOT having a reoccurrence is over %80. I hope you have both healed well.

  45. shellie says:

    i was also told she wasnt going to be a bg baby.. her agpars were only 3/10

  46. Pamela musikoyo says:

    What are the complications of shoulder dystocia?

    • At the beginning of the post I direct readers to resources which provide this information:

      Resources: You can download an information leaflet from midirs, and CETL learning have a slide presentation available online. Both of these resources give a comprehensive overview of the incidence, risk factors and the standard approach to SD. In addition references are provided for those who want/need them.

      This post focuses on management… otherwise it would be huge :)

  47. Wow! Great article and explanation on how things work. Thank you for sharing it.

  48. Soon2bmomof2 says:

    wow im so happy i came across this!! big babies run in the family, im measuring very big so the dr brought up suprapubic pressure at my last appt…found out my brother had SD 11lbs3oz, drs wanted to dislocate his shoulder, my mom wouldnt consent so they cut into her small bowel to get him out…still going to stay positive but i am definitely adding details to my birth plan in case we come across this…

    • External measurements/palpation/ultrasound are very inaccurate methods of predicting birth weight. Suprapubic pressure only works if the baby’s shoulders are stuck in the pelvic brim. Any lower and it is pointless. It also requires you to be on your back which makes your pelvis smaller. To reduced your chance of a SD you could remain mobile in labour (without an epidural) and birth in an upright, forward leaning positions spontaneously pushing (i.e. not coached) :)

  49. Smoore says:

    Hi, I recently found out that I am expecting my second child and I must say that I am very scared. With my first child the pregnancy was near perfect, but the labor was very different. After my water broke at home I went to the hospital and within a few hours I was pushing. Before I got to that stage the nurses wanted me to lay down and I refused. I continued to walk until I reached 10cm and then I layed on my back to begin pushing. After pushing for an hour, SD happened and my doctor yelled at me to get on all fours and push. My daughter was born shortly after with no injuries. I on the other hand had third-degree tearing. I applaud my doctor for her quick thinking, but I wonder if something could have been done differently to make the process less traumatic. I think the walking before delivery/pushing of the baby begins is a great idea, and keeps your mind off the pain. But using different birthing positions sounds like the way to go. In retrospect giving birth on your back sounds really dumb. By the way my daughter was 7lb 15oz and I delivered 2 days shy of my due date, I gained 30lbs and had no complications during pregnancy. I am concerned that SD will occur in this pregnancy. What should I talk to my new doc about concerning a less traumatic experience?

    • I am sorry you had a traumatic experience. You have around an 80% change of a SD NOT happening with your next birth – so you are unlikely to have a repeat SD. It might be helpful to debrief and explore the experience with someone (doula, midwife, friend) and work out what it was in particular that was traumatic about your SD. Then work out how that particular ‘thing’ could be done differently next time. For example, if the trauma was due to the environment, people panicking, new people entering the room, lights being put on, etc. this may be what you need to talk about avoiding with your new doc. Or, it might have been something completely different. I have attended SDs that were not traumatic for the woman at all. It is not necessarily the event, but how it is dealt with that creates trauma. However, it is difficult to help without further exploration of your individual situation and experience.

  50. Kristyn says:

    I am 38wks5days into my 3rd pregnancy. I have had 2 previous, vaginal, medicated hospital births. With my last birth, I went in for labor augmentation at 38+ wks. After 1-1/2 hrs of pushing, I delivered the head. SD was immediately apparent. Gentle downward traction in the McRoberts did not facilitate delivery, nor did suprapubic pressure. Finally, they reached in, delivered the posterior shoulder and applied gentle downward traction for delivery of the anterior shoulder. Besides having third degree tears and sustaining emotional trauma, both the baby and myself recovered with no lasting injuries. She was 9lbs13oz. SD has played a huge role in my birth plan, this time around. After much soul searching, I decided on a natural, non-medicated, vaginal hospital delivery. I read the books, found a doula, and an OB that was supportive of my birth plan. At 37wks4days, my OB sent me to get an ultrasound because I had measured 42cm at my 37 wk appt. Ultrasound showed a healthy, 9lbs13oz baby with normal amounts of fluid. At my 38 week apt, my OB asked me to re-evaluate my birth plan. Basically, she is concerned about the size and the past history of SD. She has not fully suggested a C-section, but has stated that most OB’s would have already scheduled me for one. She wants to support whatever decision I make, but has stated that if there is complications with a vaginal birth, she will medically speaking, have no grounds to stand on. Since this last apt, I have found myself conflicted for the first time. I have been researching like crazy. I just don’t know if I am making the right choice anymore. I feel like I may be in the small percentage of women that have a medical reason for opting for a C-section. I really don’t want surgery, but I feel like I may be putting the health of my baby at risk. I would greatly appreciate any feedback!

