Nola was ten days overdue when one of the midwives I work with called me to say she needed to be induced. "I'm worried her baby's going to be really big," my friend the midwife said. "It feels huge."
Nola was a tall, sweet-tempered, strong-bodied yet heavyset young woman. Her pregnancy had been pretty uneventful but she'd gained about forty-five pounds since her first visit with us. Fortunately, a gestational diabetes screen was normal, and for that reason we'd waited until her due date had come and gone before considering induction. Now she was close to two weeks overdue and no signs of labor yet.
I was on call that night. "Does she want to be induced?" I asked.
"Well, she's not excited about it, but she's ready to have the baby. She hasn't slept well in a week and I think she's worried about the baby's weight, too."
The truth is, estimating fetal weight is more of an art than a science. One of the few relatively accurate methods is a woman's own sense of the baby's size compared to a prior pregnancy. Third trimester ultrasounds can be wildly inaccurate when it comes to predicting weight. As for clinical exam, I always explain to women that I'm trying to estimate how many 5-pound bags of sugar their babies weigh, by gently compressing their bellies between my examining hands. As I said, an art, not science.
I met Nola at Labor & Delivery. Her cervix was actually very promising--soft, fully effaced, and almost three centimeters dilated. I discussed the options with her and we agreed to start some Pitocin. After it had been on for a couple of hours, Nola was having regular mild contractions and I decided to break her waters. After this, her labor kicked into high gear. Her contractions lasted longer and I could feel the hard uterine muscles tense up like a basketball as she breathed through the intensity.
Throughout all these interventions, Nola mantained her innate sweetness. "I'm okay, Dr. Chan," she said when I asked how she was doing. "I'm going to make it." She labored in the tub, standing, and on her hands and knees on the bed.
Dilation progressed rapidly until Nola was seven centimeters, then things slowed down. I'd turned the Pitocin off because her labor was progressing so nicely, but I turned it back on after she'd stalled at seven centimeters for a couple of hours. Restarting Pitocin did the trick. Within ninety minutes, Nola was completely dilated.
It took a while for Nola to feel a strong urge to push, but once she felt the rhythm of the second stage, she proved to be a strong and athletic pusher. It only took twenty minutes of strong pushing for the baby's head to peek through her labia.
I stuck my head out of the room. "We're getting close in here," I said to the nurses. It was just shy of three o'clock in the morning and Nola was the only woman in labor that night, so two of the nurses--Vicki and Stace--followed me back in to set up for the birth of the baby.
Nola was pushing in a semi-supported squat, with her feet up on a squat bar. Each push brought the baby's head a bit further down and just as we had the delivery table set up the baby's head crowned.
"Great!" I said to Nola. "You're so close. Keep your pushes strong."
I was sitting side-saddle at the foot of the bed. I rarely "break down" or remove the bottom half of the birthing bed when attending a delivery. It is just a bit easier to help a baby into the world with a soft mattress beneath you instead of a hard floor, and it makes the experience seem a bit less technical. As the crown of the baby's head emerged, I supported Nola's perineum and cheered her on.
It took several sets of pushes to deliver the head up to the brow. This is not unusual, but for some reason, watching the slow progress of Nola's baby made me uneasy. I have written before about the hair on the back of my neck that stands up when something's about to go wrong; I never ignore the hair, and it was rising slowly as I watched the baby's head creep outward. The crown of the head was only slightly molded but there was just something Not Right about the way it was emerging.
"Let's flex the legs way back," I said to Vicki and Stace. They were standing on either side of Nola, encouraging her pushes and monitoring the baby's heartbeat pattern, which was reassuring. At my request, they each grabbed one of Nola's feet and flexed her hips steeply. This action tilted Nola's pelvis further upright and helped the baby's face emerge. Immediately as the baby's cheeks were born, the head pulled back slightly rather than advancing further. This is called the turtle sign and signals an impending shoulder dystocia, one of the few medical emergencies that truly strikes fear in my heart.
