I like to be on call on New Year's Eve and New Year's Day because part of me really hopes to be at the birth of the first baby of the year in Rural County. I know it's dumb, but I think it would be kind of groovy. Anyway, it didn't happen this year, but I had a remarkable New Year's birth story nonetheless.
Remember Nola's birth? It involved a severe shoulder dystocia and I posted at length about the maneuvers we needed to do to get the baby delivered. The birth took seven full minutes to achieve and was just about the scariest thing I've ever been involved in. It took a long time for me to write about the event because it was so stressful and frightening I didn't want to commit the experience to words, but I thought it was time to get it out there. The comments I received were largely supportive but I was surprised to discover the post was being lambasted on a birth-related forum as an example of overly-interventive, anti-woman butchery. Many of the participants on the forum were certain that early use of the Gaskin maneuver would have resulted in the birth of the infant and avoided the physical ordeal Nola went through. Many others implied that the medical interventions used--Pitocin, for example--actually caused the dystocia, and used Nola's story as an example of why women should give birth unassisted by meddlesome attendants such as me.
I won't share my feelings about how Nola's story was used on that forum, because there is no reason to polarize the discussion about the pros and cons of contemporary obstetrics any further than it is now. I just wondered how many births these anonymous posters have attended, other than their own, and how they might have felt ten minutes after Nola's difficult birth.
Anyway, when I took over call on New Year's Eve, I had the pleasure of working with Nola once again. I hadn't seen Nola since the difficult night of her first birth, and I often wondered if this was because she didn't really want to see me. Sometimes people don't want to see a doctor again--even if they like the doc and there is no question of incompetence--because he or she reminds them of sad memories. I understand this completely, and I didn't blame Nola if she preferred to see the other providers instead of me. I knew her family felt really good about her birth because a number of her relatives receive care at our clinic and I hospitalized some of the others, and more than one took me by the hand and said "Dr. Chan, I'm so grateful to you for little Victoria," which astonished me. In my mind I've workshopped that birth a couple thousand times, and wondered what would have happened if it went just a minute longer--never mind. (Think about other things, like the fact that little Victoria was walking and talking and funny and smart, and be thankful.)
When I finally had a prenatal visit with Nola during her current pregnancy, she asked me what I thought about the risks of another trial of labor. Other providers had discussed the option of an elective C-section with her, an idea she'd initiated and they'd discouraged. We talked about all the positive choices she'd made during this pregnancy--improving her diet, managing her weight, keeping active--and I said I thought she could have this baby vaginally if she kept up the good work. The evidence about recurrence of shoulder dystocia is not very strong, and philosophically I think the only advantage of elective C-section for these women is a false sense of security.
"I really don't want to go overdue again," said Nola. "I mean, Victoria was a week overdue and she weighed more than ten pounds, and maybe if I'd been induced a week before, she'd have fit better."
"Maybe she would have," I said. "Would you want to be induced early this time?"
Nola nodded emphatically. "Oh yes I do," she said. "Can you do that?"
I shelved the discussion for later in her pregnancy, and obviously the team decided this was the thing to do because on New Year's Eve I walked in and found Nola mid-induction at 39 weeks. A recent third-trimester ultrasound estimated the baby's weight at eight-and-a-half pounds, for what a third-trimester estimated fetal weight is worth.
Nola received twenty-four hours of prostaglandins for cervical ripening. When I examined her on New Year's Day, she was ripe so I started Pitocin. Then I had a little chat with Nola.
"Now," I said, "I really have a good feeling about this birth and I don't think we're going to run into problems, but just in case we do, I want you to be ready to do a few things. First of all, I want you to move around a lot during this labor, so you don't feel stiff and weak at the end. Second, I want you to practice rolling onto your hands and knees, because if we have any problems it might be helpful to have you in that position."
"Okay," she said--one of the great things about Nola is she's up for anything. She comes from a family of people who put a lot of faith in the medical profession. Whether or not you agree with this philosophy, I have to say it helps the doctor use all the tools at her disposal.
Nola had a terrific labor. Pitocin brought on regular contractions, and I broke her waters when she was four centimeters. She made steady progress of one centimeter dilation per hour until eight centimeters, when she finally asked for some fentanyl. Transition was intense but quiet, and the next thing we knew, she felt like pushing.