    • This is your decision and you have to do what feels best for you. The doctors comment of having no grounds to stand on if complications occur is untrue. She has informed you of the risks (from her perspective) and will manage any complications arising as best she can = that is her job. It is not her job to perform surgery without consent. It seems that you were on your back and possibly being directed to push with your previous birth? These can increase the risk of SD. Perhaps different circumstances that allow our pelvis to open and baby to make his/her own journey through will result in a different outcome. As for estimating weight via ultrasound… not very accurate. However, you generally make slightly bigger babies with subsequent pregnancies. The research does not support the use of c-section or induction to prevent SD. Good luck with your decision making – it can be really hard when you are in the middle of very different perspective… ultimately it has to be what you are most comfortable with. There are risks either way – choose which ones you want. :)

    • jackie.covey@sky.com says:

      Hi I am in a similar position to you but i also have Gestational Diabetes. My 38 weeks scan showed baby measuring 4,610g. My consultant has said he won’t support an inductiona and i should have a c section. I’m booked in for the induction still tomorrow and a c section the day after. I have to make the decision to either go against the consultant and be induced or have thr c section. I also have ployhydramniosis. My midwife doesn’t think i am carrying a big baby through feeling my stomach just that i have lots and lots of fluid.
      Can i ask whether you had a natural birth or whether you opted for the c section?

      • Babycatcher55 says:

        Tell your provider to get you off your back or butt! I’ve helped moms give birth to 12 pounders by either hands and knees( Gaskin maneuver)or side lying. Oh, these births were at home….but get off your back, and there is room for the coccyx to move out of the way…no section necessary.

      • smallmama says:

        I know that this post is older, but I felt like maybe someone else reading it with the same questions might benefit from what I had to add (granted it’s anecdotal, not research-based). My mother (5’1″) was told that I was a very large baby due to her measurements. I was born barely 6 lbs, and the rest was polyhydramnios (never diagnosed, but she assured me she had a lot of fluid — PROM). My great aunt, about 5’2”-5’3,” gave birth to her second child at home, unassisted and unmedicated, and this child was 13 lbs. So it’s possible for measurements to be wrong (your midwife may be right that you have a normal baby and too much fluid), and depending on your pelvis — your body, really — even a large baby might not be an issue. I’m saying this not as a professional, but just as someone who could offer some other examples. Whatever you ended up deciding on, I hope you weren’t afraid and had a positive experience and healthy baby.

  51. mechelemybelle@embarqmail.com says:

    I actually had a son in 1991, and it has always bugged me the way that they delivered my son. The doctor or nurse whom ever was helping him had taken his elbow and shoved it into my stomache to push the baby down. I totally lost my breath , like the wind was knocked out of me. Later i found out that my son had a broken collar bone. Being 19 years old you really don’t have a clue as to what is going on. Sadly my mom admits today that she has never seen anything like that before. I kinda still suffer from that happening and not being told what was going on .