The AAFP defines shoulder dystocia as "a delivery in which additional maneuvers are required to deliver the fetus after normal gentle downward traction has failed [.....S]houlder dystocia occurs when the fetal anterior shoulder impacts against the maternal symphysis following delivery of the vertex. Less commonly, shoulder dystocia results from impaction of the posterior shoulder on the sacral promontory." In other words, shoulder dystocia results from the inability of the bony part of the baby's upper torso to pass through the bony structures of the maternal pelvis. The head of the baby delivers, but the body cannot be delivered without interventions. During the time the body is trapped in the birth canal, circulation through the umbilical cord is likely compromised by compression. Prolonged time to delivery is associated with anoxic brain injury and death, and use of excessive traction to achieve delivery of the body can cause brachial nerve injury resulting in Erb's or Klumpke's palsy. Shoulder dystocia is thought to occur in 5-9% of births of infants weighing 4000-4500g, which is common enough to warrant every birth attendant learning how to manage this potentially life-threatening complication. One approach is given in the HELPERR mnemonic:
- Call for Help
- Evaluate for Episiotomy
- Flex Legs for MacRoberts maneuver
- Apply external suprapubic Pressure
- Enter vaginal canal to perform Woods and Rubin screw maneuvers
- Remove the posterior arm
- Roll patient to hands and knees (Gaskin's maneuver)
I remember very few mnemonics, and in truth I don't remember "HELPERR," but I do remember what it tells me to do. All of the maneuvers it instructs the attendant to do are described and illustrated at this site. I had Vicki and Stace to help me, and we'd already helped Nola into MacRoberts maneuver, which had in fact revealed the dystocia.
"Lower the head and foot of the bed," I said with chilling calm. Lowering a woman's head makes MacRoberts much more effective, and lowering the foot creates more room for the birth attendent to maneuver. "And give me some suprapubic pressure." Vicki adjusted the bed setting while Stace leaned over and applied a firm pressure against Nola's pubic bone with the palm of her hand. I applied some gentle traction to the baby's head with Stace's suprapubic pressure in place. No effect. The head sat rock-still at the introitus and I didn't even feel the subtle slipping of the body behind the traction I applied, as I usually do when the body is deliverable using ordinary means.
"OK," I said--and later, Vicki and Stace told me I sounded very calm, but my heart was pounding already-- "Someone needs to call Dr. W and watch the clock." Dr. W was on call for OB, and we needed another nurse to keep track of timing and interventions so we could reconstruct the sequence of events for the medical record.
Zoe, the third nurse, came running in when we hit the emergency light. She relayed the message to call Dr. W to the ward clerk. Meanwhile, I was trying to reach into the vagina to see if I could do screw maneuvers without cuting an episiotomy. I was also trying to explain to Nola what was going on. "Your baby's shoulders are stuck in your pelvis," I said, but I didn't make eye contact. I was trying to examine the baby's position in the birth canal, but the body was jammed so tightly against Nola's perineum I could barely insert the tip of my index finger. "I have to cut an episiotomy, and you have to work with us even though this is really scary and hard on you."
Level-headed Vicki repeated what I'd said to Nola as I cut a mediolateral episiotomy at 5 o'clock. Nola was obviously petrified and her mother--who was standing at the head of the bed, by her daughter's side--was weeping. Nola's boyfriend was also crying and now Nola herself welled up with tears. Vicki reassured them in terse, measured tones. As I tried to extend the episiotomy upward, I estimated that over a minute had passed since the birth of the head. The baby was so wedged into the lower pelvis I could barely extend the episiotomy by an inch.
I squeezed both my index fingers into Nola's vagina, one behind each of the baby's shoulders, and tried to rotate the shoulders into a more adaptive position for birth. The body didn't budge. I switched hands so that my fingers were now in front of each shoulder, and tried to rotate in the opposite direction. No movement, not even a millimeter. These two maneuvers are called Woods and Rubin's screw maneuvers, and I can never remember which is which but, in the moment, that hardly mattered.
I tried a brief application of traction on the baby's head, in case my feeble screw maneuver had dislodged something. Nothing. Because my first episiotomy hadn't yielded enough access to do an effective screw maneuver, I cut another one at 7 o'clock and again tried to extend it upward, which was almost impossible given the extreme wedging of the baby's body. I repeated the screw maneuvers, with a slight budge clockwise. Traction again. "Nola, push. Big push," I said tersely. She pushed hard. I continued applying traction. Nothing. Not a centimeter.