Nola was having a lot of tailbone pain so we had her push in a supported squat at first. This helped the pain and was spectacularly effective--within four sets of pushes we saw a peek of the baby's head through her labia. I thought about having her roll onto hands and knees but she was comfortable pushing in the supported squat, and I had the squat bar set up so I could have her tilt forward onto her knees if I needed her to. I thought this would be better than having her roll completely over because I was worried about her IV line and monitor cables--yes, I had all those medical interventions going, I'm not trying to deny it--which could easily get tangled during a roll.
The baby made steady descent with Nola's strong pushes. I didn't really have to coach at all. I think she would have pushed continuously if I hadn't encouraged rest in between contractions. I was aware of a certain nervous readiness in the room--the nurses knew Nola's history, and so did I.
During those thousands of mental replays, I'd dissected the mechanics of Nola's first birth down to the minutest details. I'd concluded the Gaskin maneuver might have been useful during the shoulder dystocia for a couple of reasons. First, none of the other maneuvers had been effective, and second, the event which finally loosened up Victoria's shoulder enough for me to get her delivered was Nola raising and lowering her hips off the bed. By doing this, she'd done a modified Gaskin maneuver--changing the angle of her pelvic outlet enough to dislodge the baby's shoulders. While waiting for Nola to be completely dilated during this second labor, I'd already decided to use the Gaskin maneuver earlier if a difficult shoulder delivery were to occur. There was something about her pelvis, I thought. I didn't know what it was--her pelvic exam was normal and she had an obviously roomy, gynecoid pelvis--but my gut feeling was that changing the angle of the pelvic outlet was the right intervention for Nola.
Nothing during her second labor made me suspect a difficult shoulder delivery was ahead, but then again, nothing in her first labor did either. But I had my game face on this time. When the baby crowned, I supported the head gently and waited for the face to emerge fully. Instead, it hung up at the level of the mandible, or "turtled"--a sign of an impending shoulder dystocia.
"Big push," I said lightly. The baby turtled again. "Let's go to MacRoberts."
We helped Nola lean back in the bed and lowered the head of the bed so we could achieve effective MacRoberts positioning. This maneuver, combined with suprapubic pressure, resolves most sticky shoulders, and this is why I tried it first. The rest of the baby's face emerged, but no restitution occurred, and I couldn't get any budge.
"Nola, lift your hips up," I said.
"Up?" she asked. Bless her, she wasn't scared at all. (As soon as we'd started repositioning her, she knew what was happening and all she said was, "Oh boy, here we go.")
"Yes, up," I said. I was attempting to re-create the move she'd made during her first labor--the modified Gaskin, as I liked to call it.
She lifted and lowered her hips. The baby's head rotated clockwise perhaps five degrees, but the shoulders would not emerge. I can't begin to describe the horrifying sense of resignation which was overtaking me at this moment.
"Okay, let's go to hands and knees," I said. I sounded very calm, I didn't yell and neither did the nurses, but this moment was too much for Nola's boyfriend, Jim. He remembered her first birth and now he ran into the bathroom and sobbed. The sound amplified in the bare tiled room and suddenly the mood in the labor room was edgy. I didn't want panic to break out. "Is there someone who can help Jim?" I asked as I untangled sheets and monitor cables from Nola's feet.
It isn't easy to roll onto your hands and knees when you have a head hanging out of your vagina, but Nola somehow managed to do it. Her mother, Nancy, was right by her side and cheering her on. Now I was looking at the baby's head from the rear view. It was dusky, but not purple. Thank god! I thought. Another contraction was beginning on the monitor.
"Okay, Nola, give me a push," I said, and tugged gently on the baby's head. Nothing. I felt around the vulva for the position of the shoulders and felt the baby sliding ever so slightly: promising. "Give me another one," I said. Nola pushed mightily and after a chilling pause, the baby's shoulder's emerged and the rest of his body slid out easy as frying an egg.
Jim was still sobbing in the bathroom. The baby was dusky and floppy, so after a quick mouth and nose suctioning we clamped and Jim cut, and the nurses took the baby to the warmer. A good vigorous drying-off and he let out a lusty cry.
"Listen to him!" I said. I was so happy and sweaty and relieved and thankful, I wished I had a bell to ring. Almost everyone else was crying--Jim, Nancy, Nola--but we were all overjoyed.
The baby weighed in at nine pounds, eleven ounces--only six ounces smaller than Victoria but a pound more than the recent ultrasound. So much for third-trimester ultrasound measurements. His shoulders took one minute and fifty seconds to deliver--another shoulder dystocia, but night and day compared to Nola's first experience.