  52. Sally P says:

    I’ve had 1 SD and 3 “sticky shoulders” in all of my 5 home births with only 1 of them being caught by me :) I have had uninterrupted births for all… the only birth that wasn’t “stuck” had such an explosive Ferguson’s Reflex I just knew that baby would come out just fine. Interestingly that baby was the smallest at just under 9lbs, and narrowest shoulders, all the rest at 9lbs, with broad shoulders, and the true SD @ 10lbs8oz :) No tearing, completely intact perineum with all my births :)

  53. B B says:

    I had a water birth in Jan of 2011 and they had to use the McRoberts when baby got a little stuck. Baby came out easily with it, and I actually never realized there was an issue until I googled what a McRoberts was almost a year after the birth. I did tear, but not too bad. Now I am due any moment, and just got a call today from my midwifery group telling me they feel strongly that I should not have another water birth. Honestly, I wish I could have know this sooner, since for months I have been preparing for a similar birth in the water. Maybe they forgot about my situation until I brought it up at my last appointment and they had some time to think about it? So – my question – is it bad that I still want a water birth? Should I be more worried of a repeat with possible bad consequences since I already had one baby who got stuck? Would you recommend giving up the idea of a water birth if I were your patient? Thanks for reading. Still processing this new, and disappointing, information. Of course I want baby to be safe, so I am looking for advice/a second opinion. Thanks!

    • I think you need to discuss this with your midwives. A waterbirth will not increase the chance of you having a shoulder dystocia but I am guessing your midwives are worried about managing it in the water – it is more difficult to access you and your baby. Perhaps if you have some agreements about getting out if your baby appears to be stuck (you can get out a pool with a baby’s head out if needed) it may help everyone to feel more relaxed about a water birth. Not sure… this is something you need to work out with your birth attendants :)

    • Babycatcher55 says:

      Might be a good idea to explore other birth attendants. The chances of another SD are pretty small, and I don’t think being in water would make it worse. What I would do (from a midwife’s perspective) is watch mom during labor/pushing, let her be in the water, and if baby’s head is born and turtles, then get mom out of the water, or get her to change position. Mom could adopt a semi kneeling position, or hands and knees, and if that didn’t help there are other positions that might work better. But if the attendants panic, that makes it worse. Pelvises are not made of concrete, and babies heads mold, and most of the time someone calm and reassuring can get the baby rotated better so it can be born with no damage to itself or mom. I’ve helped moms birth 12 lbers at home successfully…and plenty of other midwives have done the same.

  54. Amanda says:

    hi,
    my 3rd pregnancy resulted in a shoulder dystocia. It was a suprise to all as we were expecting a 8lb baby and i ened up having a 10ln 2oz baby. I am short myself and only gained 14lbs with the pregnancy. my ob said my weight was great. also no GB. anyway my son was “stuck” for about 2 min. after birth they watch his arm and shoulder and he moved it fine so we moved on. well as time went on I started to noticed things at 4 weeks he would not turn his head toward the shoulder that was stuck his pt said it was because of the shoulder dystocia. well we did pt for 2 months and it resolved he can move his head both ways. Now he is 6 months old and he has his arms both of them in a backwards postion. His arms are kinda behind his back. THey are tight i have to manully rotate them foward. he can only roll over one way. when hes on his tummy his arms are in a “superman” pose straight out to his sides. the pt is also concerned that his ankles are slight tight as well and he likes to bounce on top of his feet. his toes are in a pointed position one way more then the other

    so we are back in pt but everyone say it could be from the shoulder dystocia but typical if its an injury from that it is only one arm. well its both with my baby. I have tried to find info on this and come up with nothing.
    I wish i had answers would love to hear if anyone has gone though this or something similar with there child

    • Hi Amanda
      I am no expert in this area… injury can be caused by SD – but it is usually the impacted shoulder/side only. The fact that your son seems to have problems with both arms and possibly his ankles suggest that this may be something else. Sorry, I’m not sure. Hopefully a reader will pop up and share their experience. I hope you find your answer :)

    • Jen says:

      Amanda,
      Hi! Did you ever receive a diagnoses? Your little one and birth experience sounds similar to mine. We are in the process of getting a diagnosis, and I just wondered what your outcome was. Thanks!

    • raisingcropsandbabies says:

      There are “global” brachial plexus injuries. Those affect both groups of brachial plexus nerves resulting in both arms being injured. I hope you have gotten your little one into see a Brachial Plexus Center.