The ward clerk hollered through the doorway that Dr. W was on his way, but so was Dr. B because he lived closer to the hospital. Dr. T, a pediatrician, had also been called.
"How long?" I asked Zoe.
She knew what I meant right away. How long since birth of the head. "About four minutes," she said quietly.
We were approaching a danger point. Anoxic brain injury becomes a real possibility once circulation to the baby has been compromised beyond five minutes, less if the baby has been under physiologic stress before the shoulder dystocia is identified. I tried the screw maneuvers one more time, this time forcing my fingers up into the birth canal to get a better application of pressure. Nothing.
"I'm going to try for the posterior arm," I told Zoe. Vicki and Stace still had Nola's legs supported. Nola's mother was sobbing and her boyfriend was praying loudly behind me. I barely heard them, all my attention was directed at the task at hand.
With a great deal of difficulty, I inserted my right hand as deep as I could into Nola's vagina. This was very uncomfortable for her, and she screamed. I know it seems terrible, but there was absolutely no time for any anesthesia. Even if an anesthesiologist had been in house--and there was none--by the time anesthesia was provided, it would have been too late. I reached the baby's elbow but the arm was completely extended and there was no bend in the arm to hook on to to sweep the arm across the chest and out of the vagina. Delivery of the posterior arm decreases the diameter that needs to emerge from the pelvis and therefore facilitates birth. I struggled with the baby's arm but it was completely locked into place, fully extended and I could not flex it at the elbow and therefore could not sweep it across the chest and out.
For a moment, I gave some serious thought to cutting a fourth-degree episiotomy through the rectal mucosa. The two lesser episiotomies didn't give me enough room to get the posterior arm, but I knew the subsequent repair to her rectum would be terrible for Nola and might leave her with permanent bowel symptoms for the rest of her life. It was one of those whose-life-is-more-important moments in maternity care that everyone likes to talk about but no one knows how to solve.
Some readers of this blog will wonder why I hadn't, at this point, tried the second R in HELPERR: Roll the woman onto hands and knees. This is called the Gaskin maneuver, named for the great Ina May Gaskin, a great writer and midwife who discovered that changing to this position often rotated the baby and changed the angle of the pelvis sufficiently to deliver the body of the baby. The Gaskin maneuver is a wonderful idea and intervention, and I have come to believe in its possibilities, as I discuss below, but one of the problems of having a woman hooked up to fetal monitors and an IV pump is that it takes a cooperative patient and a calm roomful of supporters to get her turned over when she is on her back. In our case, we had neither. Nola was in a state of panic, screaming and thrashing, and her family was weeping and praying.
I was re-examining the baby's position to see if there was any way for me to get the posterior arm, and I was thinking about an extreme episiotomy as described above. The room was loud and full of emotion but I don't remember what anyone said. I was trying to construct a potential save for this baby. Almost six minutes had elapsed since the birth of the head, I discovered later.
In her terror, Nola herself discovered a solution. As she struggled, she lifted her hips off the bed. Suddenly the baby's head was at my eye level. The face was now purpleish in color. "Get her back down!" I said to Vicki and Stace. With encouragement, Nola planted her backside firmly back onto the mattress. There was a shift in the baby's position, not a big one, mind you, but a change.
Suddenly, I saw a dark line between the baby's arm and the tiny bit of torso I could see if I reached into the birth canal. The axillary crease. "Hold on," I told everyone. "OK, Nola, this is it. You've got to push. I need your help."
Keeping one finger lightly hooked in the axillary crease, I applied traction at the same time as a screw maneuver. I could feel a tiny shift with each push/pull/turn. Not the normal slipping or giving way of an uneventful birth, but change and movement at least. In between each of Nola's pushes, I maintained a light traction on the baby's head and kept my finger hooked in the axilla. I wasn't actually pulling the baby out by the armpits--you're not supposed to do this, because it can damage the brachial nerve--but maintaining a rotational pressure at that point while I exerted downward pressure.
The baby's shoulders began to emerge, millimeter by millimeter. I found the second axillary crease and hooked my other index finger into it. Gradually I rotated the baby clockwise, all the way exerting normal traction at the same time as the rotational pressure on the axillae. Finally, when the tips of the shoulders were within reach, I could feel the baby's elbow within my reach. I tapped on it, and the arm flexed. I swept it across the chest and delivered the posterior arm at last. The rest of the baby's body followed. It had taken at least a full minutes to deliver the body after I'd discovered the first axilla.