Gaskin's maneuver worked well for Nola. I'm glad I spent so many nervous moments replaying her first birth in my head and also for the excellent advice from the readers of this blog. I suspect Nola has a concave angle of her coccyx, or tailbone, which is why birth in a face-up position is so difficult because these positions accentuate the concavity, whereas face-down positions pull the coccyx into a more favorable position. This is the kind of anatomical variation Gaskin's maneuver is meant to resolve, so it makes sense it should have worked for Nola.
I wonder if the critics of Nola's first experience will return to read her second birth story. They might like this one better, but I want to leave everyone with the take-home message that the Gaskin maneuver is one of many effective techniques the birth attendant should have at her disposal. What works for one woman will be ineffective for several others, and I believe we should all inform our intuition with experience. This is why, after attending almost five hundred births, I still consider myself a learner.
Great job! Just curious though, why cut the cord and move the baby to a warmer for resuscitation? Why not resuscitate the baby with the pulsating cord intact? Based on what I have read at http://www.cordclamp.com, I would think the intact cord could be beneficial.
Posted by: jstevens.wordpress.com | October 04, 2009 at 04:20 PM
Hi doc, late on all these posts, sorry. I *think* we conversed about this earlier, but can't remember...
I am NOT criticizing in any way - I think you're wonderful! Just interested in dialogue about this...
Do you think that if you took a hands-off approach, the <2 minute dystocia may have been avoided? To me - and I hope this isn't going to come back and bite me on my a$$! -- most shoulders take between 1-2 minutes! During that time, fluid is pouring out of baby's mouth, mom is resting and getting ready, baby is lining up, all good things... I feel like if a dystocia resolves without internal maneuvers, it's maybe not so much a dystocia at all?
It is my (very, very VERY humble) opinion that most shoulder dystocias are iatrogenic - caused by tugging on the head before the shoulders have turned. My approach is this: if I see the turtle sign, I *will not* reduce the perineum over the chin... which extends the neck.... and avoiding that gives more room for the shoulders to rotate. I will wait for the next contraction, or else all maneuvers are in vain. I find it takes pretty much all of a contraction for mom to push out the head... no power is left after that. If I suspect a problem, repositioning now (before A/P traction, McRoberts, etc) is wise. Obviously, I don't work much with epidurals now - but did for 9 years L&D nursing - and actually *have never met* a blocked patient who can't move to H&K... I think that is more provider assumption than reality...
Anyway, I just know that so many birth attendants seem to have a lot of shoulder dystocias, while more hands-off attendants seem to have very few. I KNOW you are hands-off, but I also (well) know the tension that can happen in a given situation, which can quickly reverse your plan to not hurry those shoulders...
Anyway, congrats on a great job and a healthy baby! And I could not agree more that late ultrasounds are USELESS. It's not rocket science to realize (okay, maybe to *admit*) that these are pathetically poor at predicting fetal weight, jeesh...
Posted by: CountryMidwife | January 18, 2009 at 05:52 PM
Hi,
I first want to say it is so refreshing to see a Dr. who wants to do so much to keep births vaginal. I have just read both of Nola's birth stories and I truly understand the feeling of...well...panic that is involved in a shoulder dystocia.
As a doula, my job is to support the entire team and only assess in a nonmedical way. As you say, we are all still learning. I wanted to share my phylosophy on what I think may be a primary cause of shoulder dystocia. I feel positioning is key. Yes, obviously when there is a shoulder dystocia the positioning is what's necessary to correct this emergency BUT there may be a way to avoid it in most cases. I feel that paying special attention to the position of the babies, in labor, can help the problem be avoided. I have learned that most c-sections are due to baby positions and less due to size of babies. We know if babies are not in a direct OA postion as they move into the birth canal then their heads are actually not going to fit the "puzzle" as well. This stands to reason that the same can happen with the shoulders. I have found that, depending on the postion of the baby, mom should be put in certain postions herself. Along with ice (to encourage baby to move it's head away) and heat (to encourage baby to move it's head toward) I believe these postions have made a difference in 98% of the births I and my doulas have attended. In the cases of the two shoulder dystocias I have seen, these moms had symptoms of malpositioned babies. The symptoms included stalled progression and back pain. I was not allowed to help her move into the necessary positions and the Dr. would not check to determine the positioning. I see Nola experienced these symptoms as well (although not the issues with the Dr.:)). Obviously there is not going to be a fix for every situation, but I thought you seemed as open to learning as I am. Maybe this will help :)
Thanks for all you do and hopefully your good work will spill over into "the big city"
Stefany Mills (CD) (DONA)
Posted by: Stefany Mills | January 14, 2009 at 10:12 AM
Great story! I'm glad things turned out well.