  55. Pingback: What is the Evidence for Induction or C-section for a Big Baby? « Evidence Based Birth

  56. steph says:

    my first was a long ‘labour’ i was left in room with no info or knowledge! after going in at 7am and eventually delivering at 3pm the following day, i didn’t even realise i has gone through shoulder dystocia. all i remember is a fair few doctors and midwife all screaming at me to get her out or she would die! they literary had both my legs wrapped round my ears.the cord then broke whilst trying to pull and after much arguing they sent me for a general for manual removal as they initially wanted me to have epidural which i refused. due to this my three others have all been delivered in hospital ( a different one i add) all 4 are healthy but i have ‘inside’ problems!
    i have since read complications and feel incredibly lucky

  57. StudentMW says:

    “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.”
    The instance of iatrogenic SD I recently saw had a NRCTG. A few prolonged decels in 2nd stage. Mum was flipped onto her back to check for full dilatation (why with a multi, seriously!?!) Then of course she stayed there, was given an epis to expedite the delivery, and immediate downward traction by the Reg, despite the in charge MW asking to wait for restitution.
    There was no movement of the mother at all, only SPP applied, traction on the baby and telling the mother to push. I (student) asked if we shoud do McR, but as her knees were already at her chest (since before the head was born) I was told no, this IS McR. (??) I believe birth occurred after some kind of internal manoeuvre (rubins 2?)
    So, my question is: due to NRCTG, you *do* need to expedite the birth, I imagine some maternal movement would have been the best way to manage/encourage this?

    • This is difficult to comment on as there are a number of questions… why was the woman on a CTG? – presumably because there were concerns about the baby? Otherwise this is not evidence based. Was the woman being coached to push? – if yes then that may explain why there were prolonged decals and why the baby became stuck. An upright position will expedite a birth quicker than an episiotomy with a multi. Yes… when a baby is compromised you might not wait, and may encourage the mother to get the baby out quicker or assist her to. But firstly – don’t compromise a baby by coaching pushing or putting the woman on her back. And a baby would need to be very compromised to attempt to pull it out without waiting for another contraction… not just a few prolonged decels. Just my thoughts without the benefit of being there.

      • StudentMW says:

        Thank you Rachel or your reply. She met criteria for CTG because of an APH. She was on H&K entering 2nd stage when there was a prolonged decel (after early decels with previous ctx). I feel that if she had not been put on her back (for the VE), and encouraged to push with her body (as was already starting to happen), the baby would have been born soon after and her position would have facilitated an easier birth of the shoulders. Until I am an experienced practitioner though, its hard to go wth your instincts! I feel like I have to just try to reflect on other’s practice to enrich my own!

        • That makes more sense. This was possibly not a physiological birth… she had an APH. The baby was potentially at risk hence monitoring and action to expedite the birth. And, yes I think your reflection re. position is probably correct. Your instincts will develop as you gain experience and continue to reflect and ask questions :)

  58. madeoneup says:

    Great post. I’m a fan of waiting for the next contraction because many SDs just are just babies that have not completed internal rotations and the contraction helps that. I also believe that moms with free mobility often know instinctively how to move “just so” and resolve many problems.

    I’m a big fan of the situational approach. Instead of randomly applying various maneuvers, figure out what is causing the SD, and then apply the maneuver that is most appropriate. Less time will be wasted, and less harm should occur if the maneuver is targeted to the specific presentation.

    Of course, it’s not always apparent what is causing a SD, or the space may be so tight that you can’t figure out what’s going on….in those cases, you have to make a logical guess based on the circumstances and proceed from there. But if you can do the best internal assessment possible and THEN proceed, that probably leads to better outcomes (though of course we have no research to confirm that).

    I had a SD with baby #4 who had one arm behind her back. As I pushed, I felt a “knocking” in my pelvis;.I think it was her trying to move her arm to the front. After the SD did not resolve, my MW reached in and assessed her position, found the arm behind the back, and moved it to the front and out. Baby came quickly at that point. All this took place in the tub with no problems. 24 minutes of pushing, including 6 minutes of SD. Baby was pink and had good heart tones throughout, which gave us flexibility in our approach.

    The arm behind the back is a rare form of SD but a tricky one because most of the other maneuvers would not help. I was VERY thankful to have a MW who assessed before she just randomly started applying maneuvers, and who never panicked or pulled. Baby was fine, needed no resuscitation, and I had no tears. We did get her some chiropractic and craniosacral therapy as a precaution, but she’s never had any problems.