The baby was dusky and not breathing. We clamped and cut and moved her to the warmer. Zoe counted out the heartbeat: sixty. We dried and stimulated briefly--no breaths. I grabbed the bag/mask setup and started giving positive-pressure ventilations. The heart rate came up minimally, but no respirations. Vicki handed me a laryngoscope and an endotracheal tube and I intubated the baby.
It took a full minute of positive-pressure ventilation through the endotracheal tube for the baby to pink up and initiate breaths on her own. She extubated herself with the force of her cough and cry. She was still a little groggy, but her heart rate was normal and she was breathing.
At this point, I turned around and saw that Dr. B had arrived. Only eleven minutes had elapsed since we'd called. I told him what we'd done and said, "If you could repair the episiotomies, because I..." and I showed him my shaking hands. Bless him, he sat right down and started sewing.
Dr. T arrived and took over care of the baby boy. Dr. T is an old-school pediatrician and he never panics. He moved the baby to the nursery, got labs and gave oxygen. Dr. W arrived--only fifteen minutes after being called, he'd driven like the devil to get there, and suddenly the whole thing looked like it had been a snap.
The baby weighed ten pounds and five ounces (4670g). His Apgars were 3, 6 and 8. His head measured 35.5 centimeters in diameter, and his chest measured 38 centimeters. That made a difference in one inch between the head, which had been born easily, and the chest, which had taken such desperate efforts to be born. Dr. T observed him in the nursery for just over an hour, then returned him to Nola. Dr. B finished repairing the episiotomies. There was no injury to Nola's rectum.
I debriefed with Nola, her mother and her boyfriend. I explained what had happened and why it had been necessary to act even though everyone was frightened and Nola was in pain. I explained this was not how I'd wanted her baby to be born, but what I felt was important to do in the moment. I repeated the whole explanation to Nola's pale and trembling father, who'd been waiting outside the room and heard her screaming during the worst of it.
It was just after four in the morning by the time I sat down. My hands weren't trembling anymore but both my upper arms were aching from the maneuvers I'd done. I ate pudding and ice cream because, after all that excitement, I didn't give a hot damn about calories. Everyone was alive and well, and this simple fact seemed cause for celebration.
After several days had passed and this story had been told to all the OB attendants and L&D nurses, I was ready to reach some conclusions from this experience:
- The textbooks are correct: You cannot predict when a shoulder dystocia will occur.
- Preparation is essential. Whether you rely on mnemonics or other memory devices, know what to do before the event occurs.
- All recommended interventions should be attempted, including the Gaskin maneuver if the woman and her supporters can participate in the maneuver. In Nola's case, her instinctive raising and lowering of her hips actually resulted in a fetopelvic realignment which made the ultimate vaginal birth possible. I have noticed this type of maneuver helping in other tight shoulder deliveries before and since Nola's birth.
- Never assume you will have more experienced or qualified help available when a crisis occurs. Nola's birth happened at three in the morning, and although help arrived as soon as they could, her situation demanded immediate intervention.
- I've said it before and I'll say it again: It pays to develop an unruffleable approach to crisis, because they will arise whether you are ready or not.
- Finally, small differences have large implications. A single inch in diameter transformed a straightforward labor into a very technical delivery.
I'm a CPM in training in getting my bachelor's in Midwifery and I love your blog. Great job helping this baby out!
Posted by: Ash | January 14, 2010 at 11:52 PM
HI TC~
This brings back a whirlwind of memories of working nightshift at that same hospital and taking a deep breath and telling myself, "you CAN do this, you HAVE to do this...there is NO ONE here to do this but YOU!!!"
take care...miss you!
RN KELLY
Posted by: RNKELLY | October 25, 2009 at 12:02 PM
I am so excited about this blog! I think that it is wonderful to have an open friendly forum.
I have had an undue % of s/d and had to do a lot of soul and text searching around it. Content that I am NOT doing those things that MAY contribute to s/d (inductions, restriction of movement, "nudging labors", forced pushing, lack of prenatal monitoring, etc..) I just have to chalk it up to my path. Seems to happen; some midwives get pph, some breech, I get s/d. Or... with positive thinking... I USED to get s/d.