Just a comment though on the Gaskin Manuever...I'm a childbirth educator and doula, and in that role I do teach my clients prenatally that it is easy to move from a squat to hands & knees by tipping forward as you describe. However, that is not the Gaskin Manuever. The Gaskin Manuever involves the rolling (which you ended up doing), and some folks think it is that rolling which helps to dislodge the stuck shoulder along with the hands & knees position opening up the pelvis front to back (when standing, place one hand on your pubic bone and the other on you tail bone--then lean forward. You will feel your hands move away from each other.). If all of the cords & IV lines are coming from the same side of the bed, it really isn't terribly difficult to coordinate the rolling.
Posted by: Jenn | January 12, 2009 at 10:06 AM
There is no way you can win on that other blog. I've read several other postings ... they are anti medical ..anti anyone who doesn't do things the way they do things. They are there with the purpose of seeking out what they see as 'medical mistakes' and blasting the medical profession.
Ignore them, they may not go away ... but you're still ok.
Posted by: Peggikaye | January 07, 2009 at 03:20 PM
I'm moved by your attention to this client, to the birth, and how receptive you were (despite, apparently, the unfriendly tone) to the suggestions or criticism of other people. Seems to me that that openness is one of the key signs of a good doctor.
Wonderful that the Gaskin maneuver worked for this mother and her baby was born healthy with your skillful help.
Posted by: Anon | January 07, 2009 at 11:31 AM
Great job. After doing a few thousand births it is my observation that the more opinionated are the less experienced. Keep the mom healthy, get the baby out in good shape--that's really our goal. I'm hoping you keep doing ob and continue to write about your experiences. Thanks for this nice and educational birth story.
Posted by: RuralObGyn | January 06, 2009 at 07:05 PM
Happy new year, and what an amazing story! I went back and read your first post on Nola, too - it was absolutely gripping.
I'm a new reader, and just wanted to say that I love the beautiful way you write about medicine.
Posted by: greenwords | January 06, 2009 at 05:18 PM
I love your birth stories. I also love how reflective and thoughtful you are about birth.
I started a reply, and it got really, really long. I decided it was more appropriate to post it on my blog.
Check it out if you'd like:
http://momstinfoilhat.wordpress.com/2009/01/06/long-dystocia-reply-turned-post/
Posted by: MomTFH | January 06, 2009 at 02:38 PM
Funnily enough, my daughter was born on New Year's Eve (day) 2008 and is actually named Victoria.
Although I am not at all a medical or birthing professional, I love your birth stories. Keep 'em coming! Your piece on fetal HR deceleration patterns was really useful to me in understanding the fetal heart monitor. I also understood quite a few technical details of Vicky's birth thanks to your blog. For example, the nurses placed a scalp monitor, and I understood that quite well thanks to you.
Our attending OB was a bit more interventionist (suction, episiotomy) than you usually are, but I suspect he had concerns about my wife getting pretty tired during the pushing stage. The baby scored 8, 9, and 9 in Apgars, so I suspect he was right about that.
After reading Nola's original story some time back, it was a pleasure to watch the OB's giant meathooks deftly winkle out Vicky's shoulders in about three seconds flat, or that is what my memory tells me. Good hands for such a large man.
Anyway -- keep up the good work.
Posted by: Luis | January 06, 2009 at 01:40 PM
While I'm not glad that the discussion about Nola's first birth was so hurtful on that other board, I AM glad that I found your blog through reading it. I've been an avid reader ever since discovering your blog, and I have to say, if you were in the area and I were pregnant, I'd be looking you up! Keep up the good work - the women you care for are lucky people!
Posted by: Heather | January 06, 2009 at 12:02 PM
Thank you for this and for the first Nola story. I'm a newcomer to your blog, so I hadn't seen it the first time around, but I was very moved to hear your recount of a very dramatic stressful event. As a medical student, it's nice to hear what it's like being a "real" doctor.
Posted by: Abby | January 06, 2009 at 11:03 AM