  59. erickajen says:

    I’m starting to wonder: what information, if any, is there on the effects on a mothers body of turning her over while delivering? If a mother is delivering on all fours and she is forced to turn over, can she end up with injuries, for example to the tailbone or hips?

    • Yes – in theory… forcing a woman into any position could result in harm or injury.

      • erickajen says:

        that is interesting.
        i had previously had a bad hip since my son in nov 2006, but ive had to go to a lot of PT after my daughter this summer, and have had a lot of tailbone pain! im so frustrated that i had her HEAD OUT and they wanted me to turn over for their own comfort. it happened fast so she delivered her own head basically, before the doctor got back in the room hahaha ;P wish i had just let her go hahaha my doula/friend would have been just fine catching :P
        oh well. sigh. it comes and goes, but this is really annoying. is there any research or study out there about this?

        • No research that I know of… but I know anecdotally that some women experience tailbone pain after birth. The tail bone (coccyx) uncurls to create space for the baby. Sometimes it does not go back to where it started. I know one woman who had problems until she had another baby and during that birth her coccyx moved back into place.

  60. Pingback: Images that Penetrate the Soul, the Power of Art | Birth Against the Machine

  61. Trevor says:

    I find it interesting that you say the following in your article: “Induction, augmentation of labour and instrumental delivery increase the chance of a shoulder dystocia happening (Gherman 2002)”.
    I clicked on the article you cited and I actually read it. They specifically state that in a peer reviewed clinical study, moms were randomized into an induction of labor group and a natural labor group…. “There were no statistically significant differences in the number of shoulder dystocia cases in either group”
    If you are going to make a statement to scare expectant mothers, at least try to make somewhat of an intelligent argument.

    • Thanks for pointing out this oversight Trevor – I appreciate readers challenging and contributing to my work – and often change it in response (none of us are perfect and I learn from being open to other opinions). I’ve just been on a searching expedition and could not get access to the entire Gherman article again. I have taken out this statement along with the statements about augmentation and instrumental delivery (although I found references for the later). I took them out because the association between augmentation and instrumental delivery and SD could be misinterpreted… babies who are going to get stuck are probably more likely to require augmentation and instrumental delivery to get them through the pelvis – so those factors are not necessarily causal. In addition this research does not really support my (hopefully somewhat intelligent) argument that hurrying birth can cause problems.
      My aim is not to scare expectant mothers only to share information and discussion. This post in particular is aimed a practitioners and I would be interested to know your thoughts on the rest of the post re. a situational approach to management of SD.

  62. Jadda says:

    Im completely brand new to this. I recently gave birth and my son suffered from.shoulder dystocia and now his arm doesn’t move as much as it should. Im worried sick and the doctors are no help. They want to wait a couple of months before taking any action. I don’t know if it’s because his nerves are damaged nor do I know the rates at which he could come out of this just fine. Are there are support groups or any place I can get more information to help me understand exactly what’s going on and the right questions to ask my doctor?

  63. Joy Horner says:

    I searched for your article today to help inform a client who’d suffered a shoulder dystocia with her previous birth and was wanting to know how to reduce the risks this time. I did not have details of her previous births but guessed pretty accurately that she’d given birth flat on her back with an epidural insitu. She’d birthed big babies, but no gestational diabetes on testing, so I assumed this was what I call a bed dystocia. I went straight to your website as your views are usually in line with my own, but you’ve put it all down clearly for clients to access. I believe a lot of shoulder dystocias can be prevented by not forcing the labour or birth – including absolutely no traction on the baby’s head. I reviewed all the links for suitability for a previously traumatised pregnant woman, not wanting to re-traumatise her.
    I got to the video link at the end and realised it was a birth I had attended several years ago as a newly independent homebirth midwife. I was the second midwife and was so glad to be working with such a calm, experienced colleague, as this was the first dystocia I had encountered (I had been a qualified midwife about 5 years by then, and had mainly worked in a hospital birth centre seeing predominantly normal birth). I am pleased to report his little baby is now a healthy young girl.
    I have not seen a shoulder dystocia since in a couple of hundred births as an Independent homebirth midwife. The reasons being all the reasons you’ve highlighted. No induction, no augmentation, freedom of maternal movement, undisturbed birth, no rushing and definately no trying to “deliver” babies by pulling on their heads.
    Thank you for presenting this information so clearly.