I have gone from fast action at the first sign of turtling to calmly waiting through the contraction(s). I know that we are on a time line, but frightening the baby and jumping to conclusions do not help. The "classic" "turtle sign" can also be snug shoulders and many babies will pull back to readjust and deliver just fine. Over response can scare the baby and turn a sticky situation into a stuck one. Watch the baby, see what it is trying to do, give baby a little help if it needs and do so gently. But first, let the baby try to help itself.(so easy to say).
I have had s/d start in squat, water, semi recumbent, hands and knees and even standing. For me, I have to say that motion is key, more than any particular position. Change positions. My preference is to move to standing with one leg hiked, if that doesnt work, then go to McRoberts w/maneuvers. At home, mom standing next to a couch and setting her foot on the arm of the couch is just about perfect. I learned it from a peace corp midwife and I have to say that it is fairly superior.
Above point that I strongly agree with;
Dont push back the peri.
Avoid epis
Have a good crew for baby
My primary additions:
Let mom and baby help
I could go on and on, but my post is already too long... thanks for providing this forum and want to tell you that I love your spirit. You got the baby out! In your situation that is no easy feat!
Warm regards.
Posted by: Shell | January 12, 2009 at 05:26 PM
I am a survivor of two shoulder dystocias at home with a certified professional midwife (CPM). Both births were intended water births, so I was in the tub when the turtling occured. The first time I had no idea what was going on. The midwife barked "Get her out -- Hands and knees" and the next thing I knew I was on the carpet on my hands and knees. She reached in for an arm or shoulder and after a second of gut-wrenching pain my baby was safe. He weighed 10 pounds and 5 ounces.
Four years later the same midwife came to the house for a pre-natal on the new baby I was expecting. My son (now 4, of course) had not seen her since his birth. He flew out of nowhere and physically attacked her! When we got him calmed down, he told me he remembered this woman b/c she had pulled on him during the birth and it still hurt to think about. We had never told him the mechanics of his birth, so this could only be a true memory. The midwife resolved it with him in a wrestling match, winning my son's respect forever.
That birth went well, and I pushed out the baby girl(10 pounds, 1 ounce) in the tub with no issues.
However, two years after that my last baby was born and we encountered SD again. I was 42 weeks and I could tell the baby was BIG, so I was expecting SD. I had full confidence in my midwife and felt much safer at home than anywhere else. Again I labored in the tub and pushed out the head. When the shoulder caught and she told me to get out, I had the presence of mind to stand up, step over the ledge of the bathtub and grab the sideboard of the sleigh bed. She reached in for the shoulder and I had to push with all my might while she pulled and twisted. Even when the shoulder came free, the baby did not come flying out. She was so large, we had to push/pull every inch down to her feet. She weighed in at 11 pounds 14 ounces!
In all of these homebirths, no episiotomy was cut, nor did any tearing occur. It probably helped that I was not lying flat on my back nor were there any tubes or monitors to consider.
As a survivor of SD, I read Nora's story with interest. All things considered, you did a fantastic job saving the life of the baby. However, you might consider how much of the problem was iatrogenic. Nora was more able to respond than you gave her credit for. If you had said to her, "Hands and knees!" as my midwife did, she likely would have obeyed rather than panicking.
One reason I have my babies at home with a CPM is because I believe that birth is the work of pregnant women. Midwifery is precious and lifesaving and important... but the midwife must remember that it is the mother who is birthing the baby.
Posted by: Jeannie | November 22, 2008 at 07:56 AM
Thanks for sharing this story. Dystocia can be so scary, but having a calm accoucheur makes such a difference.
And I completely agree about the wine, chocolates and massage.
Posted by: Dragonfly | September 09, 2008 at 06:33 AM
My biggest nightmare! Amazing to read. We are told that the suprapubic pressure should be to the anterior shoulder and then attempting to dislodge it by repeated 'compressions'.
Posted by: Midwifemuse | September 08, 2008 at 03:54 PM
Oh Theresa, I got queasy just reading, and I think I was in respiratory arrest the entire time!
Bottom line, you remembered what to do, you did what you had to do (repeatedly!) and the baby (and mom) are alive and healthy today.
