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.