    • How lovely to have a comment from the midwife in the movie! I just love the English accents – they remind me of home… and the calm but firm ‘directions’ to get out of the pool :) This movie is also a good example of how to resus with the placenta attached. I’m pleased you have not encountered another SD.

  64. Milda says:

    I am currently 34 weeks pregnant with my first baby. I had a growth scan at 30 weeks where baby was measuring on the 85th percentile. Yesterday my midwife measured fundal height (38.5cm) and told me to forget about giving birth in the Midwife Led Birth Unit (I live in London) because “this baby is going to be large and we don’t accept large babies there”. I tried to question this but was told to “go home and read about shoulder dystocia”. I was in tears for the rest of the day. I had faith in my body’s ability to give birth to my baby which is now being shattered with the image of baby stuck in my pelvis… Whats more, I still believe that Birth Unit would be the best place for me to have this baby as it would allow me to stay active (I have been doing pregnancy yoga and was very keen to “get off the bed” which BC facilitates) and reduce the chance of interventions.which could then lead to SD. Also, from everything I’ve read, it looks like no one can actually predict shoulder dystocia so why should I be prevented from giving birth in my preferred placed based of slightly augmented risk of SD? I am not obese, I don’t have diabetes and for all I know this baby might just be tall! (I’m 5.9 myself). Moreover, the Birth Center is in the same building as the Labor Unit so transfer is not an problem, I simply cannot understand this..

    • I cannot understand it either. I’d expect you to have a larger than ‘average’ baby given your height/genetics. Anyhow, the estimation of size is very inaccurate whether by measurement or scan. I am sorry that you are faced with this. Can you insist on birthing in the unit and ask to sign a waiver to cover them if anything does happen? A birth centre midwife… or a homebirth midwife for that matter should be able to manage a SD because it is a emergency that can happen without warning ie. is unpredictable.

  65. Adrienne says:

    With my first son I had a successful, yet difficult delivery that I later found out was shoulder dystocia. My son weighed only 7lbs 7oz . I had an epidural with my son at about 7 cm dilation, as I felt the contractions were exhausting me. I am now 32 weeks pregnant with our second child and my doctor has mentioned to me the choice of an elective c-section based on my last moderate dystocia. I was completely unprepared for this and would really prefer to have a vaginal delivery. I have been practicing the hypnobirthing method and hope to go without an epidural this time. Has anyone had a small baby dystocia and then an uncomplicated second delivery? I still remember the nurse telling us that my son had his arm up by his head…could that have caused the dystocia? I do not want to endanger our baby but I feel like an elective c section is extreme. Thanks for the advice!

    • Hi Adrienne
      When a baby has their arm up they their head or around their neck they can get a little stuck as they leave the pelvis. I’m very surprised that your doctor has recommended a c-section and this is not an evidence based approach. If you are upright and mobile allowing your pelvis the space to move… and your baby does not have his/her hand up by their head you are unlikely to have any problems birthing your baby. Of course you need to consider whether your care provider will support a physiological birth… and it seems that your’s does not feel comfortable with this option.

  66. A-M says:

    I love how you explain these things. It’s great to read about how to prevent SD by encouraging an unmanaged and free labour, as despite trawling the NHS website for information on SD this was news to me. I’ve not yet had children (but plan to start soon) and while I am generally pretty confident in women’s ability to birth, SD truly worries me. I was born with SD but thankfully suffered no lasting consequences. My mother is 4’10” and I was over 9lbs, which probably contributed towards it. Since I am also short (5’2″) and my husband is tall (5’11”) does this increase my risk? I do at least feel empowered that by insisting on as unmanaged and mother-led labour as possible, I can hopefully reduce my risk. Thank you for this information, I also loved the post on not judging during labour (I feel I’ll be a screamer!).

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s