Oh dear, I'm gonna need a full caramel sundae after reading this!
Posted by: Kim | September 08, 2008 at 03:30 PM
Alathea,
Thank you for commenting--both times. I appreciate your perspective and I am learning a lot from the midwives and other commenters on this post. My hope in writing these birth stories is to open up dialogue regarding birth practices and into inform my own opinions/practice style.
I do encourage all commenters to read each post carefully and to consider reading other posts on the blog to get a wider sense of my childbirth practice philosophy. I think this will help avoid misunderstandings.
Look forward to more of your comments!
Posted by: Theresa | September 08, 2008 at 12:34 PM
I was thinking about the post I made above. I did not handle my reaction very well at all. For that I am very sorry. I hope you will forgive me. I tend to forget that the home I was raised in, and the traning I've had about childbirth is quite different from most ppl in the USA. I wish I could rewrite how I posted it above.
Posted by: Alathea | September 08, 2008 at 12:24 PM
ok... I'd forgotten just how long I can hold my breath! I hardly breathed while reading this!!
Posted by: Peggikaye | September 08, 2008 at 11:58 AM
Nola would have had no problem getting on her hands and knees. The fact that she was moving her hips up and down proves that she was willing to do anything. And screw the stupid monitors.....they are worthless anyway if the baby dies. What are they gonna do?...listen the to baby die when they could have gotten rid of the dumb things and got her turned over?
OOOOOO and the Dr.'s arms were sore afterwards?????? What about how that baby felt after all the tugging and pulling that made his arms hurt? Sry if I have no sympathy for him.
I am a very firm believer that a woman should have 100% control during her labor and birth. Had she had that control, with no one telling her what to do or even hinting what to do or what position to be in, she never would have been on her back to begin with. She would have felt what was going on inside her and moved to a better position long before the Dr. found the problem.
Posted by: Alathea | September 08, 2008 at 08:26 AM
Here's one way to make an inexpensive, low-tech, firm, portable, and warm surface for resuscitating at the mother's side:
1) Place an electric heating pad on top of a large plastic cutting board or large metal cookie sheet. You can also use a breakfast-in-bed tray with folding legs.
2) Wrap the pad and the tray in a towel, taping the ends underneath the tray so they don't come undone.
3) Place receiving blankets on the towel-covered tray to have a supply of warm blankets on hand. If you want to make sure things stay clean, put everything inside a pillowcase.
4) Keep pad plugged in on low or medium during the birth. Unplug and move to the mother's side if needed for a resuscitation.
Posted by: Rixa | September 07, 2008 at 06:45 PM
SD is one of those really scary things that I hope I never encounter.
You might enjoy reading the section on SD in Anne Frye's Holistic Midwifery, vol. II. She covers all of the typical medical techniques, past and present, plus a multitude of midwifery techniques. She also discusses the difference between inlet & outlet dystocias and the different techniques for resolving each. (But I was at a state midwifery association meeting once where the midwives were talking about a recent SD, and they said, "When you have a SD, you don't exactly have time to think about whether it's an inlet or an outlet dystocia!")
Frye also emphasizes the importance of shifting the maternal pelvis, especially symettrically by doing lunges or kneeling on one leg and setting the other foot down flat (Parker position).
Another acronym & set of maneuvers she suggests is Gail Tulley's FLIP-FLOP:
F: FLIP the mother onto hands & knees
L: If the baby does not advance, have the mother LIFT the leg nearest the fetal back into a kneeling position. Choose the right leg if you are unsure as to the location of the fetal back.
O: If the baby still is not born, insert your hands and rotate the shoulder girdle into the OBLIQUE diameter of the pelvis using the "praying-hands rotational maneuver" described in detail later in the chapter (a variation on the Varney maneuver, which is an adaptation of the Woods and Rubin maneuvers & more suited for female practitioners' lesser upper body strength).
P: If the baby still is not born, deliver the POSTERIOR ARM.
Posted by: Rixa | September 07, 2008 at 06:25 PM
Yes, if you need to intentionally fracture a clavicle, try for the anterior one and snap it up - away from the baby - to avoid a pneumothorax.
All the necessary maneuvers of SD remind us we MUST know the baby's position in labor and second stage and after head emerges. Not just "vertex" but OT, ROA, etc. Get a good chart to reference (I have one I can email) and pay attention with every vag exam. You have to be able to picture what to do where in case of SD. And know that suprapubic pressure works best when given lateral force, rather than just direct AP force, to compress the shoulder together (as if the baby is hugging himself in the proper direction of the shoulder. Pushing the shoulder towards the back is not going to help at all. If shoulders are transverse, skip SP pressure and go to woods-screw. Etc.
You know it's back luck to talk about this!
Posted by: CountryMidwife | September 07, 2008 at 08:23 AM
As for intubation, there was a good 30 seconds of PPV without clinical change--not in the narrative, now that I review it--before I intubated. And the look of this baby--purple/pale, mottled, floppy, staring, not breathing--made me move more aggressively to intubation.
As for cord-cutting, normally I don't cut the cord right away. We do dry & stim and blow-by on the mother's chest. If we had a firm surface next to the mother on which to continue resuscitation, it would make the midwifery NRP model much more accessible at my hospital. I'll start exploring the option with the department manager and we'll have to review the literature to see if it will fly. In Nola's case, again, we were caught by surprise at the dystocia (really good, fast 2nd stage), and after 7 minutes had passed from head to body, I didn't feel any room to be flexible about my approach to resuscitation. Not only for my sake but for Nola and her family.
I will be much better prepared for the next time this happens.
Posted by: Theresa | September 06, 2008 at 11:50 AM
Hi Country Midwife,
This birth happened a little while back, and I've "processed" it in many ways but it has also taken a long time to blog about because I couldn't quite bring myself to put it all down into words.
EXCELLENT point about not rushing the delivery of the head. I always wait for restitution/rotation, even if it means waiting for the next contraction. There was a pause after Nola's baby's head delivered, but my sixth sense told me it was going to be stuck no matter what, and I think I was right.
I've had dozens of "tight shoulder" deliveries, and a number of shoulder dystocias, but this was the worst by far. The mechanical dynamics of the birth were obviously abnormal--the total absence of the slip and give with traction.
I think the comments about preparing for Gaskin maneuver are right on. The IV pole/monitors really were a barrier in this case, although if I'd thought about it before the birth I might have had a chance--Nola is a very strong woman! Also, things like this happening at 0300--not good.
Also, I've never been able to break a clavicle when I wanted to. (Like everyone else, I've had a few broken ones with routine births, discovered later.) So you push upward on the bone, rather than down? Interesting. Not in the books.
What I really am interested in is your perspective on the dynamics of shoulder delivery. I agree completely. This is something that doesn't get written about/formally taught enough (to MDs at least). As I progress though my birthin' career, I find the rotational dynamics of labor and birth to be essential to good outcome.
Thanks for commenting, everyone!
Posted by: Theresa | September 06, 2008 at 11:43 AM
OH, my heart pitter patters for you! The VERY worst nightmare - I'd rather have 10 cord prolapses + 20 hemorrhages than one SD. But yes, preparation, calm, and some real hand strength, that's what it takes. (so let's all of us do hand strengthening exercises - I'm serious!).
A few points which are important to me with SD or the much preferable sticky shoulders.
1) If the head/face is delivering slowly, do not push the perineum over the face. That extends the neck and gives the shoulders less room to rotate. Let it go slow. Use that time to flip to H&K, it is a huge difference in accessibility for you and diameter for mom.
2) Contrary to popular belief that if you suspect a SD "go for the shoulder" on the same contraction: I wholly disagree. I think a push to deliver the head typically uses a full contraction in the case of an impacted baby, leaving you trying to get a shoulder with no uterine force. Our pulling (ahem, applying gentle A/P traction) is nowhere as strong as the force of a uterine contraction (and that's supported by the ALSO course). It's hard, ohlordy it's hard!, but WAIT for the next contraction. Again, use the time to prepare. If mom is semi-fowlers or supine, make sure your birth assistant has a stool to stand on SP pressure... flip mom if needed... call for help... prepare for rescus... inform mom that she will have to use every ounce of her strength to push her big baby out... etc.
I am a firm believer that trying to deliver shoulders prior to external rotation and restitution impacts them into a transverse diameter and gives you very little to work with. It also tends to push arms into a military position which makes for a chest and belly dystocia! I think the vast majority of shoulder dystocias are iatrogenic because of attendants rushing the delivery. It's hard to go slow but I find it has saved time in the long run.
3) This is why I never, ever ever cut a cord on the perineum. I've never known one to not stretch enough to somersault. If you had a tight nuchal and cut it your outcome would not have been good.
4) Don't be afraid to break a clavicle. The difference is amazing. But remember to snap it up, not down.
5) Pudding, ice cream, cake, chocolate, wine and a full body massage are necessary for the poor birth attendant after a SD!
6) You will have some post traumatic stress disorder for awhile, and your trust of birth will falter. But it will come back, I promise.
Wondering why you intubated so soon rather than just bagged?
You did a great job, country doc! Go eat more ice cream :)
Posted by: CountryMidwife | September 06, 2008 at 10:43 AM
I very much enjoy reading the birth stories you share--we had a shoulder dystocia about 4 or 5 months ago that ended in the Zavanelli maneuver and it was excruciating to watch. Glad to hear things turned out well.
(but it's Ina not Ida)
Posted by: cileag | September 05, 2008 at 01:40 PM
as a student midwife I so appreciate your sharing of this story. I too have known the fear of SD.
I would love for you to know the work of Karen Strange: www.newbornbreath.com She teaches NRP in the midwifery model, fusing the USA & UK NRP manuals with perinatal psychology. Karen teaches that babies needing resuscitation do better when they are still receiving oxygen via the umbilical cord. In addition to the O2 factor, clamping & cutting right away renders a neonate hypovolemic. Less blood perfusing the alveolae makes for a more challenging transition to breathing.
In the SD I resolved, we kept the cord intact as we did PPV, then blow-by. (If we had needed to perform chest compressions, we had a hard surface prepared right next to the mother and would have left the cord alone to continue performing its function!) The placental separation gush occurred right after baby let out his first lusty cry--up until then he had sounded gurgly and whimpery. The change in cry heralded his transition, and the placenta was no longer needed.
Posted by: Abundant B'earth | September 05, 2008 at 12:31 PM
Wow! That is a great sharing of your experience. The lesson learned extends across all of medicine. Expect the unexpected. I was on pins and needles just reading this one.
Posted by: Doc | September 05, 2008 at 08:15 AM
I think pudding and ice cream were well deserved!
Posted by: Kim | September 04, 2008 at 04:24 PM
Excellent additions, DoctorJen! I usually use a bunch of positions rather than semi-sitting, but Nola ended up in this position and I had to use the bed controls rather than the woman herself to get her semi-flat instead.
Given the rapid progress in labor she had, I didn't suspect a dystocia until she was crowning, which was a disadvantage. She was a really strong-bodied woman, and I think we could have gotten her rolled over IF the emotional situation hadn't erupted.
Posted by: Theresa | September 04, 2008 at 07:20 AM
I'd add one thing to your list, and that is more preparation - not for yourself, but your staff and clients. Go over and over the maneuvers you want with your nursing staff. Practice rolling patients with IVs and monitors. If you any reason to suspect an impending shoulder, let the patient know what sort of things you might ask her to do. I've been known to watch the slow descent of the head and let mom know while she's pushing that we may need to have her move once the head is delivered. usually, they tell me they can't, but often that little bit of preparation sets the stage to be able to do it. I've been surprised by how efficiently even a mom with an epidural can move if we've calmly impressed on her how important it is for her baby's safety. And above all, when suspecting a larger baby, avoid positions that compress the sacrum (semi-sitting.) sometimes it's just the movement, not the eventual position that helps (like your client raising and lowering) so even things like rolling to side lying might help, and that's much easier than getting all the way to hands and knees - and, it's half way to hands and knees if you are able to keep and going. I also find that in hands and knees, I usually have more room to maneuver without cutting an episiotomy, and if it doesn't work to free the baby, I have more room for rotational maneuvers.
Shoulder dystocia is one of those things that truly scare me to death - there is no more helpless feeling than struggling to help a baby be born. My favorite nurse (a very experience, senior labor nurse) helped me through a bad shoulder dystocia on just my 3rd birth as an attending physician. I can still remember her calm encouragement and level-headed instructions - to me since I was panicking pretty good!
Posted by: doctorjen | September 04, 2008 at 05:26 AM